Musculoskeletal low back or leg pain 97%
Lumbar sprain or strain 70%
Degenerative disk disease 10%
Herniated disk 4%
Spinal stenosis 3%
Trauma 1 %
Congenital disease, e.g.. kyphoscoliosis <1%
Referred or visceral pain 2%
Pelvic disease Renal disease Aortic aneurysm Gastrointestinal disease Nonmechanical low back pain I %
Inflammatory arthritis Paget disease
Adapted, with permission, from Deyo RA. Low back pain. N Engl J Med 2001:344:365.
serious underlying causes. Finding "red-flag" symptoms can help the physician use diagnostic tests in a more judicious manner (Table 24—2). When the patient has worrisome symptoms or signs, in most cases, the most effective initial evaluation is plain anteroposterior and lateral radiographs of the involved area of the spine, a sedimentation rate, and a complete blood count. More expensive tests, such as MRI. should be reserved for those patients for whom surgery is being considered, because it is not required to make most diagnoses.
It is rare that the patient can recall a precipitating event. Patients often have a history of recurrent episodes of low back pain. Psychological causes have not
"RED FLAG" SIGNS AND SYMPTOMS OF LOW BACK PAIN
New onset of pain in a patient older than 50 years or younger than 20 years Fever
Unintentional weight loss
Severe nighttime pain or pain that is worse in the supine position Bowel or bladder incontinence History of cancer
Immunosuppression (chemotherapy or HIV) Saddle anesthesia Major motor weakness been consistently related to low back pain; however, there does seem to be an association with job satisfaction. During the physical examination, palpable point tenderness over the spinous processes may indicate a destructive lesion of the spine itself; however, those with musculoskeletal back pain most often have tenderness in the muscular paraspinal area. Strength, sensation, and reflexes should be assessed, especially in those with complaints of radicular or radiating pain. Straight leg raise testing, in which the examiner holds the patient's ankle and passively elevates the patient's leg to 45 degrees, is helpful if it elicits pain in the lower back. However, it is not a very sensitive or specific test. The Patrick maneuver, in which the patient externally rotates the hip. flexes the knee, and crosses the knee of the other leg with the ankle (like a number 4) while the examiner simultaneously presses down on the flexed knee and the opposite side of the pelvis, can help distinguish pain emanating from the sacroiliac joint.
In treating idiopathic low back pain, various modalities have been shown to be equally effective in the long run. Randomized, controlled trials have shown that encouraging the patient to continue his or her usual activity is superior to recommendations for bedrest. Patients without disability and without evidence of nerve root compression probably can maintain judicious activity rather than undergoing bedrest. Bedrest probably is appropriate only for individuals with severe pain or neurologic deficits. The patient should be instructed to position himself or herself so as to minimize pain; this usually consists of lying supine with the upper body slightly elevated and a pillow under the knees. Nonsteroidal antiinflammatory medications (on a scheduled rather than on an as-needed basis), nonaspirin analgesics, and muscle relaxants may help in the acute phase. Because most cases of disk herniation with radiculopathy resolve spontaneously within 4-6 weeks without surgery, this is the initial regimen recommended for these patients as well. Narcotic analgesics are also an option in cases of severe pain; however, because idiopathic low back pain is often a chronic problem, their prolonged use beyond the initial phase is discouraged. Chiropractic, physical therapy, massage therapy, and acupuncture have been studied (in trials of varying quality), with results comparable to traditional approaches. Referral to a surgeon may be considered for those patients with radicular pain with or without neuropathy that does not resolve with 4-6 weeks of conservative management.
[24.1] A 35-year-old obese hotel housekeeper presents with 1 week of lower back pain. Her history and examination are without "red flags" and completely normal, except for her weight. Which of the following is the best next step?
A. Regular doses of a nonnarcotic analgesic
B. Six weeks of bedrest
C. MRI of the lumbar spine
[24.2) A 32-year-old woman from Nigeria presents with a 12-week history of persistent lower lumbar back pain, associated with a low-grade fever and night sweats. She denies any extremity weakness or HIV risk factors. Her examination is normal except for point tenderness over the spinous processes of L4-L5. What is the most likely diagnosis?
A. Staphylococcus aureus osteomyelitis
B. Tuberculous osteomyelitis
C. Given her age, idiopathic low back pain
124.31 A 70-year-old woman presents with a 4-week history of low back pain, generalized weakness, and a 15-lb weight loss over the last 2 months. Her medical history is unremarkable, and her examination is normal except that she is generally weak. Initial laboratory tests reveal an elevated sedimentation rate, mild anemia, creatinine level 1.8 mg/dL. and calcium level 11.2 mg/dL. What is the most likely diagnosis?
A. Osteoporosis with compression fractures
B. Renal failure with osteodystrophy
C. Multiple myeloma
D. Lumbar strain
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