Low Back Pain
Low Back Pain (LBP)
• LBP is experienced in the lower back
region and is a symptom rather than a
diagnosis.
• Acute LBP lasts less than 12 weeks, while
chronic LBP persists for 12 weeks or
more.
• Management plans differ significantly
between acute and chronic LBP.
Low Back • Majority of LBP patients self-treat their
Pain Self- condition.
• Only 25% to 30% of those with LBP seek
Treatment
medical care.
and Medical
• Despite this, LBP remains one of the top
Care reasons for visits to family physicians.
Spinal Anatomy and Low
Back Pain
• Key spinal elements: vertebral bodies,
posterior facet joints, intervertebral disks,
spinal cord with exiting nerves, ligaments, and
paraspinous muscles.
• Functions: Support, movement, protection of
spinal contents.
• Intervertebral disk structure: Annulus fibrosis
and nucleus pulposus.
Etiology of Low Back Pain
• Most back pain does not have a clear etiology
• Degenerative changes in any of the structures of the
back can lead to pain.
• Strains of muscles and ligaments leading to
discomfort.
• Classification: Mechanical, non-mechanical, and non-
spinal causes.
• Mechanical back pain: Anatomic or
Mechanical functional abnormality, worsened by
vs. Non- movement.
Mechanical • Non-mechanical back pain: Persistent pain,
Back Pain often due to inflammation or infection,
Patients typically have pain both at rest and
with movement.
Common Causes of Low Back Pain
• Lumbar strain or sprain: Soft tissue inflammation, pain
radiating to buttocks or legs.
• Herniated disk: Sciatica with nerve root impingement, This
radicular pain typically radiates in a dermatomal pattern down
the leg and below the knee.
• The 30- to 55-year-old age group has the highest incidence of
herniated disks
• The L4–L5 disk and L5–S1 disk account for 95% of
herniations, the L3–L4 disk accounts for the remaining 5%.
Herniation is very rare in disks above L3
Herniation of
intervertebral
disk
Serious Back Pain
Conditions
• Cauda equina syndrome: Acute neurological
impairment, bowel or bladder dysfunction,
emergency condition.
• Spinal stenosis: Degenerative narrowing of
spinal canal, often in older individuals.
• Vertebral compression fractures: Associated
with osteoporosis, neoplastic disease.
Pain Onset and Character
• Patients should describe their pain in their own words: sharp, dull, burning, etc.
• Acute pain often suggests a disk problem or muscle strain. particularly after a specific incident.
• Chronic, constant, dull pain can indicate serious conditions, including cancer.
• Sharp burning or electric shock-like pain pain may signal nerve irritation.
• Pain that develops slowly may point to degenerative processes like spinal stenosis or
rheumatologic conditions.
• Trauma-associated pain raises concern for vertebral fractures.
Pain Location and Radiation
• Lumbar strain pain is typically in the paraspinous muscles, sometimes
radiating to the buttocks.
• Localized spinal pain may be related to bone conditions like metastatic
disease or compression fractures.
• Pain radiating below the knee is often associated with a herniated disk.
Pain Intensity and Duration
• Intensity measured via visual analog scale (VAS).
• Differentiate between acute (<12 weeks) and
chronic (>12 weeks)
• Note any associated symptoms like stiffness, which
might suggest systemic conditions.
• Identify activities or positions that exacerbate or
alleviate the pain.
• Identification of "red flag" symptoms for
Associated serious underlying conditions.
Symptoms and • Aggravating factors like increased
Aggravating intradiscal pressure or activities indicate
Factors specific spinal issues.
• Relief with sitting or forward-leaning
postures is common in spinal stenosis.
An algorithm to guide
management of low
back pain.
Assessing Motor
Strength and Reflexes
• Focus on motor strength in lower extremities, especially:
• Ankle dorsiflexion
• Extension of the great toe
• Deep tendon reflexes assessment
• Tests for asymmetry:
• Walking on heels and toes
• Repetitive heel lifts
Straight Leg Raising
Tests
• Performed with the patient supine
• Leg elevated between 30 and 60 degrees
• Objective: Detect radicular pain indicative of
a herniated disk
• Sensitivity and Specificity:SLR: Sensitive
but not specific
• Crossed SLR: More specific, less sensitive
Additional Tests
Based on Patient
History
• Abdominal exam
• Pelvic exam
• Prostate exam
• Tailored to patient's history and
specific symptoms
Conservative Management of Lower Back
Pain
• for most patients, assuming they do not have any red flags, conservative management for
the first 4 to 6 weeks is appropriate.
• Patients who have not recovered after 4 to 6 weeks should be re-evaluated, possibly with
plain radiographs or advanced imaging.
• Patients who have worrisome findings on imaging or unresolving complications of a
herniated disk (cauda equina syndrome, intractable pain, or progressive neurological
deficits) should be referred to a spine specialist for surgical evaluation.
Acute Lumbar
Strain
• Also known as lumbago
• No red flags, no significant neurological
findings
• Causes: Inflammation, ligamentous
injury, muscle spasm
• Goal: Provide pain relief until
symptoms resolve
Treatment Options for Acute Lumbar Strain
• Acetaminophen and NSAIDs: Effective for pain relief
• Mild opioids (Codeine , Tramadol, Hydrocodone) and skeletal muscle relaxants
(Cyclobenzaprine, Carisoprodol, Methocarbamol, Tizanidine): Use cautiously
• Evidence: No superior efficacy of NSAIDs over acetaminophen
• Common side effects: Gastrointestinal toxicity from NSAIDs
Muscle Relaxants and Local
Heat
• Diazepam and cyclobenzaprine for short-
term use
• Alternatives: Metaxalone for less sedation
• Local heat: An effective non-
pharmacological option
• Usage tips: Lower doses or bedtime use to
manage drowsiness from muscle relaxants
Patient Education and
Activity
• Importance of staying active to
prevent progression to chronic LBP
• Evidence: Bed rest does not decrease
pain intensity or improve function
• Recommendation: Avoid bed rest;
stay as active as possible
Herniated Disk
with
Radiculopathy • Initial treatment similar to acute lumbar strain
• Considerations for mild neurological deficits
• Treatment options: NSAIDs, muscle relaxants, and physical activity
• Special note: No significant benefit from bed rest in sciatica
Diagnostic
Testing for
LBP
• Options: Plain radiographs, CT, MRI, radionuclide bone scans
• Sensitivity and specificity: Varied across modalities
• Use cases: Compression fractures, spinal degeneration, soft
tissue assessment
Definition: LBP persisting for more than 3
months
Treatment goals: Optimize function, manage
Chronic pain, reduce healthcare utilization
Low Back Non-pharmacologic therapies: Exercise, spinal
Pain manipulation, massage
Chronic management: Often requires a
multidisciplinary approach
Which medication is considered effective
for pain relief in acute lumbar strain?
A) Antibiotics
B) Antivirals
✓ C) NSAIDs
D) Antifungals
What is the first-line management for patients
with low back pain without red flags?
A) Immediate surgery
✓ B) Conservative management for 4 to 6 weeks
C) Starting with advanced imaging
D) Referral to a spine specialist
In cases of unresolving complications of a
herniated disk, what is the recommended action?
A) Continue with conservative management indefinitely
✓ B) Referral to a spine specialist for surgical evaluation
C) Immediate surgery without specialist evaluation
D) Start physical therapy
Low back pain that persists for more than 3
months is classified as:
A) Acute
B) Subacute
✓ C) Chronic
D) Intermittent
What type of pain is typically
described in lumbar strain?
A) Sharp and localized
B) Radiating below the knee
✓ C) In the paraspinous muscles, sometimes radiating to the buttocks
D) Around the neck area
Which age group has the highest incidence
of herniated disks?
A) 20–30 years
✓ B) 30–55 years
C) 55–75 years
D) 75+ years
What is the recommended initial treatment
for herniated disk with radiculopathy?
A) Bed rest until pain subsides
✓ B) NSAIDs and muscle relaxants with physical activity
C) Immediate surgical intervention
D) Prolonged fasting and meditation
Which diagnostic test provides the most
detailed images of the soft tissues of the disk
and nerve roots in LBP?
A) X-ray
B) CT Scan
✓ C) MRI
D) Ultrasound
Low back pain that is worsened by movement
and relieved by rest is classified as:
A) Non-mechanical back pain
✓ B) Mechanical back pain
C) Chronic back pain
D) Psychogenic back pain
Which spinal disks account for the
majority of herniations?
A) L1-L2 and L2-L3 disks
B) L3-L4 and L4-L5 disks
✓ C) L4-L5 and L5-S1 disks
D) L5-S1 and S1-S2 disks
