Low back pain

#Lumbar radiculopathy, acute
Most likely given radiation below knee in dermatomal distribution, positive SLR, worse with coughing/straining. Likely [L4 given weak ankle dorsiflexion/inversion, decreased patellar reflex, pain/numbness of medial ankle/foot] [L5 given weakness of EHL/1st toe extension, decreased medial hamstring reflex, pain/numbness dorsal surface of foot] [S1 given weakness ankle plantarflexion/eversion, decreased achilles reflex, pain/numbness lateral foot/leg]. Note: L4/L5 compresses L5 root. Conservative management given no red flags (specifically no h/o trauma, steroid use, malignancy, IVDU, constitutional sx, GI/GU sx) and otherwise normal neuro exam (no saddle anesthesia, midline spinal TTP or weakness).
Dx:
- consider MRI if muscle weakness (not 2/2 pain, with maximal effort) or no improvement in 4-6 weeks
- for subacute, consider EMG/NCS if MRI unrevealing
Non-pharmacologic:
- activity as tolerated, avoid bedrest
- complementary therapies: heat/cold x 10-20 mins QID, yoga, acupuncture, chiropractic, aquatherapy, massage, "The Back Book"
- good lifting technique, sleep flat w/ pillow under knees, tempurpedic mattress
- PT if not improving in 4-6 weeks or now if severe pain/disability
Pharmacologic:
- NSAIDs x 7-14 days: Naproxen 500 mg BID (add PPI if prior GI sx; consider replacing with nabumetone if CKD1-2; no NSAIDs if CKD3-4)
-- discussed GI symptoms to be watchful for
- APAP up to 3g/day if helpful (Cochrane: same as placebo https://www.cochrane.org/CD012230/BACK_paracetamol-low-back-pain)
- cyclobenzaprine/baclofen PO PRN, voltaren gel PRN (lidocaine not usually helpful)
- RTC for any increased pain or new symptoms.

# Low back pain, non-radicular, acute
Likely lumbar muscle strain (70% of cases) vs DJD (10%), no hx/exam features of radiculopathy. Conservative management given no red flags (specifically no h/o trauma, steroid use, malignancy, IVDU, constitutional sx, GI/GU sx) and normal neuro exam (no saddle anesthesia, midline spinal TTP or weakness).
Non-pharmacologic:
- activity as tolerated, avoid bedrest
- complementary therapies: heat/cold x 10-20 mins QID, yoga, acupuncture, chiropractic, aquatherapy, massage, "The Back Book"
- good lifting technique, sleep flat w/ pillow under knees, tempurpedic mattress
- PT if not improving in 4-6 weeks or now if severe pain/disability
Pharmacologic:
- NSAIDs x 7-14 days: Naproxen 500 mg BID (add PPI if prior GI sx; consider replacing with nabumetone if CKD1-2; no NSAIDs if CKD3-4)
-- discussed GI symptoms to be watchful for
- APAP up to 3g/day if helpful (Cochrane: same as placebo https://www.cochrane.org/CD012230/BACK_paracetamol-low-back-pain)
- cyclobenzaprine/baclofen PO PRN, voltaren gel PRN (lidocaine not usually helpful)
- RTC for any increased pain or new symptoms.

#Low back pain, chronic
Etiology likely DDD/OA (10%), disk herniation/radiculopathy (4%), spinal stenosis (3%), ankylosing spondylitis (<1%). Therapies tried include ***. Given significant functional impairment, will emphasize a multimodal approach to manage pain, increase function, and maximize coping skills.
Dx:
- if not done previously, lumbar MRI w/o contrast
- if c/f AS (inflammatory pattern, <45yo), get lumbar/SI XR and/or MRI
Non-pharm tx:
- PT for supervised exercise therapy
- weight loss, smoking cessation
- Movement-based therapy with mind-body component such as Tai-chi or Yoga
- if available, pain psychology referral for cognitive behavioral therapy and mind-body interventions (mindfulness-based stress reduction, biofeedback, and progressive relaxation)
Pharm tx:
- NSAIDs PRN (not RTC)
- start duloxetine 30mg qd x 1 week then increase to 60mg qd; consider TCA instead if comorbid insomnia
- cyclobenzaprine/baclofen PO PRN, voltaren gel PRN (lidocaine not usually helpful)
- if above ineffective and still severe functional impairment, reasonable to do a short trial of tramadol (but avoid full opioid agonists)
- referral to pain clinic for consideration of epidural steroid injections; if ineffective, can trial RF ablation or surgical referral

#Low back pain with red flags
Concern for spinal process +/- cord compression 2/2 ***
*recent trauma (major vs minor in elderly/known CA);
*malignancy given night pain, supine pain, new urinary symptoms, saddle anesthesia, new weakness, constitutional sx;
*infection given fever, neurological deficits, recent instrumentation, h/o HIV or TB, IVDU, recent infection (UTI, SSTI, bacteremia, osteomyelitis, line-associated);
*compression fracture given h/o osteporosisis/steroid use/malignancy/elderly and sudden onset after coughing/bending/lifting/minor trauma with point TTP
- lumbar XR if concern for compression fracture
- MRI L-spine w/o contrast (plus contrast if immunosuppressed or suspicion for cancer or infection)
- CBC/diff, ESR/CRP, BCx, AlkPhos, PSA
- urgent ortho/neurosurg eval if cauda equina/motor weakness