Diagnosis is made by eliminating specific lower back pain causes of neurological compromise, neoplasia, inflammatory arthritis, fracture, or referred pain from other locations or organ systems.
Pain, stiffness, and/or soreness of the lumbosacral region are the symptoms. May be acute (lasting <4 weeks), subacute (4 to 12 weeks), or chronic (>12 weeks).
Patient education, return to normal activity, and self-care temperature treatments (ice, heat) are the first steps in therapy.
Non-pharmacological approaches to control pain are preferred. When these are ineffective, first-line pharmacotherapy is oral nonsteroidal anti-inflammatory drugs. Paracetamol, muscle relaxants, opioids, and duloxetine may be used as adjuncts.
Musculoskeletal lower back pain is pain, stiffness, and/or soreness of the lumbosacral region (underneath the twelfth rib and above the gluteal folds).
Lower back pain is subdivided by time frame into acute lower back pain lasting <4 weeks, subacute lower back pain lasting 4 to 12 weeks, and chronic lower back pain lasting >12 weeks.
An exclusion diagnosis is made by eliminating specific causes of lower back pain arising from neurological compromise, neoplasia, inflammatory arthritis, fracture, and referred pain from other locations or organ systems. The exact cause of pain is often impossible to identify precisely, but arises from any combination of pathology involving discs, vertebrae, facet joints, ligaments, and/or muscles.
History and exam
Key diagnostic factors
- obesity, stress, and psychiatric comorbidities
- history of prior lower back pain
- history of prior treatment
- pain radiation does not extend beyond the knee
- absence of red-flag symptoms
- absence of fever, fluctuance, exquisite tenderness to palpation
- sensory, motor, and deep-tendon reflex examinations within normal limits
- negative straight- or crossed straight-leg raise test
Other diagnostic factors
- dull, gnawing, tearing, burning, or electric pain associated with muscle spasms
- lack of pain on flexion or relief on extension
- scoliosis or kyphosis
- negative FABER, Gaenslen's, or Schober's testing
- family history of degenerative disc disease
- poor musculotendinous flexibility and abnormal posture
- stress and psychiatric comorbidities
- increasing age, up to 60-70 years
- female sex
- heavy physical and occupational activities
- tobacco use
- prolonged standing
- vitamin D levels
1st investigations to order
- clinical diagnosis
Investigations to consider
- lumbar spine MRI
- lumbar spine x-ray
- lumbar spine CT
- erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- urinalysis and culture
- blood cultures
- radionuclide bone scan
- electromyogram (EMG)
acute and subacute lower back pain (≤12 weeks)
chronic lower back pain (>12 weeks)
recurrent lower back pain
Andrew Sherman, MD, MS
Professor and Vice Chair
Department of Physical Medicine & Rehabilitation
University of Miami Miller School of Medicine
AS declares that he has no competing interests.
Dr Andrew Sherman would like to gratefully acknowledge Dr Robert W. Irwin, Dr Louise Thwaites, Dr Karen Walker-Bone, Dr Joanne Borg-Stein, and Dr Philip Chiou, previous contributors to this topic.
RWI, LT, KWB, JBS, and PC declare that they have no competing interests.
Jennifer Baima, MD
Orthopedic and Arthritis Center
Brigham and Women's Hospital
JB declares that she has no competing interests.
Alexios G. Carayannopoulos, DO, MPH
Interventional Spine Physiatrist
Pain Medicine Specialist
AGC declares that he has no competing interests.
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