Lower Back Pain


There are two types of low back pain

  1. Acute: lower back pain for less than 3 months
  2. Chronic: lower back pain that has been present for more than 3 months

Differential diagnosis


    • Steroid use > 3 months
    • Hypertension medications?


    • Osteomyelitis
    • Spinal TB
    • Urinary tract infection (sign of urinary retention)
    • Reiters disease if patient is a young guy with symptoms of STI
    • Inflammatory (seroneg/spondyloarthropathies)
    • Ankylosing Spondylitis
      • If young (20-30), no radiation, and pain is worst at movement and better with rest
    • Morning stiffness relieved by activity.
      • Joint pain,
      • Uveitis (inflammation of the uveal tract: iris, ciliary body, and choroids)


    • Osteoporotic
    • Osteomalacia
    • Paget’s


    • Spondylolisthesis: Forward displacement of a lumbar vertebra
    • Disc herniation:
      • Sciatica:
        • Pain due to entrapment of sciatic nerve
        • Patient complains of pain, burning or aching in buttocks radiating down posterior thigh to the posterolateral aspect of calf
        • Pain worse with sneezing, laughing or straining during bowel movement
      • Cauda equina syndrome:
        • Leg weakness
        • Lax anus
        • Impotence,
        • Urinary retention
        • Fecal incontinence
        • Is surgical emergency
    • Spinal stenosis:
      • is characterized by worsening of symptoms with standing and walking, with relief on bending and setting (a typical history of leaning on and bending over the shopping cart for relief of pain while shopping is suggestive of spinal stenosis).
      • Nerve root entrapment in lumbar spinal stenosis is caused by narrowing of the spinal canal (congenital or acquired), nerve root canals, or intervertebral foramina
      • This narrowing is usually caused by bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum. Disc bulging and spondylolisthesis may contribute.
      • Symptoms of significant lumbar spinal stenosis include back pain, transient tingling in the legs, and ambulation-induced pain localized to the calf and distal lower extremity, resolving with rest.
      • This pain with walking, referred to as “pseudoclaudication” or “neurogenic claudication”, is clinically distinguished from vascular claudication by the presence of normal arterial pulses
    • Pancreatitis
    • Aortic aneurysm
    • PUD
    • Kidney stone
    • Pyelonephritis
    • Prostatitis
    • Endometriosis
    • PID


  • Pain lower back with or without radiation to thighs or legs
  • Fever may be present in case of infection
  • Limping

History taking


  • Location (worse in leg or back? Radiates to shoulder?)
  • Onset
  • Duration
  • Type of pain: Deep dull pain, sharp pain,
  • Severity
  • Triggering event
  • Pattern, changes with position
  • Progression
  • Alleviating: rest, warmth
  • Aggravating Factors: lifting, walking, sitting, bending

Associated symptoms:

  • Previous illness
  • Past trauma
  • Constitutional (fever, fatigue, night sweats, wt loss, chills)
  • Eye syndromes
  • Heart diseases
  • GU (retention, frequency, overflow incontinence, hesitancy, erectile)
  • Bowel (incontinence, perianal sensory loss)
  • Other neuro: Saddle anesthesia, loss of sensation, weakness in arms / legs


  • Ask about emotional consequences of the injury, the goals of treatment and the visit, patients concerns
  • Occupational impact
  • Limitation in usual activities
  • Social / recreation / sleep
  • How long can pt sit / stand / walk
  • How much weight can lift

Past Medical History

  • Previous hx of back pain / treatment / surgery
  • Recent infection (UTI)
  • Hospitalizations for back injuries
  • HIV
  • IVDU
  • Corticosteroid use
  • Vascular disease
  • Autoimmune disease
  • Supplement use (no use vs. too much use)
  • Depression or other mental conditions
  • Past history of trauma or injuries
  • Previous history of cancer

Physical exam

Vital Signs:

  • Temperature
  • BP
  • PR
  • Weight (loss)

Inspection (cervical, thoracic, lumbar)

  • Appearance, distress, sitting or standing position
  • Posture
  • Asymmetry
  • Skin rash or redness on back or hips
  • Deformity (lordosis or loss of lordosis, kyphosis, scoliosis, rib hump)
  • Signs of inflammation, trauma, scars
  • Gluteal muscle atrophy
  • LN exams
  • Uveitis
  • Abdominal pain or tenderness
  • Balonitis


  • Abnormal gait


  • Tenderness (spinous processes & paravertebral muscles)
  • Prominence & Alignment spinous processes
  • Palpate SI joints
  • Spasm of muscles


  • Spinous processes
  • Costovertebral Angle

Range of Motion

  • Forward bending (lumbar disc herniation)
  • Extension (facet joint or spinal stenosis)
  • Lateral flexion
  • Rotation (T12 – L1)
  • Chest expansion

Trendelenbreg test

Neurological Screen

  • Motor
  • Ask client to Squat (L4)
  • Ask client to Heel walk (L5)
  • Ask client to Walk on toes (S1-2)
  • Sensory
    • Medial calf (L4)
    • 1st web space (L5)
    • Lateral foot (S1)
  • Reflex
    • Knee jerk (L4)
    • Ankle jerk (L5)
    • Babinski
  • Straight leg raise:
    • The test is positive if significant back pain, or radicular pain in the lower extremity is present.
    • A positive test may indicate sciatic or lumbosacral nerve root irritation, for example due to a prolapsed lumbar disc.
    • Dorsiflex the foot at 45 degree is pain it is indicative of sciatica pain.
    • If the leg pain increases but without spinal symptoms consider piriformis syndrome.
    • If positive watch for quada equine syndrome.
  • Femoral stretch test (L2,3,4)
  • SI joint (flex hip & knee, hyperextend opposite), sacral compression pain
  • Peripheral Vascular system
    • Inspect for venous stasis or arterial insufficiency ulcers, check femoral pulses and auscultate for femoral bruits, feel popliteal, dorsalis pedis and tibialis posterior pulses.
  • Rectal exam:
    • Tone
    • Hemorrhoid

Social History

  • Lifestyle
  • Hobbies
  • Physical activity
  • Diet and nutrition
  • Drug and alcohol use
  • Employment history
  • High risk sexual disorders

Laboratory work up

  • ESR if is febrile or if cancer is in DDx
  • Alk Phosphatase
  • PSA if suspect prostate cancer

Diagnostic tests

  • Lubosacral X-Ray
  • CT-Scan: is the test of choice to investigate pain suspected to be from multi-segmental bony stenosis and fracture
  • MRI: is the primary diagnostic tool when cauda equine or malignancy is suspected or if there is past history of cancer or history of progressive worsening radiculopathy over 4 months


  • Yoga maybe beneficial
  • Spinal traction not helpful
  • Physical therapy
  • Chiropracter manipulation may be helpful in patients with simple back pain but not on those with radiculopathy
  • Start NSAIDS if no contraindications
  • Opioids are no better than non-opioids
  • Surgery consult if:
  • Quada equine syndrome
  • Persistent sciatica
  • Sensory deficit
  • Positive straight leg raise
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