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Editors

TimoPohjolainen
EeroHirvensalo
JukkapekkaJousimaa

Low Back Pain

Essentials

  • Sufficient time for the survey of the history and for the physical examination of the patient
  • Early recognition of serious causes of back pain and of nerve root compression
  • Organization of further investigations and treatment without delay in situations where conservative treatment may lead to complications (impending cauda equina, severe functional disorders of nerves, such as disturbance of a muscle group, extensive numbness of lower extremity, and other critical "red flag" situations). In such situations the treatment should be organized in a unit capable of urgent MRI and other investigations.
  • In patients who are beyond middle age, do not have radicular symptoms but do have pain in the night must be carefully evaluated. If the symptom picture continues after a therapeutic medication trial, more thorough diagnostic investigations should be considered to exclude malignancy.
  • In elderly people with no underlying chronic back condition, lower back pain often suggests spinal stenosis.
  • Adequate treatment of pain: according to the intensity of pain the choice is paracetamol, a NSAID or a combination of a NSAID and a mild opioid analgesic
  • Avoidance of bed rest
  • Continuation or resumption of ordinary daily activities as soon as possible
  • Provision of adequate and truthful patient information on the frequency of low back pain and its often good prognosis: the pain will usually resolve but has a tendency to recur
  • Unless there is a clear disease suggesting dysfunction of radicular origin and requiring spezialiced care, treatment consists of early multidisciplinary and active rehabilitation

Epidemiology

Clinical examination

History

  • Taking a history is the most important part in the clinical examination of a back pain patient. Data obtained from the history can be classified as follows:
    • Earlier low back pain (onset of symptoms, visits at a doctor, earlier investigations, treatments and sick leaves)
    • Current low back pain (onset, nature and intensity of symptoms, pain and sensory disturbances in the lower extremity, night pain, impulse pain, perceived functional capacity, investigations, treatments and their effectiveness)
    • Other illnesses (operations, traumas, other musculoskeletal disorders, other diseases such as diabetes and arteriosclerosis in lower extremities, diseases of the urogenital system, allergies, current medication)
    • Lifestyle (physical exercise, leisure time activities, smoking, use of alcohol and drugs, diet)

Physical examination Physical Examination for Lumbar Radiculopathy in Low-Back Pain

  • In the physical examination, emphasis is placed on the detection of possible serious disease and signs of nerve root compression as well as on the assessment of functional capacity. The patient should undress to a sufficient degree.
  1. Inspection of the spine
    • Assessment of walking rhythm
    • Flattening of lordosis or scoliosis due to acute pain
    • Bending of the lumbar spine; painful restriction may indicate the degree of severity.
  2. Examination of the mobility of the back
    • Restriction in bending forward, backward and sideways may give a picture of the severity of the back pain.
    • Mobility of the spine and disturbances in the rhythm of motion provide understanding of the functional capacity of the back, and measuring the mobility is of significance in follow-up of the condition.
    • The adjusted Schober test has moderate repeatability in measuring the mobility.
    • The rotational motion of the spine and the mobility of the thorax become early restricted in ankylosing spondylitis Ankylosing Spondylitis and Axial Spondyloarthritis.
  3. Assessment of signs of nerve root compression
    • Straight leg raising (SLR) and Lasègue's test are sensitive but non-specific tests for verifying nerve root compression at S1 and L5 level.
      • The tests are interpreted as positive when they cause pain radiating from the back to the lower limb. Back pain itself or tightness behind the knee are not positive signs.
      • In nerve root compression, passive dorsiflexion of the foot during SLR test may increase the pain radiating from the back to the limb.
      • Crossing pain: Intensified radiating pain when raising the contralateral limb suggests nerve root compression.
    • Muscular strength of the lower limbs
      • Knee extension (L4 and partially L3 nerve root)
      • Dorsiflexion of the ankle (L5, partially L4 nerve root), dorsiflexion of the big toe (L5 root) and plantar flexion of the ankle (S1 nerve root)
      • Walking on heels (L5, partially L4 nerve root) or on toes (S1 root)
    • Tendon reflexes
      • Patella (L4 nerve root)
      • Achilles (S1 nerve root)
      • Babinski (upper motor neuron)
    • Patients with lower limb symptoms are examined for sense of touch on the lower medial side of the knee (L4 nerve root), medial (L5 nerve root), dorsal (L5 nerve root) and lateral (S1 nerve root) sides of the foot.
    • Decreased muscle strength of both legs (paraparesis), enhanced or multiple tendon reflexes, and a positive Babinski's sign suggest a need for neurological or neurosurgical assessment. Paraparesis is an indication for immediate referral to a hospital with a possibility to urgently carry out an MRI examination and to perform potential surgery.
    • Rectal touch (tonus of the sphincter) and the sense of touch of the perineum should be examined when cauda equina syndrome is suspected (immediate referral).
  4. Palpation of the vertebrae, sciatic nerves and lower extremities
    • Numerous tender points and associate symptoms may suggest functional symptoms and, for example, fibromyalgia Fibromyalgia.
    • Palpation or Doppler ultrasonography, or both, of the arteries in the lower extremities in patients over 50 years of age with intermittent claudication Lower Limb Ischaemia

Psychosocial risk factors

  • Psychosocial factors may impede recovery, prolong and complicate functional capacity problems and alter pain behaviour in the patient group who do not have a disease affecting nerve roots or some other specific significant disease associated with the spine. Factors suggesting an increased risk for chronicity ("yellow flags") are presented in table T1.

Factors suggesting an increased risk for chronicity of back pain

Belief that pain and physical activity are harmful
Inappropriate illness behaviour (e.g. prolonged bed rest)
Depressed mood, negativity and social withdrawal
Seeking for many different therapies
Physically strenuous work
Problems at the workplace and dissatisfaction with the work
Overprotective family or lack of support
Complaints, litigations and compensation claims

Classification of diagnostic urgency

  • Uncommon but serious causes of back pain should be recognized at an early stage. Also, signs of sciatic syndrome should be recognized.
  • Back symptoms can be divided into 3 categories on the basis of the history and the findings in clinical examination.
    1. Possible serious (tumour, infection, fracture, cauda equina syndrome, or disc herniation/spinal stenosis that causes another type of serious innervation disturbance) or specific disease (ankylosing spondylitis); see table T2
    2. Symptoms in the lower limbs suggesting nerve root dysfunction (sciatic syndrome, intermittent claudication)
    3. Non-specific back pain: symptoms occurring mainly in the back without any suggestion of nerve root involvement or serious disease.

The most common serious or specific causes for low back pain and urgency of referral

DiseaseHistory, symptoms and signsUrgency of referral to specialized care; see also indications for surgery here
Disc herniation, spinal stenosis associated with cauda equina syndrome, excruciating pain and a fresh paresis of one of the muscle groups of the lower extremityDifficulty initiating urination, urinary retention or incontinence, anal incontinence, perineal anaesthesia (saddle sensory loss), usually symptoms of lower limb paralysis and a clear sensory disturbanceImmediate referral to a unit with possibility to carry out immediate imaging and surgery
Ruptured aortic aneurysm, acute aortic dissecationSudden, excruciating pain, age above 50 years, instable haemodynamicsImmediate referral to a unit with possibility to carry out immediate imaging and surgery
Malignant tumourAge above 50 years, history of cancer, involuntary weight loss, recurrent febrile episodes, progressive symptoms, pain at rest, duration of pain for over one month, paraparesisUrgent referral; immediate referral in paraparesis
Bacterial spondylitisPrevious back operation, urinary tract or skin infection, immunosuppression, glucocorticoid medication, abuse of intravenous drugsImmediate referral
Compression fracture of the spine, sacral fractureAge above 70 years, history of falling, peroral glucocorticoid medicationImmediate referral if paresis is present, otherwise referral by appointment
SpondylolisthesisAdolescent (age 8-15 years)Referral by appointment
Spinal stenosisAge above 50 years, neurogenic claudicationReferral by appointment
Ankylosing spondylitisAge below 40 years at the onset of symptoms, pain is not alleviated by bed rest, morning stiffness, duration at least 3 monthsReferral by appointment

Serious or specific diseases

  • Immediate referral
    • Urination is not possible or there is faecal incontinence (disturbance of sphincter function).
    • The patient has excruciating pain and a developing or complete fresh paresis of some muscle group.
    • Progressive proximal (L5-S2) sensory disturbance that extends close to the cauda region, often also motor weakness (careful examination is necessary).
    • In addition to the low back pain, the patient has symptoms or clinical signs suggesting an acute severe abdominal emergency.
  • Refer to investigations in specialized care that should take place within the next 48 hours at the latest
    • Partial weakness, sensory loss or numbness appears in the lower extremities.
    • General condition is deteriorating or pain is gradually growing more severe.
    • Back pain is not alleviated by medication at rest.
    • Back pain is associated with fever.

Laboratory tests

  • Laboratory tests are usually not needed. If there are signs of a serious or specific disease, the basic laboratory tests usually needed include at least ESR, CRP, basic blood count with platelets and basic chemical urinalysis.

Imaging studies

  • Normal finding in radiography does not exclude a serious condition.
  • In primary health care, one should refrain from ordering lumbar x-ray examinations in patients with acute or subacute non-specific low back pain if there are no symptoms suggesting serious back disorder.
  • When instability of the spine is suspected, a plain x-ray in standing position is warranted (symptomatic spondylolysis and spondylolisthesis as well as degenerative states).
  • If special diagnostic examinations are needed, MRI is the first-line imaging investigation.
  • CT is a substitute investigation when planning for an emergency operation if MRI is not available or is contraindicated.

Neurophysiological investigations

  • ENMG may be useful in the situations listed below, if about 4 weeks have elapsed since the onset of nerve-based symptoms.
    • Demonstration of nerve root injury in cases where the clinical picture is not consistent with the evidence suggested by other investigations
    • The patient has neurological symptoms and signs but imaging studies do not reveal nerve root compression.
    • In chronic pain states the investigation may be indicated as a part of the comprehensive assessment.
    • The investigation is sometimes useful in prognostic assessment.
    • In differential diagnostics, if entrapment or damage of a nerve is suspected

Sciatic syndrome Epidural Steroid Injections for Low Back Pain and Sciatica

  • The most common reason for an acute sciatic syndrome is intervertebral disc herniation.
  • If the indications for emergency investigations and surgery or for urgent investigations (see below) are not fulfilled and the pain is not overwhelming for the patient, conservative treatment of a patient with sciatica may be continued for 6 weeks before consideration of surgery. If the symptoms include, despite medication, pain that becomes worse, sensory disturbance or something suggesting partial muscle dysfunction, MRI imaging is warranted already earlier. For spinal stenosis (i.e. narrowing of the spinal canal or intervertebral nerve root canal) causing chronic sciatica, see Lumbar Spinal Stenosis (LSS).
  • In sciatic syndrome caused by intervertebral disc herniation the patient may move around and act within the limits of pain Bed Rest for Acute Low-Back Pain and Sciatica. Motion may be recommended in order to maintain general vitality and functional capacity. Sometimes severe sciatic pain necessitates bed rest; the so-called psoas position often relieves the symptoms. If the pain necessitates maintaining forced attitude (certain position), it is warranted to perform imaging rapidly.
  • If the symptom picture is severe and imaging finding matches clinical symptoms, surgical discectomy provides faster pain relief than conservative management for patients with sciatica The Effectiveness and Timing of Surgical Treatment in Intervertebral Disk Herniation. Microscopy-guided surgery is used in this procedure.
  • Active and intensive exercise started 4-6 weeks after disc surgery reduces pain, improves functional status and speeds the patient's return to work without increasing the reoperation rate Rehabilitation after Lumbar Disc Surgery.

Indications for emergency investigations and emergency surgery

  • Impending cauda equina syndrome (progressive sensory disturbance of the lower leg in the area of S1-2, and progressive motor weakness, as well as difficulty urinating)
  • Cauda equina syndrome (often following the previous condition if it was not recognized)
    • Sensory disturbance of the perineal (saddle) area, tone and contraction of the anal sphincter weakened
    • Urinary retention, faecal incontinence
  • Sudden paresis
    • Progressive or sudden loss of strength in the extensor or flexor muscles of the ankle or in the thigh muscle and, often, an associated sensory disturbance
  • Excruciating pain and a forced body position
  • A typical patient safety incident occurs if no adequate follow-up is organized and the progression of symptoms is not taken into account quickly enough, in which case further investigations are delayed.

Acute low back pain with no radiating symptoms (duration less than 6 weeks) Behavioural Treatments for Chronic Low Back Pain, Spa Therapy and Balneotherapy for Treating Low Back Pain, Herbal Medicine for Low Back Pain

  • If the pain is limited to the lower back area and is tolerable, if there are no signs of neurological deficits and if, based on patient history or findings, there is no reason to suspect a severe disease or a disease that requires specific treatment, the treatment is carried out based on the patient history and clinical examination as symptomatic therapy.
  • The probably benign nature and the usually good spontaneous healing tendency of the condition are explained to the patient.
  • Sick leave is considered on an individual basis. Short sick leave is usually sufficient. The aim is that the patient returns back to work after the sick leave.

Avoidance of bed rest and continuation of regular activities

  • The patient is advised to avoid bed rest Bed Rest for Acute Low-Back Pain and Sciatica. A short period of bed rest may be necessary due to intense back pain but bed rest must not be considered as a treatment of back problems.
  • The patient is encouraged to continue ordinary daily activities or resume them as soon as possible. Pain allowing, the patient can use his/her back within reasonable limits, and there is usually no need to restrict continuation of fairly light work.

Low back pain with developing radiating symptom (duration less than 6 weeks)

  • If symptom radiating to the lower extremity develops, the patient must be followed up and, if the symptoms persist and cause trouble to the patient, MRI imaging is warranted.
  • If during the follow-up the symptom picture becomes worse, motor weakness appears and sensory disturbances increase, the patient must be referred, depending on the severity of the situation, within 0-7 days to a unit where an MRI scan can be, if necessary, performed.

Analgesics

Muscle relaxants

  • Muscle relaxants are more effective than placebo, but they are no more effective than NSAIDs, and the combination of muscle relaxants and NSAIDs brings no further benefit Muscle Relaxants for Non-Specific Low Back Pain.
  • Muscle relaxants cause drowsiness or dizziness in almost one third of the patients.
  • A muscle relaxant is, however, an alternative when NSAIDs are not suitable or cause adverse effects.

Physical activity, exercise therapy and supportive corset Exercises for Prevention of Recurrences of Low-Back Pain

  • Light exercise that maintains fitness, such as walking, can be recommended.
  • Active exercise therapy of the back and other types of exercise are not beneficial in the early stages of acute disease.
  • Lumbar supports are probably not effective in preventing the onset or recurrence of low back pain Lumbar Supports for the Prevention and Treatment of Low Back Pain.

Manipulation

  • The effectiveness of manipulative therapy in acute low back pain does not differ from other recommended treatments or sham treatment Spinal Manipulative Therapy for Acute Low-Back Pain.
  • If manipulative therapy is anyhow provided, it should be performed by a person with appropriate education and training (physician with manual therapy training, orthopaedic manipulative therapist, licensed chiropractician, osteopath or naprapath).
  • Manipulative therapy may be provided without prior imaging if there is no reason to assume that the patient has a contraindication, which include processes that soften the spine (e.g. advanced osteoporosis, tumour, infection), ankylosing spondylitis, nerve root symptoms and clinically established neurological signs, severe spondylolisthesis (degenerative or spondylotic), recent trauma and haemorrhagic diathesis.

Subacute low back pain (duration 6-12 weeks)

Investigations

  • If back pain is prolonged, further investigations for the confirmation of diagnosis, for the appraisal of treatment and, if needed, for the drawing up of a comprehensive rehabilitation plan should be performed after 6 weeks from the onset of symptoms, unless the patient's state has warranted diagnostic investigations already earlier. Depending on the symptom picture, consultation with a physiatrist, orthopaedist, rheumatologist or neurosurgeon is often needed to assess the diagnosis (special examinations), treatment, functional and working capacity and need for rehabilitation.
  • It is worthwhile to assess the patient's illness behaviour, exhaustion and depression in an interview and by pain drawings and questionnaires that the patient fills in him- or herself (e.g. Oswestry http://eprovide.mapi-trust.org/instruments/oswestry-disability-index).

Treatment and rehabilitation Physical Conditioning Programs for Chronic Back Pain, Exercises for Prevention of Recurrences of Low-Back Pain

  • If a surgically treatable cause can be found (e.g. spinal stenosis, severe instability or disc herniation), the most feasible treatment method should be agreed on with the patient taking into account the severity of symptoms. This requires an assessment by an orthopedist or neurosurgeon with experience in spinal surgery.
  • If the selected line of treatment is conservative and the prognosis of the disease probably good, goal-oriented rehabilitation that improves functional capacity and is focused on active participation by the patient has a preventive effect on the symptoms becoming chronic.
  • Thorough clinical examination, assessment of the patient's situation and detailed instructions (brief intervention) decrease the number of sick leaves and the occurrence of impairing symptoms in subacute low back pain Multidisciplinary Biopsychosocial Rehabilitation for Subacute Low Back Pain Among Working Age Adults.
  • Comprehensive and, if needed, multidisciplinary assessment of working capacity may reduce the need of sickness absence from work. Extended sick leaves increase the risk of long-term work disability.

Drug therapy

  • Basic approach to drug therapy is the same as with acute low back pain.
  • The adverse effects of analgesics in prolonged use must be considered. All NSAIDs can cause cardiovascular, gastrointestinal and renal complications.
  • Adverse effects of NSAIDs should be considered especially in the elderly who often have other long-term illnesses and medication for them, as well as impairment of kidney function, which increase the likelihood of adverse effects of drugs and of harmful drug interactions.
  • In elderly patients, low back pain that requires substantial medication suggests degenerative spinal stenosis and possible instability.
  • Antidepressants have so far not been shown to be better than placebo in the treatment of low back pain Antidepressants for Non-Specific Low Back Pain, but patient's clear depression should be treated.
  • Benzodiazepines should be prescribed with caution and antipsychotics are not recommended for back pain.

Other therapies , Spa Therapy and Balneotherapy for Treating Low Back Pain, Herbal Medicine for Low Back Pain

When to consider elective surgery

  • Pain symptom that clearly impairs functional capacity and has lasted for several weeks. It may be associated with sensory deficit, mild motor weakness or difficulties in emptying the bladder.
  • Imaging finding that matches the clinical symptom picture (spinal stenosis, displacement of a vertebra, disc herniation, facet joint cyst)
  • The benefit of surgery is assessed to be more significant than its risk factors.
  • If the symptom picture is severe, the need for surgery may be assessed already earlier.

Chronic back pain (duration over 12 weeks)

  • In the treatment of back pain that has lasted for more than 3 months, the same guidelines apply as in the subacute phase. If needed, diagnostic investigations are carried out and treatment plan is drawn up anew in cooperation of physicians from different specialities.
  • Differential diagnostics should be carried out and confirmed if imaging studies have not been done earlier.
  • Multidisciplinary rehabilitation plan is made in cooperation between physicians, physiotherapists and, as necessary, a psychologist.
  • Intensive physical training as a part of multidisciplinary rehabilitation is beneficial. Restoring of the working capacity often requires also measures directed at the work itself.

Drug therapy

  • Analgesics are used periodically according to the intensity and occurrence pattern of the pain.
  • Paracetamol, NSAIDs or a combination of a NSAID and a weak opioid may be used as analgesics Non-Steroidal Anti-Inflammatory Drugs (Nsaids) in Acute Low Back Pain.
  • Adverse effects of prolonged use of NSAIDs should be kept in mind Safe Use of Non-Steroidal Anti-Inflammatory Drugs (Nsaids).
  • Opioids alleviate chronic low back pain but they have only a minor effect on functional capacity Opioids for Chronic Low Back Pain.
  • Use of a strong opioid is decided and a therapeutic trial is carried out at a multidisciplinary pain clinic or supervised by a specialist in pain management. Other treatment modalities are to be tried before starting the use of a strong opioid, and they are continued along with the opioid treatment. Earlier or current addiction problem or misuse, chronic constipation, sleep apnoea and COPD are in most cases contraindications for opioid use. The aim of the treatment is pain relief and improvement of functional capacity.
  • Duloxetine may alleviate chronic low back pain better than placebo, and its efficacy in chronic low back pain is comparable to NSAIDs and tramadol.
  • Other antidepressants probably do not alleviate pain nor improve functional capacity Antidepressants for Non-Specific Low Back Pain. Evidence of effectiveness is based on clinical trials made with tricyclic antidepressants and serotonin reuptake inhibitors.
  • Gabapentin, pregabalin andtopiramate may alleviate neuropathic sciatic pain.

Other therapies Radiofrequency Denervation for Chronic Low Back Pain, , , Herbal Medicine for Low Back Pain, Spa Therapy and Balneotherapy for Treating Low Back Pain, Prolotherapy Injections for Chronic Low-Back Pain, Effectiveness and Complications of Adhesiolysis in the Management of Chronic Spinal Pain

Rehabilitation to improve functional and working capacity Back Schools for Chronic Non-Specific Low Back Pain, Multidisciplinary Bio-Psycho-Social Rehabilitation for Chronic Low Back Pain, Physical Conditioning Programs for Chronic Back Pain, Exercises for Prevention of Recurrences of Low-Back Pain

  • Physical training and exercises that improve physical capacity reduce the number of sick leaves.
  • Sufficiently intensive and long-term resistance training (weight training) and exercise improving general physical condition (endurance training) reduce chronic back pain and improve function Exercise Therapy for Chronic Low Back Pain.
  • Multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improves functional capacity, work participation and quality of life and reduces pain in patients with chronic back pain Multidisciplinary Bio-Psycho-Social Rehabilitation for Chronic Low Back Pain.
  • Back massage when combined with therapeutic exercise and education may alleviate chronic back pain and improve function Massage for Low Back Pain.
  • Improvement of the working capacity of a person with chronic back problems requires also measures directed to the work itself. An approving attitude by the superiors and fellow workers towards functional impairment promotes the maintenance of working capacity of a person with back problems.

Patient educational material

  • Giving patients correct information may reduce pain and promote returning to work Individual Patient Education for Low Back Pain. Patient information recommended is listed in table T3.
  • The undulating character of low back pain should be emphasized to the patient, and no freedom from symptoms should be promised. Back pain often recurs but the intensity is, however, usually mild.
  • The patient information should mention the significance of exercise habits, weight control, diet and smoking in the control of back symptoms.

Recommended patient education in back pain (adapted from Waddell et al, 1996)

Type of back painPatient information
Common, unspecific back pain - convey a positive messageBack pain is very common.
No sign of a serious trauma or disease.
Recovery usually takes days or weeks at the most. In some patients, however, the symptoms may be prolonged.
There will be no permanent harm. Recurrences are common, but even then tendency for recovery is good.
Physical activity is beneficial. Too much rest is harmful. Moderate pain is not a sign of harmfulness.
Sciatic pain - convey a cautiously positive message.Provide appropriate information regarding symptoms and prognosis.
In most cases conservative treatment suffices, however, recovery usually takes 1-2 months. Good recovery is usually to be expected. In some patients, however, the symptoms may be prolonged. Recurrences are possible.
An MRI scan is warranted if the symptom picture becomes more severe or if a symptom suggesting dysfunction of a nerve root appears.
Possibly a serious disease - avoid conveying a negative message.Further investigations are needed for making a diagnosis. Often the results of these investigations are normal.
After the investigations a specialist will decide on the best possible therapy.
Excessive physical strain should be avoided until the investigations have been completed.

    References

    • Hartvigsen J, Hancock MJ, Kongsted A ym. What low back pain is and why we need to pay attention. Lancet 2018;391(10137):2356-2367. [PubMed]
    • Pain. A Current Care Guideline. Working group appointed by the Finnish Medical Society Duodecim, the Finnish Society of Anaesthesiologists, the Finnish Association for General Practice. Helsinki: the Finnish Medical Society Duodecim, 2017. In Finnish, abstract available in English http://www.kaypahoito.fi/en/ccs00111.

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