- Degenerative (osteoarthritis)
- Positional
- Relieved with rest
- Radiculopathy (eg, disc herniation)
- Radiates to leg
- Sensory & motor findings
- Positive straight-leg raising test
- Spinal stenosis
- Pain with standing (spinal extension)
- Relieved by spinal flexion
- Spondyloarthropathy
- Young men
- HLA-B27
- Relieved with exercise
- Prolonged morning stiffness
- Spinal metastasis
- Old age
- Constant pain
- Worse at night
- Not responsive to position changes
- Vertebral osteomyelitis
- Focal tenderness
- Fevers & night sweats
- Recent infection, intravenous drug abuse, or immune compromise
Treatment
- Initial Step: Rule Out Red Flags
- Cauda Equina Syndrome: Bowel/bladder dysfunction, saddle anesthesia. → Emergent MRI & surgical decompression.
- Malignancy/Infection: Hx of cancer, IV drug use, fever, night pain, weight loss. → MRI with contrast, ESR/CRP.
- Fracture: Significant trauma, chronic steroid use. → X-ray.
- Acute Mechanical Low Back Pain (<4 weeks)
- Most common cause (muscle strain). No red flags.
- Dx: Clinical diagnosis. NO imaging.
- Tx:
- Maintain activity (avoid bed rest).
- First-line: NSAIDs.
- Alternatives: Heat, muscle relaxants.
- Physical therapy if not improving.
- Chronic Low Back Pain (>12 weeks)
- Tx: Interdisciplinary approach.
- Physical therapy (core strengthening) is mainstay.
- Consider TCAs (amitriptyline) or SNRIs (duloxetine).
- High-Yield Specific Conditions
- Herniated Disc (Radiculopathy)
- Sx: Sciatica (shooting pain down leg), positive straight leg raise.
- Tx: Conservative (NSAIDs, PT). Surgery only for progressive neuro deficits or refractory pain.
- Spinal Stenosis
- Sx: Neurogenic claudication (pain with walking, better with leaning forward/sitting - “shopping cart sign”).
- Tx: PT, epidural injections. Surgery (laminectomy) if severe.
- Ankylosing Spondylitis
- Sx: Young male, morning stiffness improves with activity.
- Dx: HLA-B27, sacroiliitis on imaging.
- Tx: NSAIDs, PT. Refractory cases: TNF-α inhibitors.