Harvey's Garden

Back pain

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2 min read

  • 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. c
      • 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.

High-Yield Step 2 CK Pearls & Pitfalls

  • Do NOT order plain X-rays or MRI for acute (<4–6 weeks) uncomplicated mechanical back pain without red flags.
  • Do NOT recommend bed rest for mechanical back pain; bed rest delays recovery. Advise continuous moderate physical activity. c
  • If Metastatic Cord Compression is suspected based on history and exam, the single next best step in management is High-dose IV Glucocorticoids (Dexamethasone), followed immediately by MRI.
  • Focal tenderness to percussion over the spine points to:
    1. Vertebral osteomyelitis / Discitis.
    2. Epidural abscess.
    3. Vertebral compression fracture.
    4. Metastasis.
  • In elderly patients presenting with acute LBP and syncope, hypotension, or pulsatile abdominal mass, immediately suspect Ruptured Abdominal Aortic Aneurysm (AAA) Focused bedside ultrasound if unstable, or CTA abdomen if stable.

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