Pain in the lower back

Clinical Perspective

Despite countless recent advances in diagnosis and treatment, low back pain remains one of the most challenging conditions in all of orthopedics. The results of both surgical and nonsurgical treatments often fall short of patient expectations, making low back pain a frustrating diagnosis for patients and providers alike. ¹

Sprain

Herniated disk

Lumbar Spinal Stenosis

1. Evaluate for serious conditions that lead to irreversible neurologic damage.

Overall, the incidence of critical spinal conditions, especially in an office setting where spinal trauma is not likely a consideration, is exceedingly low.

Unfortunately, things that are rare are also easy to miss, and the sequelae of missed critical spinal conditions are usually grave.

The specter of irreversible neurologic damage, paralysis, permanent bowel and bladder dysfunction, and other consequences of certain spinal conditions incite fear and unrest among patients and providers alike. ¹

 

 

 

Infection, hematoma, neoplasm, and critical spinal instability account for almost all of the dangerous spinal conditions we are likely to encounter in our patients.

While atraumatic critical instability of the cervical spine can be seen as a result of the destructive changes associated with rheumatoid arthritis, this condition is almost unheard of in the lumbar spine. Constitutional symptoms such as fever, chills, night sweats, and weight loss may indicate infection or neoplasm. In the spine, neoplasm is most likely metastatic disease, and there are certain cancers that typically metastasize to bone (see sidebar). Severe, intractable pain, rapidly progressive neurologic changes, gait disturbances, night pain, and the loss of the ability to ambulate are all “red flags,” as are dramatic changes in bowel or bladder function.

Pivotal Assessment	Finding	Pathophysiology
History	01. History of significant trauma
	02. Fever
	04. Leg pain
	03. Weakness or numbness	Spinal nerves relay sensation in specific parts of your body. Pressure on the nerves can cause pain in the areas that the nerves supply. Pain in the buttocks that radiates down the leg — called sciatica — is caused by this pressure.   Burning pain in buttocks or legs (sciatica). Pressure on spinal nerves can result in pain in the areas that the nerves supply. The pain may be described as an ache or a burning feeling. It typically starts in the area of the buttocks and radiates down the leg. As it progresses, it can result in pain in the foot.   Reference: https://orthoinfo.aaos.org/en/diseases--conditions/lumbar-spinal-stenosis/ Numbness or tingling in buttocks or legs. As pressure on the nerve increases, numbness and tingling often accompany the burning pain. Although not all patients will have both burning pain and numbness and tingling. Weakness in the legs or "foot drop." Once the pressure reaches a critical level, weakness can occur in one or both legs. Some patients will have a foot-drop, or the feeling that their foot slaps on the ground while walking. Less pain with leaning forward or sitting. Studies of the lumbar spine show that leaning forward can actually increase the space available for the nerves. Many patients may note relief when leaning forward and especially with sitting. Pain is usually made worse by standing up straight and walking. Some patients note that they can ride a stationary bike or walk leaning on a shopping cart. Walking more than 1 or 2 blocks, however, may bring on severe sciatica or weakness.
	History of malignancy
	Constitutional symptoms such as chills, night sweats, and weight loss may indicate infection or neoplasm. In the spine, neoplasm is most likely metastatic disease, and there are certain cancers that typically metastasize to bone Severe, intractable pain, rapidly progressive neurologic changes, gait disturbances, night pain, and the loss of the ability to ambulate are all “red flags,” as are dramatic changes in bowel or bladder function.
	constitutional symptoms (eg, unintentional weight loss or night sweats)

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