Causes Lower back pain is a common complaint seen in primary care. An acute episode is considered lower back pain lasting less than three months (Balague et al, 2007). Emergent causes associated with the complaint of lower back pain include; tumors, infections, inflammatory conditions, disc herniation, or vertebral fractures (Balague et al, 2007). Non-emergent causes include urinary tract infections, muscle strain. Assessment This complaint must be thoroughly investigated to rule out any emergent causes. “Patients should be assessed when standing and unclothed for spine symmetry, posture, and flexibility. Palpation can assess spinal (bone) versus paraspinal (soft tissue) pain and its severity” (Atlas et al, 2001). Diagnostics -Generally, imaging is not indicated for non-specific low back pain (Balague et al, 2007). If symptoms do not resolve with conservative treatment, imaging should be considered (Atlas et al, 2001). Advanced imaging such as a CT or MRI should be obtained in patients with a strong suspicion of serious etiology (Atlas et al, 2001). Other diagnostics which may be considered to identify etiology include; complete blood count, erythrocyte sedimentation rate, and urinary analysis. Treatment Treatment should begin as conservative with management including NSAIDs, activity modification, stretching, manipulation, application of heat/cold, and exercise for 4-6 weeks (Atlas et al, 2001). If symptoms do not improve or resolve management modalities may need to be elevated. Narcotics may be considered if pain is not managed well on NSAIDs. Referral Referral should be considered when a diagnosis is uncertain, when a patient is unresponsive to therapy, or for potential surgical candidates (Atlas et al, 2001). Specialists which patients may be referred to include; psychiatry, orthopedic, neurology, neurosurgery, or rheumatology.
Atlas, Steven J,M.D., M.P.H., & Deyo, Richard A,M.D., M.P.H. (2001). Evaluating and managing acute low back pain in the primary care setting. Journal of General Internal Medicine, 16(2), 120-31. doi:http://dx.doi.org/10.1111/j.1525-1497.2001.91141.x
Balagué, F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2007). Clinical update: Low back pain. The Lancet, 369(9563), 726-8. doi:http://dx.doi.org/10.1016/S0140-6736(07)60340-7 (Links to an external site.)Links to an external site.
Balagué, F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2012). Non-specific low back pain. The Lancet, 379(9814), 482-91. doi:http://dx.doi.org/10.1016/S0140-6736(11)60610-7 (Links to an external site.)Links to an external site.
Lower back pain is common but emergent situations could depict this sensation and may be an emergent situation. Health care providers must assess the patient thoroughly. Palpation of the affected area is essential to identify and differentiate misalignment, muscle tightness, swelling, calcium deposits, lumps and/or nodules (Simms, 2015). Differential diagnosis is essential in developing an appropriate treatment plan. This patient could have possible cauda equina syndrome which is a medical emergency. The cause of this medical emergency is multiple lumbar root compressions at the spinal cord root. Surgical decompression may be required to reduce or eliminate pressure on the nerve. Other differential diagnosis for lower back pain include muscle strains, primary spine disease, disc herniation, and degenerative arthritis. In the majority of cases, a precise diagnosis cannot be made (Dunphy, Winland-Brown, Porter, & Thomas, 2015). The history and physical along with test such as lumbar xray and MRI is neccessary. Majority of the time, symptoms will improve in about one to four weeks. Pharmacological treatment can include NSAIDs and muscle relaxants for one to two weeks. Non-pharmacological pain can include heat therapy and ice therapy. Management can also require the patient to get out of bed after two days of rest. If the primary physician cannot manage the symptoms the patient can be referred to a specialist such as neurologist and orthopedic surgeon. The neurologist can test for any brain abnormalities and diseases that affect the neurological system. The orthopedic consult can be on standby just in case the patient needs immediate surgery for compression. References
Dunphy, L., Brown, J., Porter, B., Thomas, D. (2015). Primary Care: The Art and Science of Advanced Practice Nursing. Philadelphia: F.A. Davis Company.
Simms, A. (2015). Clinical observations in the treatment of lower back pain. Journal of Chinese Medicine, 107, 39-32.
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