R E V I E W

A R T I C L E

JIACM 2014; 15(1): 30-41

Low back pain Signs, symptoms, and management

RK Arya*
This review of low back pain and sciatica over the past 3,500
years tries to put our present epidemic of low back disability
into historical perspective. Backache has affected human
beings throughout recorded history. Despite greater
knowledge, expertise, and health care resources for spinal
pathologies, chronic disability resulting from nonspecific
low back pain is rising exponentially in modern society.
Recurrences and functional limitations can be minimised
with appropriate conservative management, including
medications, physical therapy modalities, exercise, and
patient education. Radiographs and laboratory tests are
generally unnecessary, except in the few patients in whom
a serious cause is suspected based on a comprehensive
history and physical examination2.
Pain in the lower back or low back pain is a common
concern, affecting up to 90% of people at some point in
their lifetime1. Up to 50% will have more than one episode.
Low back pain is not a specific disease, rather it is a
symptom that may occur from a variety of different
processes. In up to 85% of people with low back pain,
despite a thorough medical examination, no specific cause
of the pain can be identified. America spends
approximately $50 billion a year on low back pain3.
Low back pain is second only to the common cold as a
cause of lost days at work. It is also one of the most
common reasons to visit a doctors office or a hospitals
emergency department. It is the second most common
neurologic complaint in the United States, second only to
headache. Low back pain accounts for approximately 15%
of the sick leave, and is the most common cause of
disability in persons less than 45 years of age. The
prognosis for most cases of low backache is good. For 90%
of people, even those with nerve root irritation, their
symptoms will improve within two months no matter
what treatment is used, and even if no treatment is given.
An historic review shows that there is no change in the
pathology or prevalence of low back pain: What has
changed is our understanding and management. There
are striking differences in health care for low back pain in
the United States and the United Kingdom, although
neither delivers the kind of care recommended by recent
evidence-based guidelines. A study in the US reported that
65% patients with low back pain sought care from family
physicians as compared against 22% in Australia 31.

Interestingly, there is an eight-fold difference in the

likelihood of undergoing surgery for low back pain
depending on the specific region in which one resides in
the USA. Despite the different health care systems,
treatment availability, and costs, there seems to be little
difference in clinical outcomes or the social impact of low
back pain in the two countries. There is growing
dissatisfaction with health care for low back pain on both
sides of the Atlantic. Future health care for patients with
nonspecific low back pain should be designed to meet
their specific needs. Moreover, there are many specialists
who claim expertise at treating these symptoms. This
includes orthopaedic surgeons, chiropractors,
neurosurgeons, physical therapists, rheumatologists,
acupuncturists, neurologists, pain management
specialists, osteopaths, physical medicine and
rehabilitation specialists, internists, and family physicians.
Naturally, the education, training, skills, and experience of
this diverse group vary considerably when it comes to
treating low back pain. Thus there exists a great deal of
variance in expertise and opinion within each health
profession and subspeciality that treat low back pain.

Causes
Back pain is a symptom. Common causes of back pain
involve disease or injury to the muscles, bones, and/or
nerves of the spine. Pain arising from abnormalities of
organs within the abdomen, pelvis, or chest may also be
felt in the back. This is called referred pain. Many disorders
within the abdomen, such as appendicitis, aneurysms,
kidney diseases, kidney infection, bladder infections, pelvic
infections, ovarian disorders, uterine fibroids, and
endometriosis among others, can cause pain referred to
the back. Normal pregnancy can cause back pain in many
ways, including stretching ligaments within the pelvis,
irritating nerves, and straining the low back. Additionally,
the effects of the female hormone estrogen and the
ligament-loosening hormone relaxin may contribute to
loosening of the ligaments and structures of the back.
z Mechanical:
o Apophyseal osteoarthritis
o Diffuse idiopathic skeletal hyperostosis
o Degenerative discs
o Scheuermanns kyphosis
o Spinal disc herniation (slipped disc)

* Consultant, Department of Orthopaedics, PGIMER, Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New
Delhi - 110 001.

Thoracic or lumbar spinal stenosis

Spondylolisthesis and other congenital
abnormalities
o Fractures
o Leg length difference
o Restricted hip motion
o Misaligned pelvis-pelvic obliquity, anteversion or
retroversion
o Abnormal foot pronation
Inflammatory:
o Seronegative spondylarthritides (e.g., ankylosing
spondylitis)
o Rheumatoid arthritis
o Infection epidural abscess, or osteomyelitis
Neoplastic:
o Bone tumours (primary or metastatic)
o Intradural spinal tumours
Metabolic:
o Osteoporotic fractures
o Osteomalacia
o Ochronosis
o Chondrocalcinosis
Psychosomatic
o Tension myositis syndrome
Pagets disease
Referred pain:
o Pelvic/abdominal disease
o Prostate cancer
o Posture
Depression
Oxygen deprivation
o
o

z
z
z

z
z

Nerve root syndromes are those that produce symptoms

of nerve impingement (a nerve is directly irritated), often
due to a herniation (or bulging) of the disc between the
lower back bones. Sciatica is an example of nerve root
impingement. Impingement pain tends to be sharp,
affecting a specific area, and associated with numbness
in the area of the leg that the affected nerve supplies.
Herniated discs develop as the spinal discs degenerate or
grow thinner. The jelly-like central portion of the disc
bulges out of the central cavity and pushes against a nerve
root. Intervertebral discs begin to degenerate by the third
decade of life. Herniated discs are found in one-third of
adults older than 20 years of age. Only 3% of these,
however, produce symptoms of nerve impingement.
Spondylosis occurs as intervertebral discs lose moisture
and volume with age, which decreases the disc height.
Even minor trauma under these circumstances can cause
inflammation and nerve root impingement, which can
produce classic sciatica without disc rupture.

Journal, Indian Academy of Clinical Medicine

Spinal disc degeneration coupled with disease in joints

of the low back can lead to spinal-canal narrowing (spinal
stenosis). These changes in the disc and the joints produce
symptoms and can be seen on an X-ray. A person with
spinal stenosis may have pain radiating down both lower
extremities while standing for a long time or walking even
short distances.
Cauda equina syndrome is a medical emergency whereby
the spinal cord is directly compressed. Disc material
expands into the spinal canal, which compresses the
nerves. A person would experience pain, possible loss of
sensation, and bowel or bladder dysfunction. This could
include inability to control urination causing incontinence
or the inability to begin urination.
Musculoskeletal pain syndromes that produce low back
pain include myofascial pain syndromes and fibromyalgia.
Myofascial pain is characterised by pain and tenderness
over localised areas (trigger points), loss of range of
motion in the involved muscle groups, and pain radiating
in a characteristic distribution but restricted to a peripheral
nerve. Relief of pain is often reported when the involved
muscle group is stretched. Fibromyalgia results in
widespread pain and tenderness throughout the body.
Generalised stiffness, fatigue, and muscle aches are
reported.
Occasionally, the source may be the sacroiliac joints or the
hip joints and musculature.
Infections of the bones, pyogenic or tubercular
(osteomyelitis) of the spine are an uncommon cause of
low back pain.
Noninfectious inflammation of the spine (spondylitis) can
cause stiffness and pain in the spine that is particularly
worse in the morning. Ankylosing spondylitis typically
begins in adolescents and young adults.
Tumours benign or malignant, primary or metastatic
can be a source of skeletal pain.
Inflammation of nerves from the spine can occur with
infection of the nerves with the herpes zoster virus that
causes shingles.This can occur in the thoracic area to cause
upper back pain or in the lumbar area to cause low back
pain.
As can be seen from the extensive, but not all inclusive,
list of possible causes of low back pain, it is important to
have a thorough medical evaluation to guide possible
diagnostic tests. Psychological and emotional factors,
particular depression, can play a role14.
Back pain is also classified into three categories based on
the duration of symptoms13:i. Acute back pain pain that has been present for

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31

six weeks or less.

ii. Subacute back pain pain that has a 6 to 12-week
duration.
iii. Chronic back pain pain present for more than
12 weeks.
2
Table I : Differential diagnosis of acute low back pain.

evaluating a person with back pain. The focus of these red

flags is to detect fractures (broken bones), infections, or
tumours of the spine. Presence of any of the following red
flags associated with low back pain should prompt a visit
to ones doctor as soon as possible for complete evaluation.

Disease or condition

Patient age
(years)

Location of pain

Quality of pain

Aggravating or
relieving factors

Signs

Back strain

20 to 40

Low back, buttock, posterior

thigh

Ache, spasm

Increased with activity or

bending

Local tenderness, limited

spinal motion

Acute disc herniation

30 to 50

Low back to lower leg

Sharp, shooting or
burning pain,
paraesthesia in leg

Decreased with standing;

increased with bending or
sitting

Positive straight leg raise

test, weakness, asymmetric
reflexes

Osteoarthritis or spinal
stenosis

> 50

Low back to lower leg;

often bilateral

Ache, shooting pain,pins

and needles sensation

Increased with walking,

especially up an incline;
decreased with sitting

Mild decrease in extension of

spine; may have weakness or
asymmetric reflexes

Spondylolisthesis

Any age

Back, posterior thigh

Ache

Increased with activity or

bending

Exaggeration of the lumbar

curve, palpable step off
(defect between spinous
processes), tight hamstrings

Ankylosing spondylitis

15 to 40

Sacroiliac joints, lumbar spine

Ache

Morning stiffness

Decreased back motion,

tenderness over sacroiliac
joints

Infection

Any age

Lumbar spine, sacrum

Sharp pain, ache

Varies

Fever, percussive tenderness;

may have neurologic
abnormalities or decreased
motion

Malignancy

> 50

Affected bone(s)

Dull ache, throbbing pain;

slowly progressive

Increased with recumbency

or cough

May have localised

tenderness, neurologic
signs, or fever

Low back pain symptoms

Red flags

Pain in the lumbosacral area (lower part of the back) is

the primary symptom of low back pain.The pain may
radiate down the front, side, or back of the leg, or it may
be confined to the lower back. The pain may become
worse with activity. Occasionally, the pain may be worse
at night or with prolonged sitting such as on a long car
trip.

1. Recent significant trauma such as a fall from a height,

motor vehicle accident, or similar incident.

One may have numbness or weakness in the part of the

leg that receives its nerve supply from a compressed
nerve. This can cause an inability to plantarflex the foot.
This means one would be unable to stand on ones toes
or bring the foot downward. This occurs when the first
sacral nerve is compressed or injured. Another example
would be the inability to raise the big toe upward. This
results when the fifth lumbar nerve is compromised.

When to seek medical care

The Agency for Healthcare Research and Quality has
identified 11 red flags32 that doctors look for when

32

2. Recent mild trauma in those older than 50 years of

age: A fall down a few steps or slipping and landing
on the buttocks may be considered mild trauma.
3. History of prolonged steroid use: People with asthma,
COPD, and rheumatic disorders, for example, may be
given this type of medication.
4. Anyone with a history of osteoporosis: An elderly
woman with a history of a hip fracture, for example,
would be considered high risk.
5. Any person older than 70 years of age: There is an
increased incidence of cancer, infections, and
abdominal causes of the pain.
6. Prior history of cancer.
7. History of a recent infection.
8. Temperature over 100 F.
9. IV drug use: Such behavior markedly increases risk of

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an infectious cause.
10. Low back pain worse at rest: This is thought to be
associated with an infectious or malignant cause of
pain, but can also occur with ankylosing spondylitis.
11. Unexplained weight loss.

Neurologic evaluation
Examination of the back:
Palpation
- Range of motion or painful arc
- Stance
- Gait
- Mobility (test by having the patient sit, lie down, and stand up)
- Straight leg raise test

The presence of any of the above would justify a visit to a

hospital.
The presence of any acute nerve dysfunction should also
prompt an immediate visit. These would include the
inability to walk or inability to raise or lower your foot at
the ankle. Also included would be the inability to raise
the big toe upward or walk on the heels or stand on the
toes. These might indicate an acute nerve injury or
compression. Under certain circumstances, this may be
an acute emergency. Loss of bowel or bladder control,
including difficulty starting or stopping a stream of urine,
or incontinence, can be a sign of an acute emergency and
requires urgent evaluation in an emergency department.
If the patient cannot manage the pain using the medicine
currently prescribed, this may be an indication for a reevaluation or visit to a hospital.
The history and review of systems include the patients
age, constitutional symptoms, and the presence of night
pain, bone pain, or morning stiffness (Table II). The patient
should be asked about the occurrence of visceral pain,
symptoms of claudication and neurologic symptoms such
as numbness, weakness, radiating pain, and bowel and
bladder dysfunction.
It is also important to inquire about the specific
characteristics and severity of the pain, a history of trauma,
previous therapy and its efficacy, and the functional
impact of the pain on the patients work and activities of
daily living. An assessment of social and psychologic
factors (e.g., depression) may yield information that affects
the treatment plan.
Table II: Key aspects of the history and physical
examination in the patient with acute low back pain2.
History
z
Onset of pain (e.g., time of day, activity)
z
Location of pain (e.g., specific site, radiation of pain)
z
Type and character of pain (sharp, dull, etc.)
z
Aggravating and relieving factors
z
Medical history, including previous injuries
z
Psychosocial stressors at home or workRed flags: age greater than 50 years,
fever, weight loss
Physical examination
Informal observation (e.g., patients posture, expressions, pain behaviour)
z
Comprehensive general physical examination, with attention to specific areas
as indicated by the history
z

Journal, Indian Academy of Clinical Medicine

Physical examination
As part of the initial evaluation, the physician should
perform a thorough neurologic examination to assess
deep tendon reflexes, sensation, and muscle strength
(Table II). Peripheral pulses should also be assessed, and
the abdomen should be palpated to search for
organomegaly. The physician should assess joint and
muscle flexibility in the lower extremities, examine the
entire spine and assess stance, posture, gait, and straight
leg raising. Pain with forward flexion is the most common
response and usually reflects mechanical causes. If pain is
induced by back extension, spinal stenosis should be
considered. The evaluation of spinal range of motion has
limited diagnostic use15, although it may be helpful in
planning and monitoring treatment. A patient unable to
walk heel to toe, and squat and rise may have neurologic
compromise.
Red flags for physical examination
1. Saddle anaesthesia.
2. Loss of anal sphincter tone.
3. Major motor weakness in lower limbs.
4. Fever.
5. Vertebral tenderness.
6. Limited spinal range of motion.
7. Neurologic findings persisting beyond one month.
8. Structural spinal deformity.
Physical examination findings associated with specific
nerve root impingment33
Nerve root
Strength
Sensation
Reflex
L2
Iliopsoas
Anterior thigh, groin
None
L3
Quadriceps
Anterior/lateral thigh
Patellar
L4
Quadriceps, ankle
Medial ankle, foot
Patellar
dorsiflexion
L5
First toe dorsiflexion Dorsum of foot
None
S1
Ankle plantarflexion Lateral plantar foot
Achilles
Nonorganic signs
Functional overlay, or sign of excessive pain behaviour,
should be assessed. Non-organic signs of physical

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33

impairment have been described16. The presence of three

or more of these signs are thought to suggest a non
physiologic element of the patients presentation. In this
situation, further psychological testing and/or behavioural
intervention may be warranted.
Waddell signs: Non-organic signs indicating the presence
of a functional component of back pain
1. Superficial, non-anatomic tenderness.
2. Pain with simulated testing (e.g., axial loading, or
pelvic rotation).
3. Inconsistent responses with distraction (e.g., straight
leg raises while the patient is sitting).
4. Nonorganic regional disturbances (e.g., nondermatomal sensory loss).
5. Over-reaction.

Laboratory tests
The comprehensive evaluation may include a complete
blood count, determination of erythrocyte sedimentation
rate and other specific tests as indicated by the clinical
evaluation. In particular, these tests are useful when
infection or malignancy is considered a possible cause of
a patients back pain.

Radiographic evaluation
Why we need imaging?
z
To provide precise anatomical information.
z
To perform clinical diagnosis.
z
To plan an effective treatment.
z
To assess the efficacy of treatment.
z
To plan and perform a diagnostic or therapeutic
intervention.
Plain-film radiography
Plain-film radiography is rarely useful in the initial
evaluation of patients with acute-onset low back pain. At
least two large retrospective studies have demonstrated
the low yield of lumbar spine radiographs4, 5. In one of
these studies, plain-film radiographs were normal or
demonstrated changes of equivocal clinical significance
in more than 75 per cent of patients with low back pain.
The other study found that oblique views of the spine
uncovered useful information in fewer than 3 percent of
patients. At the first visit, anteroposterior and lateral
radiographs should be considered in patients who meet
any of the criteria listed in Table IV 6,7,8. Exposure to
unnecessary ionising radiation should be avoided. The
issue is of particular concern in young women because

34

the amount of gonadal radiation from obtaining a single

plain radiograph (2 views) of the lumbar spine is
equivalent to being exposed to daily chest radiograph for
more than one year17.
Indications for radiographs in the patient with acute
low back pain
z
History of significant trauma.
z
Neurologic deficits.
z
Systemic symptoms.
z
Temperature greater than 38C (100.4F).
z
Unexplained weight loss.
z
Medical history:
- Cancer
- Corticosteroid use
- Drug or alcohol abuse
z
Ankylosing spondylitis suspected.
Two major drawbacks to radiography are difficulty in
interpretation and an unacceptably high rate of false
positive findings. Plain films provide following specific
information:
z
Uni-segmental (like in tuberculosis) or multisegmental involvement as seen in lumbar
degenerative disc disease.
z
Acute or chronic process. Chronic changes include
decreased inter-vertebral height, vacuum
phenomenon as in disc herniation, end-plate
remodelling with spur and sclerosis, and spinal malalignment.
z
Congenital or acquired pathology.
z
Mal-alignment as in scoliosis or kyphosis.
z
Destruction and erosion as seen in tumours or
infection.
Plain films have high sensitivity and specificity for bony
pathologies like acute fractures, spondylosis, or
spondylolisthesis, scoliosis, kyphosis, gross degenerative
disease. They have a low or no sensitivity and specificity
for soft-tissue pathologies like disc herniation, marrow
infiltration, spinal infection, and tumours.
Myelogram
It is an X-ray study in which a radio-opaque dye is injected
directly into the spinal canal. Its use has decreased
dramatically since MRI scanning. A myelogram nowadays
is usually done in conjunction with a CT scan. CT
myelography has become the investigation of choice to
study disc herniation and/or arachnoiditis in postoperative spine with metal hardware in place. It is also
useful when clinical findings are compelling and are not

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adequately explained by CT and/or MRI. This study is

however unable to differenciate disc herniation from bony,
mal-alignment, infectious or other extradural lesions. The
most important limitation of myelography is its inability
to visualise entrapment of nerve root lateral to the
termination of nerve root sheath. It is thus unable to
detect any far lateral disc herniations. Rarely used
nowadays as better non-invasive radiological
investigations are available. Complications are headache,
nausea, vomiting, back pain, and seizures.
Computed tomographic (CT) scanning
The principal value of CT is its ability to demonstrate the
osseous structures of the lumbar spine and their
relationship to the neural canal in an axial plane. A CT
scan is useful in diagnosing tumours, fractures, and
partial-to-complete dislocations. In showing the relative
position of one bony structure to another, CT scan is
also helpful in the diagnosis of spondylolisthesis. The
limitation of CT includes less detailed images and
possibility of obscuring non displaced fractures or
simulating false ones. In addition, radiation exposure
limits the amount of lumbar spine that can be scanned,
and the results are adversely affected by patient
movement. Spiral CT addresses these weaknesses
because it is more accurate and faster, which decreases
a patients exposure to radiation.
Magnetic resonance imaging (MRI)
MRI has emerged as the procedure of choice for diagnostic
imaging of neurologic structures related to low back pain.
MRI is better than CT in showing the relationship of the
disc to nerve, and at locating soft-tissue and non-bony
structures. For this reason, it is better than CT at detecting
early osteomyelitis, discitis, and epidural type infection or
haematomas.
MRI provides high resolution multiaxial, multiplanar
images of tissues with no known biohazard effects. The
only contraindication to MRI is the presence of
ferromagnetic implants, cardiac pacemaker, intracranial
clips, or claustrophobia.
Magnetic resonance imaging (MRI) and computed
tomographic (CT ) scanning have been found to
demonstrate abnormalities in normal asymptomatic
people9,10. Thus, positive findings in patients with back
pain are frequently of questionable clinical significance.
In one study, MRI scans revealed herniated discs in
approximately 25 per cent of asymptomatic persons less
than 60 years of age, and in 33 per cent of those more
than 60 years of age 11 . Clearly, the presence of
abnormalities does not correlate well with clinical
symptoms. Therefore it is very important to correlate

Journal, Indian Academy of Clinical Medicine

clinical findings with MRI findings. Their routine use is

discouraged in acute back pain unless a condition is
present that may require immediate surgery, such as with
cauda equina syndrome or when red flags are present and
suggest infection of the spinal canal, bone infection,
tumour, or fracture. Compared with MRI, CT scanning is
less sensitive to patient movement and is also less
expensive. MRI may also be considered after one month
of symptoms to rule out more serious underlying
problems. MRIs are not without problems. Bulging of the
discs is noted in up to 40% of MRIs performed on people
without back pain. Other studies have shown that MRIs
fail to diagnose up to 20% of ruptured discs that are found
during surgery.
MRI or CT studies should be considered in patients with
worsening neurologic deficits or a suspected systemic
cause of back pain such as infection or neoplasm. These
imaging studies may also be appropriate when referral
for surgery is a possibility.

Bone scintigraphy
Bone scintigraphy, or bone scanning, can be useful when
radiographs of the spine are normal but the clinical
findings are suspicious for osteomyelitis, bony neoplasm
or occult fracture. However, this technique is unlikely to
demonstrate bone changes when radiographs and the
erythrocyte sedimentation rates are normal.

Physiologic assessment
Electrodiagnostic assessments such as needle
electromyography and nerve conduction studies are
useful in differentiating peripheral neuropathy from
radiculopathy or myopathy. If timed appropriately, these
studies are helpful in confirming the working diagnosis
and identifying the presence or absence of previous
injury. They are also useful in localising a lesion,
determining the extent of injury, predicting the course
of recovery and determining whether structural
abnormalities (as seen on radiographic studies) are of
functional significance.
The physician needs to be aware of the limitations of
electrodiagnostic studies. Because the tests depend on
patient cooperation, only a limited number of muscles
and nerves can be studied. In addition, the timing of the
studies is important, because electromyographic
findings may not be present until two to four weeks after
the onset of symptoms. Hence, electrodiagnostic studies
have only a limited role in the evaluation of acute low
back pain.
Electrodiagnostic studies may not add much if the clinical

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35

findings are not suggestive of radiculopathy or peripheral

neuropathy. These tests should not be considered if they
will have no effect on the patients medical or surgical
management.

is frequently felt in the back.

Because electrodiagnostic studies are examinerdependent, they should ideally be performed by

physicians who are specialists in electrodiagnostic
medicine14,15.

What are the points to be noted in the patient

with backache?
z
z
z

Self-care at home

General recommendations are to resume normal, or near

normal activity as soon as possible. However, stretching
or activities that place additional strain on the back are
discouraged. Sleeping with a pillow between the knees
while lying on one side may increase comfort or lying on
your back with a pillow under your knees.

Ibuprofen, available over the counter, is an excellent

medication for the short-term treatment of low back pain.
Because of the risk of ulcers and gastrointestinal bleeding,
avoid this medication for a long time.

Acetaminophen has been shown to be as effective as

ibuprofen in relieving pain.

Topical agents such as deep-heating rubs have not been

shown to be effective.
Some people seem to benefit from the use of ice or heat.
Their use, although not proven effective, is not considered
to be harmful. Take care: Do not use a heating pad on
high or place ice directly on the skin.
Most experts agree that prolonged bed rest is associated
with a longer recovery period. Further, people on bed rest
are more likely to develop depression, blood clots in the
leg, and decreased muscle tone. Very few experts
recommend more than a 48-hour period of decreased
activity or bed rest. In other words, advise patients to get
up and get moving to the extent they can.

Medical history
Because many different conditions may cause back pain,
a thorough medical history will be performed as part of
the examination.
Questions regarding the onset of the pain:
Were you lifting a heavy object and felt an immediate
pain? Did the pain come on gradually? What makes the
pain better or worse? Ask questions referring to the red
flag symptoms and about recent illnesses and associated
symptoms such as cough, fever, urinary difficulties, or
stomach illnesses. In females, about vaginal bleeding,
cramping, or discharge. Pain from the pelvis, in these cases,

36

z
z
z
z
z
z
z
z

Age of the patient.

Any history of cancer (like prostate or breast
carcinoma).
Unexplained weight loss.
Long-term use any steroidal drugs or drugs for AIDS.
Duration of back pain.
Any pain. or worsening of pain. at rest.
Drug abuse.
Numbness or weakness of legs.
History of injury to the back.
Urinary disturbance (difficulty in passing urine).
Work status.
Educational level of the patient.
Any pending cases in court against the patient.
Workers compensation issues.
Previous failed treatment for backache.
Depression.

Physical examination
To ensure a thorough examination, ask the patient to put
on a gown. Watch for signs of nerve damage while patient
walk on heels, toes, and soles of the feet. Reflexes are
usually tested using a reflex hammer. This is done at the
knee and behind the ankle. Make the patient lie flat on
the back, one leg at a time is elevated, both with and
without the assistance. This is done to test the nerves,
muscle strength, and assess the presence of tension on
the sciatic nerve. Sensation is usually tested using a pin,
paper clip, broken tongue depressor, or other sharp object
to assess any loss of sensation in legs.
Depending on these findings, it may be necessary to
perform an abdominal examination, a pelvic examination,
or a rectal examination. These examinations look for
diseases that can cause pain referred to the back.The lowest
nerves in the spinal cord serve the sensory area and muscles
of the rectum, and damage to these nerves can result in
inability to control urination and defaecation.This becomes
very important if cauda equina syndrome is suspected.

Rest
Previously, bed rest was frequently prescribed for patients
with back pain. However, several studies have shown that
this measure has an adverse effect on the course and
outcome of treatment. One randomised clinical trial found

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that patients with two days of bed rest had clinical

outcomes similar to those in patients with seven days of
bed rest20. The group with a shorter rest period missed 45
per cent fewer days of work and presumably avoided the
effects of deconditioning and the fostering of a
dependent sick role.
Laboratory and radiographic findings in selected
causes of low back pain
Disease or
condition

Laboratory tests

Radiographs

Back strain

No abnormalities

Usually negative
Radiographs may show incidental
spondylotic changes.

Acute disc
herniation

If testing is timed
properly, positive
findings for
electrodiagnostic studies
in the presence of root
entrapment

Possibly, narrowed intervertebral

disc spaces on radiographs.
CT and MRI can reveal level and
degree of herniation.
Myelography localises site of disc
herniation and the presence of root
entrapment.

Osteoarthritis

ESR and WBC count plus

differential typically
normal

Asymmetric narrowing of joint

space.
Sclerotic subchondral bone.
Marginal osteophyte formation.

Spondylolisthesis No abnormalities

Abnormal intervertebral movement

on radiographs obtained with spine
in flexion and extension.
Radiographs may reveal pars defect.
Bone scans can reveal pars defect not
visible on radiographs.

Ankylosing
spondylitis

ESR may be elevated

Mild anaemia possible
Positive human
leukocyte antigen-B27
assay in 90 per cent of
affected patients

Radiographs of pelvis are positive for

sacroiliac joint sclerosis and
narrowing.
Bone scans are useful for
demonstrating increased activity in
sacroiliac joints, facets, or
costovertebral joints.

Infection

Elevated ESR; WBC

count may be normal
Blood culture or
tuberculin test may be
positive

Radiographs may show vertebral

end-plate erosion, decreased
intervertebral disc height, changes
indicative of bony erosion and
reactive bone formation.
Gallium citrate scanning or Indiumlabelled leukocyte imaging may be
positive.

Malignancy

Anaemia
Increased ESR
Prostate-specific antigen
or alkaline phosphatase
level may be elevated

Radiographs may show bony erosion

or blastic lesions.
Bone scans are useful for early
demonstration of blastic lesions.
CT localises cortical lesions earlier
than radiographs.
MRI is useful for demonstrating softtissue tumours involving the spinal
cord.

Journal, Indian Academy of Clinical Medicine

The current recommendation is two to three days of bed

rest in a supine position for patients with acute
radiculopathy21, 22. The biomechanical rationale for bed
rest is that intradiscal pressures are lower in the supine
position. However, rolling over in bed may result in
increased intradiscal pressures. Sitting, even in a reclined
position23, actually raises intradiscal pressures and can
theoretically worsen disc herniation and pain. Activity
modification is now the preferred recommendation for
patients with non-neurogenic pain. With activity
restriction, the patient avoids painful arcs of motion and
tasks that exacerbate the back pain.

Physical therapy modalities

Superficial heat (hydrocolloid packs), ultrasound (deep
heat), cold packs, and massage are useful for relieving
symptoms in the acute phase after the onset of low back
pain. These modalities provide analgesia and muscle
relaxation. However, their use should be limited to the first
two-to-four weeks after the injury. The use of deep heat
may be subject to a number of restrictions21.
No convincing evidence has demonstrated the long-term
effectiveness of lumbar traction22 and transcutaneous
electrical stimulation 23 in relieving symptoms or
improving functional outcome in patients with acute low
back pain. Therapy should emphasise the patients
responsibility for spine care and injury prevention.

Corsets
The role of corsets (lumbosacral orthoses, braces, back
supports, and abdominal binders) in the treatment of
patients with low back pain is controversial at best24. Use of
a corset for a short period (a few weeks) may be indicated
in patients with osteoporotic compression fractures.

Exercise
Aerobic exercise has been reported to improve or prevent
back pain25. The mechanism of action is unclear, and the
relationship between cardiovascular conditioning and rate
of recovery is not universally accepted. Excess weight,
however, has a direct effect on the likelihood of developing
low back pain, as well as an adverse effect on recovery26.
In general, exercise programmes that facilitate weight loss,
trunk strengthening, and the stretching of
musculotendinous structures appear to be most helpful
in alleviating low back pain. Exercises that promote the
strengthening of muscles that support the spine (i.e., the
oblique abdominal and spinal extensor muscles) should
be included in the physical therapy regimen. Aggressive
exercise programmes have been shown to reduce the
need for surgical intervention27.

Vol. 15, No. 1

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37

Selected therapies for low back pain

Therapy

Indications

Contraindications

Prescription

Superficial heat
(hydrocolloid packs)

Analgesia
Reduction in muscle spasm
Increased tolerance for exercise

Impaired sensation, circulation

cognition
Oedema
Bleeding diathesis

Apply to affected area for 20 to 30 minutes; inspect

skin frequently during therapy; repeat application
every 2 hours as needed.

Ultrasound (deep heat)

Analgesia
Increased length of periarticular
ligaments and tendons

Same as for superficial heat

Never use deep heat near cardiac
pacemaker or fluid-filled cavities
(e.g., eyes, uterus, testes,
aminectomy sites)21.
Avoid use of deep heat near open
epiphyses, malignancies, or joint
arthroplasties21.

Apply 0.5 to 2.0 W per cm2 to affected area for 10 to

15 minutes before range-of-motion exercises are
performed.

Cold packs

Analgesia
Limitation of oedema formation
in acute musculoskeletal injury

Impaired sensation, circulation,

cognition
History of cold intolerance

Apply to affected area for 20 to 30 minutes; inspect

skin frequently during therapy; repeat application
every 2 hours for 48 hours after injury as needed.

Chiropractic

adversely affect the outcome of therapy32.

Patients with acute or chronic back pain frequently seek

chiropractic intervention. The Agency for Healthcare
Research and Quality (AHRQ), previously the Agency for
Health Care Policy and Research (AHCPR)28, and the
Clinical Standards Advisory Group (CSAG)29 acknowledge
the potential value of a short course of spinal
manipulation in patients with acute low back pain.
However, further research is needed to clarify the
subgroup of patients most likely to benefit from this
intervention30.

Indications for surgical evaluation

Patient education
It is critical to solicit the active participation of patients
in spine care. Successful treatment depends on the
patients understanding of the disorder and his or her
role in avoiding re-injury. Many hospitals and large
businesses offer programmes on back protection. These
programmes emphasise measures for avoiding spinal
injury and review appropriate postures for sitting, driving,
and lifting. Weight loss and healthy lifestyle classes are
also widely available.

Psychologic evaluation
Psychosocial obstacles to recovery may exist and must
be explored. Studies have shown that workers with lower
job satisfaction are more likely to report back pain and to
have a protracted recovery31. Patients with an affective
disorder (e.g., depression), or a history of substance abuse
are more likely to have difficulties with pain resolution. It
is important for the physician to find out whether the
patient has any pending litigation, because this can often

38

Of all industrialised nations, the United States of America

has the highest rate of spinal surgery (e.g., five times that
of Great Britain)33. Studies examining the outcomes of
conservative and surgical treatment of back pain have
revealed no clear advantage for surgery. In one
prospective study of 280 patients with herniated nucleus
pulposus diagnosed by myelography34, the surgical group
demonstrated more rapid initial recovery than the medical
treatment group. However, after approximately four years,
outcomes appeared to be roughly equivalent in both
groups; by 10 years, no appreciable differences in outcome
were found.
Select groups of patients with acute low back pain should
undergo immediate surgical evaluation. Patients with
suspected cauda equina lesions (characterised by saddle
anaesthesia, sensorimotor changes in the legs and urinary
retention) require immediate surgical investigation.
Surgical evaluation is also indicated in patients with
worsening neurologic deficits or intractable pain that is
resistant to conservative treatment.

Medications
Medication treatment options depend on the precise
diagnosis of the low back pain. Medication in several
classes have been shown to have moderate, primarily
short-term benefits.
Nonsteroidal anti-inflammatory medications: (NSAIDs) are
the mainstay of medical treatment for the relief of back
pain25. Ibuprofen, naproxen, ketoprofen, and many others

Journal, Indian Academy of Clinical Medicine

Vol. 15, No. 1

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are available. No particular NSAID has been shown to be

more effective for the control of pain than another.
However, you may switch from one NSAID to another to
find one that works best for your patient.

anaesthetic may be helpful in chronic back pain. Their use

remains controversial.

COX-2 inhibitors: Such as celecoxib (Celebrex), are more

selective members of NSAIDs. Although increased cost
can be a negative factor, the incidence of costly and
potentially fatal bleeding in the gastrointestinal tract is
clearly less with COX-2 inhibitors than with traditional
NSAIDs. Long-term safety (possible increased risk for heart
attack or stroke) is currently being evaluated for COX-2
inhibitors and NSAIDs.

Surgery is seldom considered for acute back pain unless

sciatica or the cauda equina syndrome is present. Surgery
is considered useful for people with certain progressive
nerve problems caused by herniated discs.

Acetaminophen: It is considered effective, safe, and less

costly for treating acute pain as well26. NSAIDs do have a
number of potential side effects, including gastric irritation
and kidney damage with long-term use27.
Muscle relaxants: Paraspinous muscle spasm associated
with acute back injuries of various aetiologies responds
well to these medications. Muscle relaxants are effective
in the management of non-specific low back pain, but the
adverse effects require that they be used with caution29.
Opioid analgesics: These drugs are considered an option
for pain control in acute, severe, and disabling back pain
that is not (or unlikely to be) controlled with
acetaminophen or NSAIDs. The use of these medications
is associated with serious side effects, including
dependence, sedation, decreased reaction time, nausea,
and clouded judgment28. One of the most troublesome
side effects is constipation. This occurs in a large
percentage of people taking this type of medication for
more than a few days. A few studies support their shortterm use for temporary pain relief. Their use, however,
does not speed recovery.
Depression is common in patients with chronic low back
pain and should be assessed and treated appropriately24.
Tricyclic antidepressants: Are an option for pain relief in
patients with chronic low back ache. Gabapentin is
associated with a small, short-term benefit in patients with
radiculopathy.
Steroids: Systemic steroids are not recommended for the
treatment of low back pain with or without sciatica30.
Steroid injections into the epidural space have not been
found to decrease duration of symptoms or improve
function and are not currently recommended for the
treatment of acute back pain without sciatica. Benefit in
chronic pain with sciatica remains controversial. Injections
into the posterior joint spaces, the facets, may be beneficial
for people with pain associated with sciatica.Trigger point
injections have not been proven helpful in acute back pain.
Trigger point injections with a steroid and a local

Journal, Indian Academy of Clinical Medicine

Low back pain surgery

Other therapies
Spinal manipulation
Osteopathic or chiropractic manipulation appears to be
beneficial in people during the first month of symptoms.
Studies on this topic have produced conflicting results.
The use of manipulation for people with chronic back pain
has been studied as well, also with conflicting results. The
effectiveness of this treatment remains unknown.
Manipulation has not been found to benefit people with
nerve root problems.
Acupuncture
Current evidence does not support the use of
acupuncture for the treatment of acute back pain.
Scientifically valid studies are not available. Use of
acupuncture remains controversial.
Transcutaneous electric nerve stimulation (TENS)
TENS provides pulses of electrical stimulation through
surface electrodes. For acute back pain, there is no
proven benefit. Two small studies produced inconclusive
results, with a trend toward improvement with TENS. In
chronic back pain, there is conflicting evidence regarding
its ability to help relieve pain. One study showed a slight
advantage at one week for TENS but no difference at
three months and beyond. Other studies showed no
benefit for TENS at any time. There is no known benefit
for sciatica.
Exercises
In acute back pain, there is currently no evidence that
specific back exercises are more effective in improving
function and decreasing pain than other conservative
therapy. In chronic pain, studies have shown a benefit from
the strengthening exercises. Physical therapy can be
guided optimally be specialised therapists.

Follow-up
After their initial visit for back pain, patients are
recommended to follow their doctors instructions as
carefully as possible. This includes taking the medications
and performing activities as directed. Back pain will, in all

Vol. 15, No. 1

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39

likelihood, improve within several days. Tell patients not

to be discouraged if they do not achieve immediate
improvement. Nearly everyone improves within a month
of onset of the pain.

Low back pain prevention

The prevention of back pain is, itself, somewhat
controversial. It has long been thought that exercise and
an all-around healthy lifestyle would prevent back pain.
This is not necessarily true. In fact, several studies have
found that the wrong type of exercise such as high-impact
activities may increase the chance of suffering back pain.
Nonetheless, exercise is important for overall health and
should not be avoided. Low-impact activities such as
swimming, walking, and bicycling can increase overall
fitness without straining the low back.
Specific exercises
Patients should learn from their doctor about how to
perform these exercises.
Abdominal crunches, when performed properly,
strengthen abdominal muscles and may decrease the
tendency to suffer back pain.
Although not useful to treat back pain, stretching exercises
are helpful in alleviating tight back muscles.
The pelvic tilt also helps alleviate tight back muscles.
Lumbar support belts
Workers who frequently perform heavy lifting are often
required to wear these belts. There is no proof that these
belts prevent back injury. One study even indicated that
these belts increased the likelihood of injury.
Standing
While standing, keep your head up and stomach pulled
in. If you are required to stand for long periods of time,
you should have a small stool on which to rest one foot at
a time. Do not wear high heels.
Sitting
Chairs of appropriate height for the task at hand with good
lumbar support are preferable. To avoid putting stress on
the back, chairs should swivel. Automobile seats should
also have adequate low-back support. If not, a small pillow
or rolled towel behind the lumbar area will provide
adequate support.
Sleeping
Individual needs vary. If the mattress is too soft, many
people will experience backaches. The same is true for
sleeping on a hard mattress. Trial and error may be
required. A piece of plywood between the box spring and
mattress will stiffen a soft bed. A thick mattress pad will

40

help soften a mattress that is too hard.

Lifting weights
Patients should not lift objects that are too heavy for them.
If they want to attempt to lift something they should keep
their back straight up and down, head up, and lift with
the knees. One should keep the object close by, and not
stoop over to lift. One should tighten the stomach muscles
to keep the back in balance.

Low back pain prognosis

The prognosis for people with acute back pain associated
with red flags (described earlier) depends on the
underlying cause of the pain. Up to 90% of people
experience an episode of back pain without other health
concerns, and their symptoms will go away on their own
within a month. For about half, back pain may return.
About 80% of people with sciatica will eventually recover,
with or without surgery. The recovery period is much
longer than for uncomplicated, acute back pain.
One can improve ones chances of early recovery by
staying active and avoiding more than two days of relative
bed rest.

Quick tips to a healthier back

Following any period of prolonged inactivity, begin a
programme of regular low-impact exercises. Speed walking,
swimming, or stationary bike riding 30 minutes a day can
increase muscle strength and flexibility. Yoga can also help
stretch and strengthen muscles and improve posture.
Patients should ask their physician or orthopaedist for a list
of low-impact exercises appropriate for their age and
designed to strengthen lower back and abdominal muscles.
Advice to patients
z Always stretch before exercise or other strenuous
physical activity.
z Do not slouch when standing or sitting. When
standing, keep your weight balanced on your feet.
Your back supports weight most easily when
curvature is reduced.
z At home or work, make sure your work surface is at a
comfortable height for you.
z Sit in a chair with good lumbar support and proper
position and height for the task. Keep your shoulders
back. Switch sitting positions often and periodically
walk around the office or gently stretch muscles to
relieve tension. A pillow or rolled-up towel placed
behind the small of your back can provide some
lumbar support. If you must sit for a long period of
time, rest your feet on a low stool or a stack of books.

Journal, Indian Academy of Clinical Medicine

Vol. 15, No. 1

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z
z
z

Wear comfortable, low-heeled shoes.

Sleep on your side to reduce any curve in your spine.
Always sleep on a firm surface.
Ask for help when transferring an ill or injured family
member from a reclining to a sitting position or when
moving the patient from a chair to a bed.
Do not try to lift objects too heavy for you. Lift with
your knees, pull in your stomach muscles, and keep
your head down and in line with your straight back.
Keep the object close to your body. Do not twist when
lifting.
Maintain proper nutrition and diet to reduce and
prevent excessive weight, especially weight around
the waistline that taxes lower back muscles. A diet with
sufficient daily intake of calcium, phosphorus, and
vitamin D helps to promote new bone growth.
If you smoke, quit. Smoking reduces blood flow to
the lower spine and causes the spinal discs to
degenerate.

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