Low Back Pain

Question 1

Differential for low back pain:

Answer 1

compression fracture
herniated nucleus pulposus
paraspinal muscular strain/sprain/spasm
spinal stenosis
spondylosis (degenerative changes of the spine)

spondylolisthesis (forward displacement of a vertebra)
spondylolysis (defect or fracture of the pars interarticularis of the vertebral arch)
connective tissue disease
inflammatory spondyloarthropathy
malignancy
vertebral diskitis/osteomyelitis
referred pain from other conditions (e.g., pancreatitis, pyelonephritis, abdominal aortic aneurysm, nephrolithiasis)

Question 2

Red flags for low back pain

Answer 2

significant trauma (or minor trauma in older patients with osteoporosis)

major or progressive motor or sensory deficit
new-onset bowel or bladder incontinence or urine retention

loss of anal sphincter tone

saddle anesthesia

history of cancer that can metastasize to bone

pain increased or unrelieved by rest

pain with unexplained weight loss

prolonged history of glucocorticoid use

Intravenous drug use

immunosuppression

severe pain or history of spine surgery

fevers

Question 3

When to image low back pain

Answer 3

When red flags show up.

The most appropriate choice and sequence of imaging studies (radiography, MRI, and/or CT) depends on the particular diagnoses that the clinician wishes to confirm or exclude