Takeaways

• Low back pain is one of the most common complaints seen in clinics with 84% of adults experiencing low back pain at some point in their lifetime (Allegri et al., 2016).
• When evaluating lumbar spine disorders, knowledge of key exam findings that are specific or more consistent with one disorder over another can aid in diagnosis and faster treatment.
• The role of imaging in evaluating low back pain and diagnosing lumbar spine disorders is controversial and may not be helpful due to the inconsistency in ability to detect and classify lumbar disorders and the high potential to detect incidental findings.
• Treatments of lumbar spine disorders focus on treatment of pain and slowing the progression of disease. This should be a multimodal approach involving pharmaceuticals, nonsurgical therapies, and procedural/surgical options. 

 

Lumbar spine disorders encompass a wide range of conditions including degenerative disc diseases, herniated discs, spondylothsthesis, spinal stenosis, fractures, and osteoporosis. Discovery of an underlying lumbar spinal disorder often begins with a patient seeking relief from low back pain – one of the most common chief complaints seen among medical facilities as 84% of adults experience low back pain at some point in their lifetime (Allegri et al., 2016). Another common initial presentation of lumbar spine disorders is pain or numbness in both or one lower extremity (Hegmann, 2019). Yet, this is still often accompanied by a varying degree of back pain. 

 

Specific Diagnostic Findings

Differentiating between lumbar disorders in a clinical setting can be complex. However, key specific exam findings are consistent with certain conditions (Hegmann, 2019). Neurogenic (or pseudo) claudication is a hallmark of lumbar spinal stenosis, where pain is exacerbated with walking, standing, and/or maintaining certain postures, and relieved with sitting or lying (Levin, 2019). Lumbar disc herniation with radiculopathy can be evaluated and supported by manual muscle testing, supine straight leg raise, Lasègue sign, and crossed Lasègue sign (Hegmann, 2019). Degenerative lumbar spondylolisthesis can present as one or a combination of the following: asymptomatic with only occasional back pain; chronic low back pain with or without radicular symptoms and with or without positional variance; radicular symptoms with or without neurologic deficit, with or without back pain; and intermittent neurogenic claudication (North American Spine Society Evidence-Based Clinical Guidelines Committee, 2014). Osteoporotic lumbar fractures, also known as compression fractures, cause a sudden onset of pain and have localized pain and tenderness over the spine on examination (Wheeler, 2019). 

By knowing which questions to ask and the various tests to perform, clinicians can narrow their differential diagnoses list, which can provide a more specific treatment plan and potentially improve treatment outcomes. 

 

Imaging

In general, imaging studies may not necessarily be helpful unless symptoms are persistent; red-flag symptoms are present; treatment responses are inconsistent; or invasive treatment is a consideration (Hegmann, 2019). This may be due to difficulty in specifying or classifying lumbar disorders on imaging and the frequent detection of incidental findings, thereby delaying accurate treatment. Asymptomatic degenerative disk disease is an incidental finding in as many as 54% of persons who undergo imaging (Hegmann, 2019).

Within the first 4-6wks of symptoms, x-rays are not advised for lumbar back pain with the exception of red flag findings (Hegmann, 2019). MRIs are the preferred imaging method to diagnose and classify most lumbar spine disorders (Allegri et al., 2016).   CT scan can more be helpful in certain disorders, especially where MRI’s are contraindicated, such as in facet syndrome, or when the MRI result is inconclusive (Hegmann, 2019).

 

Treatment  

Treatment of lumbar spine disorders revolves around prevention of worsening pathophysiology and treating the pain caused by these conditions. Some pain treatments can address multiple different disorders as the treatment of pain is consistent among most lumbar spinal disorders with some exceptions. Therefore, identifying the specific diagnosis prior to treatment may be unnecessary and, in fact, can prolong a patient’s discomfort and increase patient costs. 

For pain, NSAIDs and muscle relaxers are often first line agents, followed by antidepressants, gabapentinoids, and other pharmaceutical pain relievers (National Institute of Neurological Disorders and Stroke [NINDS], 2020). Acupuncture, TENs unit therapy, physical therapy, and spinal manipulation are a few nonsurgical therapies that can improve pain and slow the progression of disease (NINDS, (2020). The National Associates for Spine Specialists (NASS) guidelines for low back pain recommends the use of a “back school” program to reduce pain and enhance functionality in patients with chronic low back pain (Cassidy, 2020). However, there was not a uniform “back school” program that the NASS identified as most effective. Usually the program is an in-person multiple course program and works to strengthen self-management of back pain, giving patients a feeling of independence and control.  

If invasive injections are needed, referral to a pain specialist is necessary (Levin, 2019). 

For more information…

 

VA/DoD Clinical Practice Guideline for Diagnosis and Treatment of Low Back Pain

North American Spine Society

Clinical Guidelines

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College 

Management of Vertebral Compression Fractures

 

References 

Allegri, M., Montella, S., Salici, F., Valente, A., Marchesini, M., Compagnone, C., . . . Fanelli, G. (2016). Mechanisms of low back pain: A guide for diagnosis and therapy. F1000Research, 5, 1530. doi:10.12688/f1000research.8105.1

Cassidy, C.R., Enix, D.E., Robbins, D.S., Stout, A.A., & Tauzell, R.A.(2020). Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. North American Spine Society, 101 -157.

Hegmann, K. T., Travis, R., Belcourt, R. M., Donelson, R., Eskay-Auerbach, M., Galper, J., . . . Weiss, M. S. (2019). Diagnostic Tests for Low Back Disorders. Journal of Occupational and Environmental Medicine, 61(4). doi:10.1097/jom.0000000000001551

Levin, K. (2019, December 18). Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis. Retrieved December 30, 2020, from https://www.uptodate.com/contents/lumbar-spinal-stenosis-pathophysiology-clinical-features-and-diagnosis?search=lumbar+spinal+stenosis

National Institute of Neurological Disorders and Stroke (NINDS). (2020, April 27).  Low Back Pain Fact Sheet. Retrieved December 30, 2020, from https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/low-back-pain-fact-sheet

North American Spine Society Evidence-Based Clinical Guidelines Committee. (2014). Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis 2nd Edition. North American Spine Society, (2), 25-28.

Wheeler, S. G., MD, Wipf, J. E., MD, Staiger, T. O., MD, Deyo, R. A., MD, MPH, & Jarvik, J. G., MD, MPH. (2019, June 25). Evaluation of low back pain in adults. Retrieved December 26, 2020, from https://www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults?search=diagnosing+lumbar+compression+fractues