Prehospital Care
If the patient's back pain is from a traumatic injury, full spinal precautions using a long backboard for spinal immobilization should be used for extrication if needed and left in place during transport, unless there is extended transport times where risk of skin breakdown exists, particularly in older patients. If transport is going to be prolonged, it is reasonable to log roll the patient onto a soft stretcher if enough personnel are available to do so while maintaining spinal precautions.
If no history of trauma is present, spinal precautions is not necessary, as the patient may experience significant exacerbation of pain by lying on a rigid board. If the patient is brought into the emergency department on a rigid board, they should be removed from the board at the first opportunity.
If a rigid board is necessary, the patient may be made more comfortable by supporting the lower extremities with a pillow or blanket.
Emergency Department Care
If new neurologic deficits are noted accompanied by bowel or bladder dysfunction one should suspect cauda equina syndrome. This is a true emergency, and emergency imaging is mandated. MRI is the preferred imaging modality in this situation. [26] If cauda equina syndrome is strongly suspected, the practitioner should consider giving dexamethasone without delay to prevent further loss of neurologic function while pursuing confirmatory testing.
Conservative therapy is the mainstay of treatment, as even those with true sciatica generally respond. [27] Ultimately, only 2% of patients with sciatica and 4-6% of patients with true disc herniation require surgery. Conservative therapy traditionally includes the following:
Bed rest, once the cornerstone of treatment, is no longer widely recommended. A growing body of evidence suggests that even brief bed rest is not necessary except in patients with true sciatica. In this case, the supine position decreases pressure on the spinal cord itself and is useful for the first 2-3 days. Early mobilization with gentle range of motion and strengthening exercises are recommended for patients with nonsciatic back pain. [28, 29, 30] Early return to work on light duty or restricted activity leads to better long-term outcomes.
Pharmacologic therapy primarily involves both anti-inflammatory medication and muscle relaxants. [29] Opioid medications may be used initially to gain relief in acute illness or injury, but should be used sparingly.
Athough opioids may provide modest short-term pain relief, their long-term use is associated with increased functional impairment. Literature review of randomized, controlled trials using the GRADE methodology showed that evidence of long-term efficacy is lacking and that any short-term effect is likely not to be clinically important within recommended dosing. [31]
Steroids, while highly recommended by some practitioners, lack prospective confirmation of their value. Some physicians may prescribe a single burst or short course of oral steroids, which can be beneficial, particularly in those with a significant degree of inflammation. Epidural steroid injection may also bring significant short-term relief, but this treatment is not without adverse effects and has not been shown to provide lasting benefit. [32] Unless the patient is allergic to the medicine or it is otherwise contraindicated, severe low back pain can be improved significantly with a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. Opioid narcotics should be used sparingly and only in the acute phase for the first several days. Comparative studies between opioids and nonsteroidal anti-inflammatory drugs have not shown any differences in pain or function after the first few days of therapy. Long-term management with opioids is not indicated. [33]
Use of hot or cold compresses has never been proven scientifically to speed symptom resolution, but some patients may experience brief relief. Gentle flexion/extension exercises are helpful. [34, 35] Spinal traction is ineffective.
Evidence-based clinical practice guidelines from the American Pain Society (APS) for patients with chronic low back pain describe the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation. [36]
Practice guidelines for nonradicular pain include the following:
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Interdisciplinary rehabilitation emphasizing cognitive-behavioral approaches should be considered for patients who do not respond to usual interventions.
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Provocative discography (injecting material into a disc nucleus in an attempt to reproduce the patient's typical pain) is not recommended.
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Facet joint corticosteroid injection, prolotherapy (repeated injections of irritant material to stimulate an inflammatory response), and intradiscal corticosteroid injection are not recommended.
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Persistent disabling symptoms and degenerative spinal changes should prompt discussion and shared decision-making regarding surgery or interdisciplinary rehabilitation (evidence is insufficient to weigh the risks and benefits of vertebral disc replacement in these patients).
Practice guidelines for persistent radiculopathy include the following:
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For patients with herniated discs, the use of epidural steroid injection should be discussed.
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For patients with herniated discs and disabling leg pain from spinal stenosis, surgical options should be discussed.
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For patients with persistent pain after surgery, the risks and benefits of spinal cord stimulation should be discussed.
Consultations
ED consultation with a specialist is necessary for patients who present with acute cauda equina syndrome, demonstrate intractable pain, or have evidence of a serious etiology (eg, epidural abscess, hematoma, or tumor), or where a social situation makes hospitalization necessary.
Whether orthopedic or neurosurgical consultation is chosen depends on local custom and resources.
Other medical consultation may be needed if the cause of back pain is not mechanical.
Medical Care
Outpatient follow-up is generally managed by the patient's private physician. Patients with true sciatica or nerve root findings may also require consultation with an orthopedic surgeon or a neurosurgeon.
Spinal manipulation is not recommended. Rubinstein et al, in an evidence based review of published literature, did not support any significant benefits from spinal manipulation. [37]
Short-term physical therapy with gentle exercises may be of some benefit.
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Short-term physical therapy has not been proven significantly more effective than self-care with instructions by the physician. However, patients appear to prefer therapy to self-care when surveyed.
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Sertpoyraz et al compared isokinetic and standard exercise programs for chronic low back pain. Pain, mobility, disability, psychological status, and muscle strength was measured. Forty patients were randomly assigned to a program that took place in an outpatient rehabilitation clinic. Results showed an equal effect in the treatment of low back pain, with no statistically significant difference found between the two programs. [35]
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Cost-benefit ratio should be considered prior to physical therapy referral from the ED.
Studies of back pain patients in England suggest that a stratified management approach including prognostic screening, and a treatment approach targeting primary care efficiency and physiotherapy, leads to greater health gains for patients with back pain. Significant improvements were noted in the stratified management group at both 4- and 12-month follow-up with respect to physical and emotional wellbeing, pain intensity, work days missed, and quality of life. [38]
Inpatient care for low back pain is typically not required. Patients with cauda equina syndrome, epidural abscess, spinal tumor, systemic illnesses, or those with poor social support should be admitted for further evaluation and management.
Time-sensitive transfer to other facilities may be necessary in patients with suspected or known cauda equina syndrome or epidural hematoma or abscess, or if emergent MRI or a needed consultant is not available at the treating hospital. All suspected cauda equina patients should receive dexamethasone before transfer. Suspected or known epidural abscess patients should receive empiric antibiotics against staphlococcus, streptococcus, and gram-negative bacilli; and in suspected or known epidural hematomas in patients on anticoagulants, the anticoagulant agent should be reversed if possible before transport to avoid delays in treatment.
Patients with compressive tumors or abscesses should be transferred to a center that has a spine surgeon who can provide decompression in a timely manner if unavailable at the treating hospital.
Prevention
Back muscle strengthening exercises have value in preventing future episodes of low back strain. [39]
Weight loss in overweight patients results in less strain on back muscles.
Practicing proper lifting techniques results in less back strain.
General overall improvement of physical conditioning can decrease low back pain exacerbations. [40]
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Magnetic resonance image of the lumbar spine. This image demonstrates a herniated nucleus pulposus at multiple levels.
