Back Pain Differential Diagnosis: A Comprehensive Guide for Clinicians

Back pain stands as a ubiquitous health concern, prompting countless individuals to seek medical attention, particularly in emergency settings. Its persistent nature often leads to significant disability, impacting people across all age demographics. While mechanical and nonspecific factors are frequently implicated, the diverse range of potential etiologies, varying with age, necessitates a nuanced approach to diagnosis and treatment.

This article provides an in-depth exploration of the differential diagnosis of back pain. Designed for healthcare professionals, this resource aims to enhance the ability to discern the varied origins of back pain, promptly identify warning signs indicative of serious underlying conditions, and formulate a robust, interprofessional strategy for both diagnosis and management. Emphasis will be placed on evidence-based conservative strategies for nonspecific back pain, underscoring the importance of maintaining physical activity overreliance on pharmacological interventions. This guide is crucial for healthcare providers seeking to improve patient outcomes, reduce the debilitating effects of back pain on quality of life and productivity, and mitigate associated healthcare costs.

Objectives:

• Explore the broad spectrum of etiologies in the differential diagnosis of back pain.
• Recognize critical red flags in back pain presentations that necessitate immediate attention to rule out serious conditions, including malignancy and cauda equina syndrome.
• Outline a comprehensive list of management strategies relevant to the differential diagnosis of back pain.
• Construct interprofessional team approaches to enhance care coordination and communication in the evaluation and management of patients presenting with back pain.

Introduction to Back Pain Differential Diagnosis

Back pain represents a leading complaint in primary care and emergency departments, imposing a substantial economic burden. Annual expenditures for back pain management are estimated at a staggering $200 billion, encompassing direct healthcare costs, lost productivity, and workers’ compensation claims.¹ This condition significantly diminishes work hours, overall productivity, and profoundly affects the workforce.

The origins of back pain are varied and complex, spanning a wide array of causes in both adult and pediatric populations. While the majority of cases are categorized as mechanical or nonspecific, constituting approximately 90% of presentations, it is imperative for healthcare providers to remain vigilant and consider rarer, yet potentially serious, underlying etiologies.²,³ The focus on common causes must not overshadow the necessity of a thorough differential diagnosis to identify and address less frequent but critical conditions.

Effective management of back pain hinges on two pivotal aspects: the prompt identification of red flags and the accurate determination of the underlying cause to guide appropriate treatment. While most cases can be effectively managed with conservative approaches, the presence of nerve dysfunction or other alarming symptoms necessitates comprehensive investigation and a multidisciplinary approach.⁴ A systematic differential diagnosis is crucial to guide clinical decision-making.

Treatment modalities for back pain range from pharmacological interventions, targeting peripheral and central neurological pathways and muscle relaxants,⁵ to various forms of physical therapy designed for nonpharmacological management and rehabilitation.⁶ Alternative therapies, such as acupuncture, have also demonstrated moderate efficacy in alleviating back pain.⁷ Surgical intervention is typically reserved for cases involving severe nerve dysfunction or serious underlying conditions like malignancy.⁸ For back pain persisting beyond six weeks post-injury, advanced imaging techniques like radiography, computed tomography (CT), or magnetic resonance imaging (MRI) are warranted to further investigate the differential diagnosis.

A comprehensive evaluation is paramount in pinpointing the precise cause of back pain and formulating a tailored therapeutic strategy. Accurate differential diagnosis and subsequent targeted treatment can significantly enhance patients’ functional capacity and overall quality of life.

Etiologies in Back Pain Differential Diagnosis

The differential diagnosis of back pain encompasses a broad spectrum of conditions, broadly classified into several etiological categories:⁹

• Traumatic Causes: Back pain frequently arises from traumatic events, either through direct impact or indirect forces. Examples include whiplash injuries, strains, and traumatic fractures of the spine.
• Degenerative Conditions: The musculoskeletal structures of the back are susceptible to degeneration over time due to aging, overuse, or pre-existing pathologies. Conditions such as intervertebral disc herniation and degenerative disc disease are prominent examples in this category.
• Oncologic Etiologies: Primary or secondary malignant lesions can develop within the anatomical structures of the back. Pathologic fractures of the axial skeleton may occur as a serious complication of spinal malignancies.
• Infectious Processes: Infections affecting the musculoskeletal structures of the back can result from direct inoculation, such as post-surgical infections, or spread from a distant infection site. Spinal osteomyelitis and discitis are key considerations in the differential diagnosis.
• Inflammatory Conditions: This category includes non-infectious, non-malignant inflammatory conditions. Ankylosing spondylitis and sacroiliitis are representative examples. Chronic inflammation can lead to the development of spinal arthritis.
• Metabolic Disorders: Disruptions in calcium and bone metabolism can manifest as back pain. Osteoporosis and osteosclerosis are metabolic conditions that should be considered.
• Referred Pain: Pain originating from visceral organ inflammation or pathology can be referred to the back. Examples include biliary colic, pulmonary diseases, and aortic or vertebral artery pathologies. This necessitates considering systemic conditions in the differential diagnosis.
• Postural Factors: Prolonged maintenance of upright postures, especially in occupations requiring prolonged sitting or standing, can induce back pain. Pregnancy and certain occupations predispose individuals to postural back pain.
• Congenital Anomalies: Inborn structural conditions of the axial skeleton can be a source of back pain. Kyphoscoliosis and tethered spinal cord syndrome are examples of congenital conditions to consider.
• Psychiatric and Psychogenic Factors: Back pain may also be a manifestation in patients with chronic pain syndromes and underlying mental health conditions. Furthermore, the possibility of malingering should be considered in the differential diagnosis, particularly in medicolegal contexts.

The duration of symptoms is a critical factor in the differential diagnosis. Acute back pain often arises from different causes compared to chronic back pain. A detailed clinical evaluation, supplemented by appropriate diagnostic examinations, is typically sufficient to pinpoint the exact etiology of back pain. Depending on the clinical findings, referral to specialists such as orthopedic surgeons, neurologists, rheumatologists, or pain management specialists may be warranted for further evaluation and targeted treatment planning.

Epidemiology of Back Pain

Back pain is a pervasive health issue affecting a significant portion of the adult population globally. Epidemiological studies indicate that up to 23% of adults worldwide experience chronic low back pain, with alarming recurrence rates ranging from 24% to 80%.¹⁰,¹¹ The lifetime prevalence of back pain in adults is exceptionally high, reaching up to 84%.¹²

While less prevalent in pediatric populations compared to adults, back pain is not uncommon in children and adolescents. A Scandinavian study highlighted that point prevalence of back pain was approximately 1% in 12-year-olds and increased to 5% in 15-year-olds. By late adolescence, around 50% of individuals would have experienced at least one episode of back pain by age 18 for girls and age 20 for boys.¹³ The lifetime prevalence of back pain in adolescents steadily rises with age, approaching adult levels by the age of 18.¹⁴ Understanding these epidemiological trends is crucial for healthcare providers in assessing the likelihood and potential causes of back pain across different age groups.

History and Physical Examination in Back Pain Differential Diagnosis

A cornerstone of accurately diagnosing back pain lies in a thorough history and physical examination. Determining the onset of pain is a primary step in the differential process. Acute back pain, typically lasting less than 6 weeks, is frequently associated with traumatic injuries or sudden exacerbations of chronic conditions, such as metastatic malignancy. Chronic back pain, persisting for more than 12 weeks, may be linked to mechanical issues or long-standing underlying conditions.

Eliciting information about factors that provoke or alleviate the pain provides valuable diagnostic clues. Understanding these aggravating and relieving factors not only aids in diagnosis but also guides clinicians in selecting appropriate pain management strategies tailored to the individual patient.

The quality of pain is a critical discriminator, helping differentiate between visceral and non-visceral pain sources. Well-localized pain often suggests an organic etiology. Associated symptoms accompanying back pain can further narrow the differential diagnosis, pointing towards specific underlying causes.

Gathering comprehensive medical, family, occupational, and social history is essential. For instance, a history of prior cancer treatment should heighten suspicion for metastasis or secondary spinal tumors. Similarly, family history of autoimmune arthritides may suggest a hereditary component. Travel history to regions with endemic tuberculosis should raise concerns for Pott disease or spinal tuberculosis. Occupational history, particularly involving prolonged sitting, can be a significant factor in both acute and chronic back pain.

A focused physical examination should incorporate inspection, auscultation, palpation, and provocative maneuvers. Visual inspection of the back might reveal deformities, signs of inflammation, or skin lesions, although often the cause is not visually apparent. Auscultation becomes relevant when pulmonary pathology is considered in the differential diagnosis. Palpation helps identify areas of localized musculoskeletal tenderness.

Provocative tests can provide crucial insights into the etiology of back pain. The straight-leg-raising (SLR) test is particularly useful in assessing for lumbar disc herniation. The test is performed by passively raising the patient’s leg between 30° and 70°. A positive SLR test is indicated by ipsilateral leg pain developing at less than 60° of leg elevation. The crossed SLR test, involving raising the leg contralateral to the suspected side of disc herniation, is even more specific than the ipsilateral SLR test for diagnosing disc herniation.¹⁵,¹⁶

The Stork test, used to evaluate for spondylolysis, is another clinically relevant maneuver. The examiner supports the patient while they stand on one leg and hyperextend their back. The test is repeated on the opposite leg. Pain experienced during hyperextension indicates a positive Stork test.

The Adam test is utilized to screen for scoliosis. The patient bends forward with feet together, arms extended, and palms apposed. An examiner observing from the front can detect a thoracic hump indicative of scoliosis.¹⁷

Assessing range of motion, limb strength, deep tendon reflexes, and sensory function is crucial for evaluating the integrity of both the musculoskeletal and neurological systems.

Presence of red flags during history taking or physical examination necessitates further diagnostic imaging and testing. Red flags are critical indicators of potentially serious underlying conditions. The following are key red flags to be aware of in both adult and pediatric populations:

Red Flags for Serious Conditions in Adults:¹⁸,¹⁹

• Malignancy:
  • History: Previous history of metastatic cancer, unexplained weight loss.
  • Physical Exam: Focal tenderness to palpation in patients with known cancer risk factors.
• Infection:
  • History: Recent spinal procedure (within 12 months), intravenous drug use, immunosuppression, prior lumbar spine surgery.
  • Physical Exam: Fever, presence of wound in the spinal region, localized pain, and tenderness.
• Fracture:
  • History: Significant trauma (relative to patient age), prolonged corticosteroid use, osteoporosis, age over 70 years.
  • Physical Exam: Contusions, abrasions, tenderness to palpation over spinous processes.
• Neurological Compromise:
  • History: Progressive motor or sensory loss, new onset urinary retention or incontinence, new fecal incontinence.
  • Physical Exam: Saddle anesthesia, anal sphincter atony, significant motor deficits across multiple myotomes.

Red Flags for Serious Conditions in Pediatric Patients:²⁰,²¹

• Malignancy:
  • History: Age younger than 4 years, nocturnal pain (nighttime pain).
  • Physical Exam: Focal tenderness to palpation in the context of cancer risk factors.
• Infection:
  • History: Age younger than 4 years, nocturnal pain, history of tuberculosis exposure.
  • Physical Exam: Fever, wound in the spinal region, localized pain, and tenderness.
• Inflammatory Conditions:
  • History: Age younger than 4 years, morning stiffness lasting longer than 30 minutes, pain improving with activity or hot showers (suggestive of inflammatory back pain).
  • Physical Exam: Limited range of motion, localized pain, and tenderness.
• Fracture (Stress Fractures):
  • History: Participation in activities involving repetitive lumbar hyperextension, such as cheerleading, gymnastics, wrestling, and football.
  • Physical Exam: Tenderness to palpation over spinous process, positive Stork test.

Evaluation and Diagnostic Modalities in Back Pain Differential Diagnosis

In the majority of cases, a detailed history and physical examination are sufficient to establish a working differential diagnosis for back pain. Early imaging in adults without red flags has been associated with poorer outcomes, potentially leading to increased invasive procedures with minimal patient benefit.²²,²³ This principle also applies to pediatric populations. However, the presence of any concerning red flags necessitates further diagnostic testing to refine the differential diagnosis and exclude serious conditions. In adults, persistent back pain lasting longer than 6 weeks despite appropriate conservative management is also an indication for imaging. In pediatric patients, imaging is generally recommended for continuous pain lasting more than 4 weeks.⁹¹

Plain anteroposterior and lateral (APL) radiographs of the axial skeleton are useful for detecting bone pathologies, such as fractures, dislocations, and some tumors (See Image. Multiple Myeloma Involving the Spine). Magnetic resonance imaging (MRI) is the preferred modality for evaluating soft tissue lesions, including nerves, intervertebral discs, and ligaments. MRI excels in detecting conditions such as disc herniation, spinal cord compression, and soft tissue tumors. Both radiography and MRI can reveal signs of malignancy and infection, but MRI is superior in assessing soft tissue involvement and early stages of bone marrow changes in conditions like osteomyelitis and malignancy.²⁴,²⁵ Bone scans, while less specific than MRI, may be useful in detecting osteomyelitis, discitis, and stress fractures, particularly when MRI is contraindicated or unavailable.²⁶

In adolescents with MRI evidence of disc herniation, a computed tomogram (CT) may be indicated to rule out apophyseal ring separation, a condition occurring in approximately 5.7% of these patients.²⁷ CT scans provide detailed bony anatomy and are excellent for evaluating fractures and bony lesions.

Electromyography (EMG) and nerve conduction studies are valuable in patients with prior spinal surgery who may be experiencing radiculopathy or plexopathy as postoperative complications. These studies help assess nerve function and identify nerve impingement or damage. Image-guided diagnostic injections, such as sacroiliac joint injections, can aid in confirming sacroiliac joint dysfunction as a source of pain.⁹²

Laboratory investigations may be warranted in certain cases of back pain to further refine the differential diagnosis, particularly when infection, inflammation, or malignancy are suspected. Rheumatologic assays, including HLA-B27, antinuclear antibody (ANA), rheumatoid factor (RF), and Lyme antibodies, are generally not specific for back pain and are typically not helpful in routine differential diagnosis.²⁸,²⁹ However, inflammatory markers like C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can be useful in detecting inflammatory or infectious processes.³⁰ A complete blood count (CBC) and blood cultures may be indicated to assess for infection or malignancy. Elevated lactate dehydrogenase (LDH) and uric acid levels may be found in conditions associated with rapid marrow turnover, such as leukemia or tumor lysis syndrome, though these are less specific to back pain itself.³¹

Treatment and Management Strategies Based on Differential Diagnosis

The management of back pain varies significantly between adults and pediatric patients, reflecting differences in common etiologies and underlying pathologies. While degenerative disease and musculoskeletal injuries are more prevalent causes in adults, overuse and muscle strain are more frequent in children and adolescents. Rare causes such as malignancy and metabolic conditions also present differently across age groups. Therefore, treatment strategies must be appropriately tailored based on both the specific condition identified in the differential diagnosis and the patient’s age.

Management of Back Pain in Adults

For acute back pain in adults, the initial step is to rule out serious underlying conditions through careful history, physical exam, and targeted investigations when indicated. If no red flags are present, patient reassurance and symptomatic relief are the primary goals. First-line treatments for acute, nonspecific back pain are primarily nonpharmacological and include:⁹³

• Early return to normal activities, with modifications to avoid heavy labor or exacerbating activities.
• Activity modification to avoid movements or postures that provoke pain.
• Patient education on the nature of back pain, self-management strategies, and prognosis.

Second-line treatment options, considered if initial measures are insufficient, may include nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, opioids (for short-term severe pain), spinal manipulation, physical therapy, superficial heat application, and alternative therapies such as acupuncture and massage. Patient education tailored to individual circumstances is crucial for preventing pain aggravation and recurrence. Follow-up appointments are typically scheduled within 2 weeks to reassess symptoms and functional status. Resumption of normal routines should be encouraged if the patient is asymptomatic at follow-up.

For adults presenting with acute radicular back pain, initial management may include NSAIDs, exercise, and potentially traction or spinal manipulation. Diazepam and systemic steroids have not demonstrated significant additional benefit in acute radicular pain.

Diagnostic tests become necessary if serious conditions cannot be confidently ruled out, or if pain persists despite conservative management. Referral to specialists for further evaluation and advanced treatments should be considered when indicated by the differential diagnosis.

The management approach to chronic back pain in adults is similar in principle, starting with excluding serious underlying etiologies. If the cause remains nonspecific, maintaining activity and avoiding pain-provoking factors are paramount. Exercise therapy and cognitive behavioral therapy (CBT) are considered first-line treatments for chronic nonspecific back pain.³²,³³ Second-line treatments may include spinal manipulation, massage, acupuncture, yoga, stress reduction techniques, NSAIDs, selective norepinephrine reuptake inhibitors (SNRIs), and interdisciplinary rehabilitation programs.³⁴,³⁵,³⁶

The role of anticonvulsants like gabapentin and topiramate in chronic back pain management remains uncertain, with evidence of limited efficacy.³⁷,³⁸ Transcutaneous electrical nerve stimulation (TENS) units do not appear to be more effective than placebo for chronic back pain in many studies.³⁹

Surgical referral is generally reserved for patients with disabling low back pain persisting for more than one year, particularly when specific structural pathology amenable to surgery has been identified in the differential diagnosis, and conservative treatments have failed.⁴⁰ However, the evidence for the efficacy of some common invasive procedures, such as epidural steroid injections and lumbar disc replacement, is mixed, and careful patient selection is crucial.⁴¹,⁴²

Management of Back Pain in Children and Adolescents

Treatment of back pain in pediatric patients is less extensively studied compared to adults. However, activity modification, physical therapy, and NSAIDs are generally considered first-line therapies. If a serious pathology is identified in the differential diagnosis, treatment should be based on the established standard of care for that specific condition. Spondylolysis resulting from repetitive spinal stress may be managed conservatively, similar to adults. However, young athletes actively engaged in sports may require referral for surgical intervention in certain cases.⁴³,⁴⁴ Symptoms persisting beyond 6 months of conservative therapy or Grade III or IV spondylolisthesis may warrant referral to a pediatric spine surgeon for further evaluation and possible surgical management.⁴⁵,⁴⁶

Patients diagnosed with Scheuermann’s kyphosis in the differential diagnosis may be managed conservatively with physical therapy and guided exercise if the spinal curvature is less than 60°. Bracing may be added for patients with curvatures between 60° and 70°. Surgical correction is typically indicated for spinal curvatures greater than 75°, especially if conservative measures have failed and the patient’s skeletal maturity is reached.⁴⁷,⁴⁸ Spinal curvature of 20° or greater during peak growth, significant scoliosis, progressive curvature, and atypical scoliosis are also indications for surgical referral in pediatric patients.⁴⁹

Differential Diagnosis: Specific Conditions

The following sections outline specific conditions that commonly present with back pain in adults and children, categorized to aid in differential diagnosis. Associated symptoms and key physical examination findings are highlighted. This list is not exhaustive but includes the most prevalent and clinically significant conditions in the differential diagnosis of back pain.

Differential Diagnosis of Back Pain in Adults

• Lumbosacral Muscle Strains and Sprains:

  • Etiology: Typically results from acute traumatic incidents or repetitive overuse injuries.
  • Symptoms: Pain worsens with movement and improves with rest.
  • Physical Findings: Restricted range of motion, muscles tender to palpation.

• Lumbar Spondylosis (Degenerative Joint Disease):

  • Etiology: Degenerative changes in the lumbar spine, common in individuals over 40 years.
  • Symptoms: Hip pain may be present; pain exacerbated by lower limb extension or rotation.
  • Physical Findings: Neurologic exam usually normal unless significant nerve compression is present.

• Intervertebral Disc Herniation:

  • Etiology: Herniation of the nucleus pulposus, most frequently in the L4-S1 segments.
  • Symptoms: May include associated paresthesia, sensory changes, and muscle weakness or reflex changes depending on the nerve root involved. Radicular pain is a hallmark symptom.
  • Physical Findings: Positive straight leg raise test, neurological deficits corresponding to affected nerve root.

• Spondylolysis and Spondylolisthesis:

  • Etiology: Spondylolysis is a defect in the pars interarticularis, often stress-related; spondylolisthesis is the anterior slippage of one vertebra over another.
  • Symptoms: Back pain radiating to the gluteal area and posterior thighs; neurologic deficits if present, typically follow the L5 distribution.⁵⁰
  • Physical Findings: Pain on spinal extension, hamstring tightness may be present.

• Vertebral Compression Fracture:

  • Etiology: Fracture of vertebral body, often due to osteoporosis, trauma, or malignancy.
  • Symptoms: Localized back pain worsening with flexion; point tenderness on palpation. May be acute or chronic.
  • Risk Factors: Steroid use, vitamin D deficiency, osteoporosis, advanced age.

• Spinal Stenosis:

  • Etiology: Narrowing of the spinal canal, often due to degenerative changes.
  • Symptoms: Leg sensory and motor weakness relieved by rest (neurogenic claudication).
  • Physical Findings: Neurologic exam may be initially normal but progresses with increasing stenosis; symptoms often provoked by lumbar extension.

• Spinal Tumors:

  • Etiology: Primary or metastatic neoplasms of the spine. Metastatic tumors are far more common (97% of spinal tumors are metastatic).⁵¹
  • Symptoms: May be accompanied by unexplained weight loss, focal tenderness to palpation, or known malignancy risk factors. Night pain is a concerning symptom.
  • Red Flags: History of cancer, unexplained weight loss, night pain.

• Spinal Infections:

  • Etiology: Infections of the vertebral column or surrounding tissues. Common types include vertebral osteomyelitis, discitis, septic sacroiliitis, epidural abscess, and paraspinal muscle abscess. Consider tuberculosis spondylitis (Pott’s disease) in patients from endemic regions.⁵²
  • Risk Factors: Recent spinal surgery, intravenous drug use, immunosuppression.
  • Symptoms: Fever, wound in the spinal region, localized pain, and tenderness.

• Vertebral Fracture (Traumatic):

  • Etiology: Resulting from significant trauma.
  • Risk Factors: Trauma, prolonged corticosteroid use, osteoporosis, age > 70 years.
  • Physical Findings: Contusions, abrasions, tenderness to palpation over spinous processes.

Differential Diagnosis of Back Pain in Children and Adolescents

• Spinal Tumors:

  • Etiology: Though less common than in adults, spinal tumors in children are serious. Osteoid osteoma is a relatively common benign tumor presenting with back pain, often relieved by NSAIDs.⁵³,⁵⁴,⁵⁵
  • Symptoms: Fever, malaise, weight loss, nighttime pain, and recent onset scoliosis may be present.
  • Red Flags: Night pain, unexplained weight loss, neurological symptoms.

• Spinal Infections (Discitis, Osteomyelitis):

  • Etiology: Bacterial infections of the disc space or vertebral body. Common conditions are vertebral osteomyelitis, discitis, septic sacroiliitis, epidural abscess, and paraspinal muscle abscess. Epidural abscess is a serious consideration with neurologic deficits and radicular pain.⁵⁶,⁵⁷
  • Symptoms: Fever, malaise, weight loss, nighttime pain, and recent-onset scoliosis. Patients may refuse to walk.
  • Red Flags: Fever, neurological deficits, refusal to bear weight.

• Intervertebral Disc Herniation and Slipped Apophysis:

  • Etiology: Disc herniation is less common in children than adults but can occur. Slipped apophysis is a separation of the vertebral ring apophysis.
  • Symptoms: Acute back pain, radicular pain, and recent-onset scoliosis.
  • Physical Findings: Positive SLR test, pain on spinal forward flexion.

• Spondylolysis, Spondylolisthesis, and Posterior Arch Lesions:

  • Etiology: Spondylolysis and spondylolisthesis as described in adults; posterior arch lesions are less common.
  • Symptoms: Acute-onset back pain with radicular pain.
  • Physical Findings: Hamstring tightness, positive SLR test, and pain on spinal extension.

• Vertebral Fracture:

  • Etiology: Trauma is the most frequent cause. Stress fractures can occur insidiously.
  • Symptoms: Acute back pain, potentially associated with other injuries in trauma. Stress fractures may present with progressive postural changes. Neurologic deficits may be present.

• Muscle Strain:

  • Etiology: Muscle overuse or minor injury.
  • Symptoms: Acute back pain typically associated with muscle tenderness without radiation.

• Scheuermann’s Kyphosis:

  • Etiology: Structural kyphosis developing during adolescence.
  • Symptoms: Chronic back pain associated with rigid kyphosis.

• Inflammatory Spondyloarthropathies:

  • Etiology: Juvenile idiopathic arthritis and related conditions.
  • Symptoms: Chronic pain, morning stiffness lasting greater than 30 minutes, and sacroiliac joint tenderness.

• Psychological Disorders (Conversion Disorder, Somatization Disorder):

  • Etiology: Psychological distress manifesting as physical symptoms.
  • Symptoms: Persistent subjective pain with normal physical findings.

• Idiopathic Scoliosis:

  • Etiology: Scoliosis of unknown cause, most common type.
  • Symptoms: Most commonly asymptomatic, positive Adam test. Back pain may be present but often due to another coexisting condition.⁵⁸

Prognosis of Back Pain

The prognosis for back pain is significantly influenced by its underlying etiology. In adults, the majority of nonspecific back pain cases resolve without long-term complications. The effectiveness of conservative management and patient education underscores the subjective nature of pain and its frequent association with stress and psychosocial factors. However, in a subset of patients with nonspecific back pain, factors such as previous back pain episodes, greater symptom intensity, depression, fear-avoidance behaviors, and radiating leg or widespread pain are associated with a higher risk of developing chronic and disabling back pain.⁵⁹

Social determinants play a critical role in back pain prognosis.⁶⁰ Factors such as low educational attainment, physically demanding occupations, inadequate compensation, and poor job satisfaction are linked to poorer outcomes, including increased disability rates.⁶¹,⁶² Lifestyle factors also contribute; a body mass index (BMI) over 25 and smoking are associated with persistent back pain.⁶³

Prognostic studies in pediatric back pain are less extensive than in adults, but etiology remains a key determinant of outcome.⁶⁴ For example, back pain caused by malignancy carries a higher risk of disability compared to muscle strain.⁶⁵ Some studies suggest that nonspecific back pain in younger individuals is exacerbated by behavioral comorbidities.⁶⁶ Conduct problems, attention deficit hyperactivity disorder (ADHD), passive coping mechanisms, and fear-avoidance behaviors have been identified as negative prognostic factors in pediatric back pain.⁶⁷,⁶⁸

Complications of Back Pain

The potential complications of back pain are largely determined by its underlying etiology. Complications can be both physical and social. Physically, back pain can become chronic, leading to persistent pain, deformity, and neurological deficits. Socially, back pain can result in disability, reduced economic productivity, and increased absenteeism from work and school. A 2015 global burden of disease study reported that back pain accounted for 60.1 million years of disability worldwide, making it the leading cause of disability globally.⁶⁹ In the United States, low back pain is the most common reason for disability claims.⁷⁰

Early and effective management of back pain, guided by accurate differential diagnosis, is crucial to prevent chronicity and minimize complications. Promoting early ambulation and physical activity, while addressing modifiable risk factors like obesity, can improve outcomes and prognosis.

Postoperative and Rehabilitation Care for Back Pain

Rehabilitation strategies for back pain are tailored to the underlying cause, patient comorbidities, and individual health goals. The McKenzie method, focusing on mechanical diagnosis and therapy, is often cited as beneficial, especially for chronic nonspecific low back pain.⁷¹ Clinical practice guidelines for physical therapy recommend a multifaceted approach, including manual therapy, trunk strengthening exercises, centralization techniques, directional preference exercises, and progressive endurance training for rehabilitation.⁷² Occupational therapy plays a vital role in assisting patients with activities of daily living and recommending adaptive equipment to enhance function and reduce pain. Ergonomic assessments and assistive devices during patient transfers are important in healthcare settings to reduce low back pain incidence among healthcare workers.⁷³

Deterrence and Patient Education for Back Pain

Patient education is paramount in preventing back pain recurrence and aggravation. Educational strategies must be individualized, considering personal risk factors and lifestyle. Individuals in sedentary occupations should be encouraged to maintain physical activity to achieve and maintain a healthy body weight, as BMI over 25 is a significant risk factor. Those in physically demanding occupations should receive guidance on proper lifting techniques, load lightening, and avoiding repetitive back twisting and heavy lifting.

All patients should be strongly advised to avoid smoking, a known risk factor for back pain across all age groups.⁷⁴,⁷⁵ Intensive patient education programs, approximately 2.5 hours in duration, focusing on activity modification, maintaining activity levels, and early return to normal routines, have proven effective in facilitating return to work for adults with back pain.⁷⁶

In pediatric populations, while the direct link between bookbag weight and back pain is debated, the American Academy of Pediatrics recommends that bookbags should not exceed 10% to 20% of a child’s body weight as a general guideline.⁷⁷

It is essential to communicate to all patients that while most episodes of back pain are self-limited, they should seek immediate medical attention if they experience concerning symptoms, such as sudden onset of sensory or motor weakness, or red flag symptoms identified earlier in this guide.

Pearls and Key Considerations in Back Pain Management

Key practice points to remember in the management and differential diagnosis of back pain:

For Adults:

• Early imaging is generally not indicated in acute low back pain without red flags. ⁷⁸
• First-line pharmacological treatment for acute low back pain includes NSAIDs. Acetaminophen is less effective for acute low back pain. ⁷⁹,⁸⁰
• Muscle relaxants may provide short-term relief for acute low back pain. ⁸¹
• Antidepressants are not routinely recommended for acute low back pain. ⁸²
• The McKenzie method can be effective in identifying directional preference and centralization, guiding treatment. ⁸³,⁸⁴,⁸⁵

For Children:

• Children with transient back pain and a history of minor injury without significant physical findings can be managed conservatively without extensive evaluation.
• Abnormal physical findings, constant pain, nighttime pain, or radicular pain necessitate further evaluation to refine the differential diagnosis. ⁸⁶
• Plain APL radiographs are recommended as the initial radiographic study in children with persistent back pain or red flags.
• Consider laboratory tests in the presence of clinical red flags, especially when infection or malignancy is suspected. Thoracic malignancy and infection are relatively more common in children than adults, particularly in those younger than 4 years. ⁸⁷

Enhancing Healthcare Team Outcomes in Back Pain Management

Effective management of back pain, informed by a comprehensive differential diagnosis, necessitates a collaborative, interprofessional healthcare team. This team optimally includes primary care providers, nurses, pharmacists, nutritionists, physical therapists, occupational therapists, radiologists, and medical specialists relevant to the specific case.

The primary care provider serves as the initial point of contact and orchestrator of care. Evaluation begins with a thorough history and physical examination, guiding initial treatment decisions and determining the need for further diagnostic testing and specialist referrals. Patient education, particularly emphasizing smoking cessation and weight management, is a critical role of the primary care provider. ⁸⁸

Nurses reinforce patient education, clarify follow-up instructions, and address patient queries regarding nonpharmacological therapies and the importance of continued physical activity in back pain management. Ensuring clinical stability prior to discharge and coordinating care plans are essential nursing responsibilities.

Pharmacists contribute by educating patients on prescribed medications, clarifying benefits, risks, and proper administration, and highlighting potential overdose risks. Pharmacists should proactively communicate with prescribers to resolve any prescription ambiguities.

Nutritionists and obesity medicine specialists address the impact of obesity on back pain. They provide dietary guidance and, when appropriate, manage obesity through lifestyle modifications and pharmacotherapy to facilitate weight loss and improve back pain outcomes. ⁸⁹

Physical therapists design and supervise exercise programs tailored to manage back pain and prevent recurrence. Physical therapy is effective in reducing opioid dependence in back pain management. Occupational therapists provide ergonomic assessments and recommend assistive devices to optimize function in work and home environments.

Radiologists play a key role in interpreting imaging findings and advising on further imaging as needed, contributing to accurate differential diagnosis.

Specialist referrals may include pain specialists for chronic pain management, rheumatologists for inflammatory conditions, neurosurgeons for severe radiculopathy or progressive neurological deficits, and mental health therapists for addressing psychosocial aspects of chronic pain and implementing cognitive behavioral therapy. ⁹⁰ Alternative medicine practitioners may also contribute to improving patient function and pain management.

Effective interprofessional communication is crucial to avoid duplicative testing and conflicting treatments, ensuring a cohesive and patient-centered approach to back pain management.

Figure. Multiple Myeloma Involving the Spine.

This lateral lumbar spine x-ray demonstrates lytic lesions within the L1 and L4 vertebral bodies, indicative of multiple myeloma.

References

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Disclosure: Vincent Casiano declares no relevant financial relationships with ineligible companies.

Disclosure: Gurpreet Sarwan declares no relevant financial relationships with ineligible companies.

Disclosure: Alexander Dydyk declares no relevant financial relationships with ineligible companies.

Disclosure: Matthew Varacallo declares no relevant financial relationships with ineligible companies.