Low Back Pain Prevalence

Low back pain (LBP) is the fifth most common reason for all doctor visits. In the U.S., lifetime prevalence of LBP is 60% to 80%. The direct and indirect costs for treatment of LBP are estimated to be $100 billion annually. Fortunately, most LBP resolves in two to four weeks.

Dr. Lee continues: “There are many causes for LBP. For presenting symptoms that have a broad differential diagnosis, I find it helpful to think of systems of etiologies in which diseases or conditions can be categorized.”

TEACHING POINT

Common Causes of Back Pain

Musculoskeletal (MSK) and Non-MSK Causes of Back Pain

MSK Causes

Axial:

• Degenerative disc disease
• Facet arthritis
• Sacroiliitis
• Ankylosing spondylitis
• Discitis
• Paraspinal muscular issues
• SI dysfunction

Radicular:

• Disc prolapse
• Spinal stenosis

Trauma:

• Lumbar strain
• Compression fracture

Non-MSK Causes

Neoplastic:

• Lymphoma/leukemia
• Metastatic disease
• Multiple myeloma
• Osteosarcoma

Inflammatory:

• Rheumatoid Arthritis

Visceral:

• Endometriosis
• Prostatitis
• Renal lithiasis

Infection:

• Discitis
• Herpes zoster
• Osteomyelitis
• Pyelonephritis
• Spinal or epidural abscess

Vascular:

• Aortic aneurysm

Endocrine:

• Hyperparathyroidism
• Osteomalacia
• Osteoporosis
• Paget disease

Dr. Lee suggests, “Now, let’s look a bit more at the risk factors for mechanical low back pain that you can review with Mr. Payne during your history.”

Dr. Lee continues, “The major task in treating back pain is to Now that you have a diagnosis of disc herniation with radiculopathy for Mr. Payne, let’s discuss what would you like to do for him distinguish the common causes for back pain (95% of cases) from the 5% with serious underlying diseases or neurologic impairments that are potentially treatable.”

TEACHING POINT

Risk Factors for Low Back Pain

• Prolonged sitting, with truck driving having the highest rate of LBP, followed by desk jobs
• Deconditioning
• Sub-optimal lifting and carrying habits
• Repetitive bending and lifting
• Spondylolysis, disc-space narrowing, spinal instability, and spina bifida occulta
• Obesity
• Education status: low education is associated with prolonged illness
• Psycho-social factors: anxiety, depression stressors in life
• Occupation: Job dissatisfaction, increased manual demands, and compensation claims

TEACHING POINT

Red Flags For Serious Illness or Neurologic Impairment with Back Pain

• Fever
• Unexplained weight loss
• Pain at night
• Bowel or bladder incontinence
• Neurologic symptoms
• Saddle anesthesia

HISTORY

You and Dr. Lee take a few minutes to review Mr. Payne’s chart:

Vital signs:

• Temperature: 98.6° Fahrenheit
• Heart rate: 80 beats/minute
• Respiratory rate: 12 breaths/minute
• Blood pressure: 130/82 mmHg
• Weight: 170 pounds
• Body Mass Index: 24 kg/m2

Past Medical History: Diabetes, well controlled. Hypertension, fair control. Hyperlipidemia, fair control.

Past Surgical History: None

Social History: Works as a truck driver, which involves lifting 20-35 lbs 4 hours of the day, married with 2 daughters,

Habits: Quit smoking two years ago, drinks 1 to 2 beers occasionally on the weekends, no history of IV drug use.

Medication:

• metformin 500mg 2 twice daily
• glyburide 5mg 2 twice daily
• amlodipine 2.5 mg daily
• lisinopril 40 mg daily
• simavastin 40 mg daily

Allergies: No known drug allergies

After introducing yourself to Mr. Payne, you sit down across from him and begin your history, focusing on the key elements.

“Can you tell me about your back pain?”