Special Operations Forces Medical Handbook

3-6

Symptom: Back Pain, Low

CDR Scott Flinn, MC, USN

Introduction: Low back pain is an extremely common afiction. Most low back pain results from strain or
mechanical stress, is self-limited and resolves in 4-6 weeks. Identication of worrisome signs or symptoms
(e.g., pain over 6-8 weeks, night pain, weight loss, neurological injury including loss of bowel and bladder
control) will determine which patients require additional testing or treatment. Evaluate trauma causing low
back pain for the presence of a fracture. Immobilize properly if possible. Although very common in adults, low
back pain is unusual in children and adolescents and warrants investigation.

Subjective: Symptoms
Constitutional: Worrisome symptoms include persistent fever, night pain, weight loss and progressive
neurological symptoms such as progressing weakness or saddle anesthesia. Loss of bowel or bladder control
in a non-trauma patient suggests cauda equina syndrome, a rare condition that is a surgical emergency to
prevent chronic neurologic damage.
Location: Low back pain may be midline, one-sided, radiate into the hip or buttock. Numbness or tingling
radiating past the knee, and/or lower extremity weakness suggests a herniated disc pushing on a nerve.
Focused History: Was there any trauma? (suspect a fracture). Are there neurological symptoms such
as numbness, tingling or weakness? (if acute from trauma, suspect fracture, otherwise suspect a nerve
impingement from a herniated disc or other cause). Are there warning signs that pain is due to a serious
condition? (night pain and unexplained weight loss of a large amount [e.g., 20 pounds] suggest a cancerous
cause) Is the pain chronic? (if greater than 2-3 months in duration, may need evaluation for worrisome
cause like herniated disc, tumor) Is there a persistent fever (greater than 2 weeks) and fatigue or malaise?
(suggests infection or other cause)

Objective: Signs
Using Basic Tools: Acute traumatic low back pain – screen for signs of fracture.
Inspection: Obvious deformities –acute trauma (think fracture) or chronic pain (look for scoliosis). Any mass

• tumor. Skin erythema – infection or tumor.
  Palpation: Step-off on spinous processes –sign of fracture. Palpable spasm—sign of trauma. Palpable
  mass--tumor. Abnormal neuro exam including motor function (extensor hallucis longus [great toe pulled up],
  peroneals [feet held up and out/inverted], and quadriceps extension), sensation (rst metatarsal to anus), or
  deep tendon reexes (Achilles and patellar tendon) indicates a possible CNS lesion or trauma. If there is loss
  of sensation in the anal area, check the anal sphincter tone. Loss of sphincter tone and sensation about the
  anus suggests neurologic damage to the sacral nerves, such as in cauda equina syndrome or serious damage
  to the spinal cord. Unless other red ags are present, initial evaluation of low back pain does not require
  X-rays. Manual muscle test scale is 0-5 with 0 being absent and 5 normal. Deep tendon reexes are 0-4
  scale, with 0 being absent, 2 normal, and 4 being hyperactive with clonus.

Assessment:
Differential Diagnosis
The differential diagnosis of low back pain is extensive and includes mechanical low back pain, sciatica,
herniated disc with or without nerve impingement, spondylolysis with or without spondylolisthesis, scoliosis,
sacroiliac joint dysfunction, infection, ankylosing spondylitis, spinal stenosis, abdominal aortic aneurysm
in elderly patients, various benign and malignant tumors, fracture, and cauda equina syndrome. See
Symptom: Joint Pain and other related topics in this book. Urological conditions such as stone disease and
pyelonephritis may present as back pain (see GU chapter). Other problems may be referred to the back from
the abdomen, including labor (see Symptom: OB Problems) and pancreatitis (see GI: Pancreatitis).

Plan:
Treatment
Primary: Usual treatment of mechanical low back pain includes ice, anti-inammatories such as ibuprofen