High Priority Low Back Pain Questions

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A 68-year-old woman you last saw 9 months ago for a routine physical exam comes to see you complaining of low back pain that began about 1 week ago. She denies suffering any trauma to her back but reports that several weeks ago she felt a slight “tinge” when she lifted one of her bags while on vacation with her husband. Her only other current health problem is well-controlled hypertension. She does have a history of breast cancer 9 years ago, but she was successfully treated with chemotherapy.

Your physical exam reveals no abnormalities other than the patient complaining of a mild increase in pain when walking and bending over.

1. Based on the history and the exam, you should:

A.  Order a plain X-ray film of the lower back.

B.  Order an MRI of the back.

C.  Order a CT scan of the back.

D. Wait a few more weeks before ordering any further testing.

E. Refer the patient to a spine surgeon for evaluation.

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Answer: D. Wait a few more weeks before ordering any further testing.

As with younger patients, in the absence of radiation of the pain into the legs or other “red flags,” it appears nothing is to be gained in patients 65 years and older by proceeding with testing before waiting 4 to 6 weeks after the onset of pain.

A recent study found that there is no difference in outcome after 1 year in patients who underwent testing shortly after the pain began compared with those for whom the testing was delayed.

2.  You would consider more immediate radiologic examination to be indicated if the patient reported which of the following:

A. A history of unexplained recent weight loss.

B. She has had similar back pain a number of times over the past 20 years.

C. The pain is exacerbated by lying down, and the past few nights she has had to sleep sitting up in a chair.

D.  All of the above

E. A and C

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Answer: E. A and C

Unexplained weight loss and back pain exacerbated by lying down both are red flags that warrant immediate work-up. Both are suggestive of serious etiologies, most notably cancer. Most patients with mechanical low back pain report that lying down reduces the pain or has no effect on it. In contrast, an extended past history of similar pain reduces the likelihood of a serious new problem being the cause of the current pain.

3.  The patient says she has heard that epidural steroid injections are an excellent treatment for low back pain and asks if you would consider referring her for them. You respond:

A.  These are first-line treatment for this type of pain, and I will refer you.

B.  At best, these usually provide brief and limited benefits.

C.  Because of your age, they are contraindicated.

D.  They are contraindicated because of your history of breast cancer.

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Answer: B. At best, these usually provide brief and limited benefits.

Studies have found little evidence that supports the use of epidural steroid injections for low back pain, even in the presence of radicular pain.

References:

Chou R, Hashimoto R, Friedly J, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med. 2015 Sep;163:373-381.

Jarvik JG, Gold LS, Comstock BA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015;313:1143-1153.