A thorough history and physical exam are critical in the evaluation of the patient with back pain in both adult and pediatric populations.

The historical characteristics of the pain that require elucidation are very similar for the two populations. The mechanism of injury is often a valuable clue in diagnosis. The intensity and the quality of pain or whether the pain radiates helps narrow the differential. The alleviating and provoking factors of back pain can provide insight. Furthermore, previous treatments are all critical for gathering a thorough history of present illness. It may also be helpful to assess the impact on the patients daily living the pain has caused, such as work/school absenteeism, as useful clues for functional impairment. Past medical and family history (including the history of cancers or inflammatory conditions) and social history (including periods of injection drug use, exercise regimens, periods of exposure to tuberculosis) can also change the most likely working diagnosis. The character of the pain can help differentiate neuropathic pain from nociceptive pain, while the duration of pain helps establish the acute or chronic nature of the pain. Chronic pain is often centralized and has a specific set of signs and symptoms that include allodynia and hyperalgesia. The mechanism of the backs elucidates the likelihood of a herniated disc or acute muscle spasm. The location of the pain may help to decipher between a compression fracture, SI joint injury, and degenerative arthritic changes. Exacerbating and relieving factors such as positional changes to pain severity, as well, the effectiveness of various medications can also help narrow the differential diagnosis. Radiation of pain is a useful tool to help assess for radicular symptoms. The severity of pain also helps the provider clue in on the effect the illness or injury may have on the patient's quality of life. Furthermore, associated symptoms such as weakness, sensation changes, difficulty with ambulation, bowel or bladder changes, fever, chills, unexplained weight loss, and pain awakening the patient from sleep are all useful questions to rule out for severe pathology. 

The physical exam is also performed similarly between the age groups as long as the patient is old enough to communicate and participate in the review. The physical exam should include inspection, palpation, the range of motion, strength testing, provocative maneuvers, and neurologic (limb strength, sensation, and deep tendon reflex) assessments. Several provocative exercises help demonstrate or decrease suspicion of different processes.

A straight leg raise (SLR) can be complete by raising the patient’s leg to 30 to 70 degrees. Ipsilateral leg pain at less than 60 degrees is a positive test for lumbar disk herniation. The likelihood ratio (LR) of a straight leg raise is 2, with ave likelihood ratio (NLR) of 0.5. If the pain reproduction occurs contralaterally, it is a positive test for a lumbar disk herniation with LR of 3.5 and NLR of 0.72.[9][10][9]

One leg hyperextension test/stork test: Have the patient stand on one leg and (while being supported by the provider) have them hyper-extend their back. Repeat this maneuver on both sides. Pain with hyperextension is positive for a pars interarticularis defect.[11]

Adam test: Have the patient bend over with feet together and arms extended with palms together. The practitioner should observe from the front. If a thoracic lump is present on one side or the other, it is an indication of scoliosis.[11]

There are numerous other examination techniques; however, they have mixed evidence for inter-practitioner reliability and poor sensitivities or specificities.

Red flags on history or physical exam feature that, when present, should raise the provider’s suspicion for a process that may require imaging for proper diagnosis. These differ slightly from adults to children based on the incidence of diseases in these age groups:

Adults[5][12][13][9]:

• Cauda equina syndrome:
  • History: Progressive motor/sensory loss, new urinary retention or incontinence, new fecal incontinence
  • Physical exam: Saddle anesthesia, anal sphincter atony, significant motor deficits of multiple myotomes
• Fracture:
  • History: Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years
  • Physical exam: Contusions, abrasions, tenderness to palpation over spinous processes
• Infection:
  • History: Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery
  • Physical exam: Fever, wound in the spinal region, localized pain, and tenderness.
• Malignancy:
  • History: History of metastatic cancer, unexplained weight loss
  • Physical exam: Focal tenderness to palpation in the setting of risk factors

Pediatric red flags are the same as adults with a few notable differences[14][15]:

• Malignancy:
  • History: age less than four years, nighttime pain
• Infectious:
  • History: age less than four years, nighttime pain, history of tuberculosis exposure
• Inflammatory:
  • History: age less than four years, morning stiffness for greater than 30min, improving with activity or hot showers
• Fracture:
  • History: activities with repetitive lumber hyperextension (sports such as cheerleading, gymnastics, wrestling, or football linemen)
  • Physical exam: Tenderness to palpation over spinous process, positive Stork test

While typically, history and physical exams are sufficient for evaluation of back pain, the presence of red flags, or pain that may require further investigation. Early imaging in the adult population correlates with worse outcomes and more invasive treatments without a corresponding improvement in outcomes.[16][17] Imaging for adults should part of the management of symptoms that last longer than six weeks with appropriate conservative management.[16] Protracted pain in children should have imaging; however, the definition of protracted has not been as clearly defined as it is in adults.

Anteroposterior and lateral plain films should be sufficient to evaluate for boney pathology. In contrast, magnetic resonance imaging (MRI) may be necessary to evaluate for soft tissue lesions, nerve root/cord compression from a bulging disc, malignancy, and inflammatory conditions of the spine and surrounding tissues.[18][19] Bone scans may demonstrate osteomyelitis, discitis, and stress reactions, but remains inferior to MRI to evaluate these conditions.[20] In adolescents with MRI evidence of herniated disc, one may consider computed tomogram (CT) to confirm or rule out apophyseal ring separation as this occurs in 5.7% of these patients.[21] For complex cases, such as patients with a history of previous spinal surgery, EMG or nerve conduction studies are needed to help aid in the diagnosis of possible radiculopathy or plexopathy. Empirical treatment with a diagnostic injection is also used in cases of suspected SI joint injury. 

In addition to imaging, one may consider laboratory evaluation if red flags are present. Rheumatologic assays such as HLA-B27, antinuclear antibody (ANA), rheumatoid factor (RF), and Lyme are typically not helpful. They are unspecific for back pain.[22][23][24] Inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can be a useful test. Seperately a complete blood count (CBC) and blood cultures may assist in the diagnosis of inflammatory, infectious, or malignant etiologies as well. The addition of lactate dehydrogenase (LDH) and uric acid may assist in diagnosing a condition with rapid marrow turnover such as leukemia.[25]

There are various treatments for pain based on etiology, age, and chronicity of the back pain. The best evidence in adult back pain according to the "Noninvasive treatments for low back pain: current state of the evidence" clinician summary published by the Agency for Healthcare Research and Quality in 2016:

In adults:

For radicular low back pain, nonpharmacologic interventions such as exercise, traction, and spinal manipulation have shown some benefits but have relatively weak levels of evidence to support it. Non-steroidal anti-inflammatory drugs (NSAIDs) have moderate evidence of benefit. However, other pharmacologic interventions, such as diazepam and systemic steroids, do not seem to provide benefits. [AHRQ,  2016].

For non-radicular acute or subacute low back pain, acetaminophen appears to have weak evidence of no benefit. However, NSAIDs, heat, and muscle relaxants have moderate evidence for positive gain. Massage has weak evidence that leans toward being advantageous.[AHRQ 2016]

For non-radicular chronic low back pain, there is moderate evidence to support physical therapy[AHRQ 2016], particularly utilizing the McKenzie method. [26],[27] Acupuncture also has moderate-strength evidence to support its benefit in this population. Tai chi, Yoga, psychological techniques (such as biofeedback and progressive relaxation), Spinal manipulation, and multidisciplinary rehab all have weak evidence that leans toward benefit.[AHRQ 2016],[28] Back schools also have some evidence of benefit.[29] As far as pharmacologic management of chronic low back pain, NSAIDs and duloxetine demonstrate ongoing benefit, while opioids only demonstrate short-term benefits. [AHRQ 2016] Gabapentin is a very commonly used anticonvulsant for chronic pain; however, it has not demonstrated a significant benefit for patients with chronic low back pain.[30]Topiramate is more effective than a placebo.[31] Topical anesthetics such as lidocaine patches and transcutaneous electrical nerve stimulation (TENS) units do not appear more effective than placebo.[32][33]

According to the American Pain Society, surgical referral should be reserved for patients with disabling low back pain impacting the quality of life for greater than one year.[34] However, there is mixed evidence, for some of the most commonly performed invasive procedures such as injection therapy of the epidural space, facet joints, or local sites, spinal fusion, or lumbar disk replacement.[34],[35],[36]

In children:

In pediatrics, treatments for pain are less well studied. However, activity modification, physical therapy, and NSAIDs have broad support as first-line therapies.[11] If there is an underlying malicious cause present, the treatment of those underlying disorders is the standard of care. A majority of spondylolysis may be managed conservatively as above, but some will need a referral for surgical intervention. Persistent symptoms after greater than six months of conservative therapy or Grade III or IV spondylolisthesis may be referred to a pediatric spine surgeon for further evaluation.[37],[38],[39],[40] In patients with Scheuermann's kyphosis, physical therapy and guided exercise may be sufficient for patients with less than 60 degrees curvature, bracing may be added for patients with curvature less than 70 degrees. Surgical correction may be indicated for the patient with greater than 75 degrees curvature, especially if they have failed conservative measures and are skeletally mature.[41][42] Scoliosis of 20 degrees or more during peak growth, significant scoliosis, progressive curvature, and atypical scoliosis are all indications for surgical referral.[43]

The differential diagnosis for back pain is comprehensive when considering the pediatric population. Below is a review of the more common diagnoses along with history or physical exam features that may increase your index of suspicion. This list is not comprehensive but represents the more likely and more concerning conditions that make up the differential.

Adults[44][3][45][46]

• Lumbosacral muscle strains/sprains
  • Presentation: follows traumatic incident or repetitive overuse, pain worse with movement, better with rest, restricted range of motion, tenderness to palpation of muscles
• Lumbar spondylosis
  • Presentation: patient typically is greater than 40years old, pain may be present or radiate from hips, pain with extension or rotation, the neurologic exam is usually normal
• Disk herniation
  • Presentation: usually involves the L4 to S1 segments, may include paresthesia, sensory change, loss of strength or reflexes depending on severity and nerve root involved
• Spondylolysis, Spondylolisthesis
  • Presentation: similar to pediatrics, spondylolisthesis may present back pain with radiation to the buttock and posterior thighs, neuro deficits are usually in the L5 distribution
• Vertebral compression fracture
  • Presentation: localized back pain worse with flexion, point tenderness on palpation, may be acute or occur insidiously over time, age, chronic steroid use, and osteoporosis are risk factors
• Spinal stenosis
  • Presentation: back pain, which can be accompanied by sensory loss or weakness in legs relieved with rest (neurologic claudication), neuro exam can be within normal limits or can have progressive loss of sensation, as well as weakness.
• Tumor
  • Presentation: a history of metastatic cancer, unexplained weight loss, focal tenderness to palpation in the setting of risk factors
  • Clinical note: 97% of spinal tumors are metastatic disease; however, the provider should keep multiple myeloma in the differential
• Infection: vertebral osteomyelitis, discitis, septic sacroiliitis, epidural abscess, paraspinal muscle abscess
  • Presentation: Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery, fever, wound in the spinal region, localized pain, and tenderness
  • Clinical note: Granulomatous disease may represent as high as one-third of cases in developing countries.
• Fracture
  • Presentation: Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years, Contusions, abrasions, tenderness to palpation over spinous processes

Pediatrics[47][48][49][50][51][52]:

• Tumor
  • Presentation: fever, malaise, weight loss, nighttime pain, recent onset scoliosis
  • Clinical note: Osteoid osteoma is the most common tumor that presents with back pain - classically, the pain is promptly relieved with anti-inflammatory drugs such as NSAIDs
• Infection: vertebral osteomyelitis, discitis, septic sacroiliitis, epidural abscess, paraspinal muscle abscess
  • Presentation: fever, malaise, weight loss, nighttime pain, recent onset scoliosis
  • Clinical notes: Epidural abscess should be a consideration with the presence of fever, spinal pain, and neurologic deficits or radicular pain; discitis may present with a patient refusing to walk or crawl
• A herniated disk, slipped apophysis
  • Presentation: Acute pain, radicular pain, positive straight leg raise test, pain with spinal forward flexion, recent onset scoliosis
• Spondylolysis, spondylolisthesis, lesion or injury to the posterior arch
  • Presentation: Acute pain, radicular pain, positive straight leg raise test, pain with spinal extension, tight hamstrings
• Vertebral fracture
  • Presentation: acute pain, other injuries, traumatic mechanism of injury, neurologic loss
• Muscle strain
  • Presentation: acute pain, muscle tenderness without radiation
• Scheuermann’s kyphosis
  • Presentation: chronic pain, rigid kyphosis
• Inflammatory spondyloarthropathies
  • Presentation: chronic pain, morning stiffness lasting greater than 30min, sacroiliac joint tenderness
• Psychological Disorder (conversion, somatization disorder)
  • Presentation: normal evaluation but persistent subjective pain
• Idiopathic Scoliosis:
  • Presentation: positive Adam’s test (for more significant angle curvature), most commonly asymptomatic
  • Clinical note: Of note, no definitive evidence that scoliosis causes pain, but patients with scoliosis have more frequently reported pain; therefore the provider should rule out other causes before attributing pain to scoliosis

Many factors seem to predict worse outcomes for patients who suffer from back pain. Prior episodes of back pain, greater intensity of back pain, and the presence of leg or widespread symptoms are all associated with worse “chronic disabling pain.” Lifestyle activities also seem to play a role, including patients having higher body mass indexes (greater than 25) and smoking contributing to worse outcomes. Depression, catastrophizing, and fear-avoidance behavior all worsen outcomes, including disability rates. There are also underlying social factors that have significant prognostic accuracy. These factors all have significant interplay, such as low educational attainment, having a job that requires significant physical workloads, poor compensation, and poor job satisfaction all negatively impact outcomes.[53][54][55][56][57]. Overall, the vast majority of back pain cases improve and do not leave a significant impact on a patient's quality of life or function. 

There is less clear prognostic evidence for pediatrics. However, one valid assumption is that the prognosis largely relies on the underlying etiology of the pain. The pain caused by cancer will likely have a different impact on disability than a muscle strain. Similarities exist in the pediatric population and adults, however. In regards to non-specific back pain, some studies lean toward increasing back pain with behavioral comorbidities. Conduct problems, attention deficit hyperactivity disorder (ADHD), and psychological distress, as well as passive coping strategies, and fear-avoidance behavior.[58][59][60][61][62]

Complications are largely determined based on underlying etiology; however, they can mostly subdivide into physical and social complications. Physically, complications can include cauda equina syndrome, chronic pain, and deformity (in excellent conditions). Socially, complications are usually measured by disability, decreased gross domestic product, and increased absenteeism. A study in 2015 found that back pain was responsible for 60.1 million years lived with disability worldwide. This data represents the most common cause of disability globally.[63] In the US, low back pain accounts for the most common reason for disability.[64] No one wants to miss a potential malignancy or severe nerve root compression that results in paralysis. These feared complications are what keep providers up at night. Due diligence and a high index of suspicion are what help negate these potential adverse outcomes. The global impact of back pain is hard to quantify. Stopping acute pain before it becomes chronic is the ounce of prevention, well worth a pound a cure. Sedentary activity leads to worsening obesity, which, in turn, causes more back pain. The easiest way to break this cycle is through active patient engagement and motivate patients to work towards recovery.

After review of the evidence, it would seem that the best patient education that can be provided to prevent back pain is to maintain healthy body weight with a body mass index (BMI) less than 25, as higher BMI correlates with worse outcomes.[53] Patients of all ages should avoid smoking as it increases rates of back pain in all ages.[65][66] Continuing to engage in physical activity as fear-avoidant behaviors worsen disability. There is strong evidence that intensive patient education lasting for 2.5 hrs discussing activity modification, staying active, and early return to normal activity is more effective for returning to work.[67] There is mixed evidence about whether bookbag weight plays a role in pediatric back pain [68][25]. Still, despite the unclear evidence, the American Academy of Pediatrics recommends that book bags do not exceed 10 to 20% of the child’s body weight.[AAP 2004]. Furthermore, it is never normal to have sensation changes, weakness, difficulty ambulating, pain awakening from sleep, or bowel or bladder incontinence associated with back pain. These are potential signs and symptoms of more serious injury and require urgent medical evaluation. Fortunately, the vast majority of cases of back pain are self-limited and improve over a few weeks. Furthermore, in cases of persistent back pain, following the acute period (six weeks), imaging may be indicated. Back pain unresponsive to initial conservative management may warrant evaluation by a specialist and may benefit from more invasive treatment modalities such as injections or surgery. 

There are practice pearls worth remembering in the evaluation and treatment of back pain.

For adults[69][70][71][72][73][74][75][76][77]:

• History and physical exam are sufficient for evaluation of non-traumatic, acute back pain in the absence of red flags - avoid imaging before six weeks in severe back pain in the absence of red flags.
• NSAIDs, opioids, and topiramate are more effective than placebo in the short-term treatment of nonspecific chronic low back pain.
• Acetaminophen, antidepressants (except duloxetine), lidocaine patches, and TENS are not consistently more effective than placebo in the treatment of chronic low back pain.
• Consider a physical therapy referral for McKenzie method techniques to reduce the risk of recurrence; intensive patient education that includes advice to stay active, avoid aggravating movements, and return to regular activity as soon as possible is effective in patients with nonspecific pain.

For children[78][62][79]:

• Children with back pain who have no significant physical findings, a short duration of pain, and a history of minor injury can be treated conservatively with no further evaluation.
• Children with back pain, either abnormal physical findings, constant pain, nighttime pain, or radicular pain, should receive further evaluation.
• Anterioposterior and plain lateral films are the first line radiographic studies.
• Consider laboratory evaluation to accompany your radiographs as malignancy and infection are higher on the differential diagnosis for pediatric patients over adults.
• Tumor and infection needs to be ruled out for back pain in children four years and younger

Back pain affects millions of people and is a leading cause of chronic pain and disability. It also leads to higher costs of healthcare. The first line assessment of back pain comes from the patient's primary care provider. They are essential in the evaluation and treatment of back pain. The help identifies red flags for urgent treatment and referral, help minimize unnecessary procedures or opioid prescriptions, and are critical in limiting the development of chronic pain.

The patient's who develop chronic pain may benefit from seeing a chronic pain specialist for both medication management and interventional procedures. Signs and symptoms of inflammatory arthritis of the lumbar spine should be further evaluated by a Rheumatologist. Either severe radiculopathy or rapid neurological changes should be evaluated by a neurosurgeon urgently. Management of comorbid depression is also paramount. Cognitive-behavioral therapists and or psychiatrists are needed to help co-manage patients with back pain with comorbid mental health disorders. The physical therapist should be involved early in the care and urge the patient to exercise regularly. The dietitian should encourage a healthy diet and body weight maintenance.

Furthermore, a nutritionist or obesity medicine specialist can help with weight loss and is both useful for both primary and secondary prevention of back pain. An acupuncturist, osteopathic manipulative medicine specialist, yoga, and ti chi instructors can also be instrumental in improving function in patients with both acute and chronic low back pain. The pharmacist plays an essential role in the care for complex patients with chronic pain; patients may be on multiple opioids and sedatives requiring frequent monitoring. Furthermore, radiologists aids in the diagnosis of various etiologies of back pain, including spinal stenosis and disc herniation.

Back pain, if not treated appropriately, can become chronic and debilitating over time. There is some debate as to the most appropriate treatment for back pain to maximize outcomes. Disease-oriented medicine, not holistic, has proven to have relatively weak outcomes regarding chronic back pain.  Approaching the treatment of pain from an interprofessional approach maximizes the chances of having better results. 

Nursing should assist the clinical team with educating the patient on non-narcotic pain medications and possibly on alternative means of pain control, including yoga, deep breathing, and acupuncture. Clinicians should refrain from empirically prescribing narcotics as they lead to addiction, tolerance, and abuse. In the rare instances when narcotics are specified, both the pharmacist and clinician should work together to avoid long-term prescriptions of controlled drugs.

Bearing in mind the clinical clues which provide worse prognostic outcomes such as underlying mental health disorders, kinesiophobia, obesity, and smoking, it is likely to be helpful to treat the whole patient with an interprofessional team. Screening for some of these comorbidities as a primary care provider may be of assistance if the patient is not responding to conservative therapy. The primary physician can also offer smoking cessation and other lifestyle management counseling to the patient. The interprofessional team should communicate with each other to prevent duplication of treatments and tests, and this also helps deliver the same message to the patient.

Outcomes

The addition of early physical therapy has shown benefit more rapid improvement of health care utilization and opioid use.[80] [Level I] The addition of a provider skilled in cognitive behavioral therapy may assist with patients with an underlying mood disorder that can contribute to symptoms as well as the development of coping skills.[81] [Level I] Interventions aimed at lowering the patient's weight may also provide significant back pain relief; however, the evidence is not as compelling.[82] [Level IV]