Back Pain is one of the most common causes for patients to seek medical care.
90 % of back pain is mechanical pain, Also called nociceptive pain.
10 % is neuropathic pain also called radiculopathy.
First step of diagnosis is differentiate between two of them.
Second and most important is to identify red flags to exclude malignancies or other serious conditions.
Most important red flags include:
weakness, bowel or bladder incontinence, or pain that awakens patients from sleep in both children and adults. Focal tenderness to palpation, Progressive motor or sensory loss. tenderness to palpation over spinous processes.
Mechanical pain: Is most common and is due to injury to the spine, intervertebral discs or soft tissues.
Lumbago is common mechanical pain, often is labeled as Low back pain, acute back pain or a strain to either the quadratus lumborum muscle or the paraspinal muscles. So back muscle strain is lumbago. And common cause of back pain.
lumbosacral muscle strains/sprains follows traumatic incident or repetitive overuse, pain worse with movement, better with rest, restricted range of motion, tenderness to palpation of muscles.




Another common cause is disc herniation, and its also traumatic back pain.
usually involves the L4 to S1 segments, may include paresthesia, sensory change, loss of strength or reflexes depending on severity and nerve root involved.
A straight leg raise test can be done to identify possible lumbar disk herniation.
Patient is lying straight, 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.


Pregnancy causes also mechanical back pain.


Lumbar Spondylosis - Patient typically is greater then 40 years old. Pain can radiate to hips. Pain with extension or rotation. Neurological exam is normal.

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, patient has history of metastatic cancer, unexplained weight loss, focal tenderness to palpation in the setting of risk factors. 97% of spinal tumors are metastatic diseases; however, the provider should keep multiple myeloma in the differential.
Infection: 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.
Fracture. Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years, Contusions, abrasions, tenderness to palpation over spinous processes.


Treatment:
Treatment is depends underlying cause.
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.
For non-radicular acute or subacute low back pain, NSAIDs, heat, and muscle relaxants have moderate evidence for positive gain. Massage has weak evidence that leans toward being advantageous.
For non-radicular chronic low back pain, there is moderate evidence to support physical therapy.
Acupuncture also has moderate-strength evidence to support its benefit in this population. Tai chi, yoga, psychological techniques (such as biofeedback and progressive relaxation),
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