Orthopedics - Back Pain

Back Pain

Diagnosis/Definition

A condition of pain in the lower (lumbar-sacral) back region, with or without radiation of symptoms to the buttocks or lower extremities, in the non-pregnant patient.

Initial Diagnosis and management

• Elicitation of history and performance of physical examination.  Special attention to presence or absence of "red flags" to include: age <18 or >55; history of malignancy, steroid use, or HIV positivity; weight loss or constitutional symptoms; structural deformity; anal or urethral sphincter disturbance; saddle anesthesia; gait disturbance; or widespread neurologic deficit.

• If red flags are present, diagnostic testing may include plain radiographs; CBC; ESR; bone scan; CT scan and/or MRI scan and electrodiagnosis as indicated.

• If red flags are absent a diagnostic workup is generally not necessary.

• Initial treatment for the first 2 weeks consists of: reassurance that most episodes resolve uneventfully within 6 weeks; encouragement to maintain as close to normal activity as is tolerable; avoidance of bed rest greater than 24 hours; NSAIDS (unless contraindicated); muscle relaxants for up to one week; acetaminophen as needed; weak opiates (codeine; propoxyphene) unless contraindicated; passive modalities (e.g. ice, heat) for symptomatic relief, profiling for active duty personnel or duty limitations.

Ongoing management and objectives

If pain has not improved in 2 weeks: re-evaluate for "red flags", change NSAID, and consider referral to Physical Therapy for evaluation and treatment while continuing to follow patient.

Indication a profile is needed

• Any limitations that affect strength, range of motion, and general efficiency of feet, legs, lower back and pelvic girdle.
• Slightly limited mobility of joints, muscular weakness, or other musculo-skeletal defects that may prevent hand-to-hand fighting and disqualifies for prolonged effort.
• Defects or impairments that require significant restriction of use

Specifications for the profile

• Weeks 1-2
  • Run at own pace and distance
  • No marching greater than 2 miles
  • No sit ups
  • No ruck sacks
  • No lifting greater than 15lbs
  • No repetitive bending
• Weeks 2-4
  • Gradually return to normal activity

Patient/Soldier Education or Self care Information

• See attached sheet
• Demonstrate deficits that exist
  • Describe/show soldier his/her limitations
• Explain injury and treatment methods
  • Use diagram attached to describe injury, location and treatment.
• Instruct and demonstrate rehab techniques
  • Demonstrate rehab exercises as shown in attached guide
  • Warm up before any sports activity
  • Participate in a conditioning program to build muscle strength
  • Do stretching exercises daily
• Ask the patient to demonstrate newly learned techniques and repeat any other instructions.
• Fine tune patient technique
• Correct any incorrect ROM/stretching demonstrations or instructions by repeating and demonstrating information or exercise correctly.
• Encourage questions
  • Ask soldier if he or she has any questions
• Give supplements such as handouts
• Schedule follow up visit with primary care
  • If pain persists or worsens
  • The pain does not improve as expected
  • Patient is having difficulty after three days of injury
  • Increased pain or swelling after the first three days
  • Patient has any questions regarding care

Indications for referral to specialty care

• Focal neurologic signs with abnormal imaging studies (urgent consult if worsening) - Orthopedics Spine referral with xrays done.  Consider MRI prior to referral (without contrast unless tumor suspected).

• Focal neurologic signs with normal imaging studies (urgent if worsening) Orthopedic Spine referral.

• Incapacitating radiculopathy unresponsive to therapy - Orthopedic referral.  MRI of lumbar spine prior to referral (without contrast usually).

• Abnormal plain radiographs associated with red flags - Orthopedics Spine referral.  MRI of lumbar spine prior to referral (without contrast usually).

• Loss of bladder or bowel control - (urgent) Neurosurgery referral.

• Extra-spinal conditions such as, Urologic, GI, Gynecologic, Vascular, Neurologic, Rheumatologic, or Systemic - referral to subspecialty appropriate to affected organ system.

• If pain has not improved within 6 weeks, refer to Physical Medicine and Rehabilitation for evaluation and management.

Referral criteria for return to Primary Care

• Resolution of symptoms; or, implementation of continuing treatment program that can be managed in primary care portal with periodic subspecialty follow-up.

• Persistence of back pain without true radicular symptoms > 6 months – consider permanent profiling addressing such as lifting limitations and sit-up limitations.

• MEB referral goes to TAMC Orthopedic MEB and Peblo MED regarding mechanical back pain.

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