Back Pain


Article Author:
Vincent Casiano


Article Editor:
Nikhilesh De


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
2/24/2019 1:22:33 PM

Introduction

Back pain is one of the most common causes for patients to seek emergency care. It has a broad range of potential etiologies for both adult and pediatric populations. The etiologies differ depending on the patient population, but most commonly it is mechanical or non-specific in nature. Back pain causes significant rates of disability and can be a problem that persists from childhood into adulthood. It is essential to be able to evaluate patients of all ages and understand the unique differences in the presentation in these different populations. Knowing the common red flags of back pain in both children and adults can guide the provider to appropriate evaluation and treatment.

Etiology

Back pain is a broad topic with many potential etiologies that are broken mainly in four major categories[1]

  • Mechanical: which is caused by the spine, intervertebral discs, or soft tissues
  • Inflammatory: which is caused primarily due to inflammatory spondyloarthropathies
  • Oncologic: Which is caused by lytic lesions to the spine, cancers of the marrow, or nerve compressive phenomena from adjacent space occupying lesions
  • Infectious: Infections of the spine, discs, epidural abscesses, or muscular/soft tissue abscesses

It is important to note, however, that many non-back-related disorders may result in pain that patients perceive in the back such as biliary colic, pneumonia, and obstructive or infectious renal disease. Therefore, it is prudent not to exclude these processes from your differential diagnosis while evaluating the patient.

Epidemiology

Back pain is widespread in the adult population. Some studies have shown that up to 23% of the world’s adults suffer from chronic low back pain. This population has also shown a one-year recurrence rate of 24% to 80%.[2][3] Some estimates of lifetime prevalence are as high as 84% in the adult population.[4]

However, the prevalence is much less apparent in the pediatric literature. One Scandinavian study demonstrated that the point prevalence of back pain was approximately 1% for 12-year-olds and 5% for 15-year-olds, with a with a cumulative incidence increasing to 50% by age 18 for females and by age 20 for males.[5] An extensive systematic review demonstrated an annual rate of adolescents suffering from back pain of 11.8% to 33%.[6]

History and Physical

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 (if one is present), the intensity and the quality of pain, whether the pain radiates, what the alleviating and provoking factors for the pain are, and what treatments have been tried (and whether those treatments were effective) are all critical for the gathering a thorough history of present illness. It may also be helpful to assess what 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 physical exam is also performed similarly between the age groups as long as the patient is old enough to communicate and participate in the exam. 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 maneuvers are helpful for demonstrating or decreasing suspicion of different processes.

Straight leg raise (SLR): performed 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. Likelihood ratio (LR) of 2, negative likelihood ratio (NLR) of 0.5. If the pain reproduction occurs contralaterally, it is a positive test for lumbar disk herniation with LR of 3.5 and NLR of 0.72.[7]

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.[8]

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 for scoliosis.[8]

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

Red flag historic or physical exam features 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[3][9][10][7]:

  • 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 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[11][12]:

  • Malignancy:
    • History: age less than 4 years, nighttime pain
  • Infectious:
    • History: age less than 4 years, nighttime pain, history of tuberculosis exposure
  • Inflammatory:
    • History: age less than 4 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

Evaluation

While typically history and physical exam are sufficient for evaluation of back pain, the presence of red flags or pain that is protracted may require further investigation. Early imaging in the adult population correlates with worse outcomes and more invasive treatments without a commensurate improvement in outcomes.[13][14] Imaging for adults should be reserved for symptoms that last longer than six weeks with appropriate with appropriate conservative management.[13] 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, whereas 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.[15][16] Bone scans may demonstrate osteomyelitis, discitis and stress reactions, but remains inferior to MRI to evaluate these conditions.[17] In adolescents with MRI evidence of herniated disc, one may consider CT to confirm or rule out apophyseal ring separation as this occurs in 5.7% of these patients.[18]

In addition to imaging, one may consider laboratory evaluation if red flags are present. Rheumatologic assays such as HLA-B27, ANA, RF, and Lyme are typically not helpful in the evaluation due to their unspecificity.[19][20][21] Inflammatory markers such as CRP and ESR along with CBC and blood cultures may assist in the diagnosis of inflammatory, infectious, or malignant etiologies. The addition of LDH and Uric acid may assist in diagnosing a condition with rapid marrow turnover such as leukemia.[22]

Treatment / Management

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. NSAIDs has moderate evidence of benefit, however other pharmacologic interventions such as diazepam and systemic steroids do not seem to provide benefit. [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 benefit. Massage has weak evidence that leans toward benefit.[AHRQ 2016]

For non-radicular chronic low back pain, there is moderate evidence to support physical therapy[AHRQ 2016], particularly utilizing the McKenzie method. [23],[24] 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],[25] Back schools also have very weak evidence of benefit.[26] 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.[27]Topiramate, however, has been found to be more effective than placebo.[28] Topical anesthetics such as lidocaine patches and transcutaneous electrical nerve stimulation (TENS) units do not appear more effective than placebo.[29],[30]

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.[31] 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.[31],[32],[33]

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.[8] If there is an underlying malicious cause present, 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 6 months of conservative therapy or Grade III or IV spondylolisthesis may be referred to a pediatric spine surgeon for further evaluation.[34],[35],[36],[37] 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.[38],[39] Scoliosis of 20 degrees or more during peak growth, significant scoliosis, progressive curvature, and atypical scoliosis are all indications for surgical referral.[40]

Differential Diagnosis

The differential diagnosis for back pain is very broad, especially 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[41][1][42][43][41]:

  • 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, 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 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 with sensory loss or weakness in legs relieved with rest (neurologic claudication), neuro exam normal.
  • 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 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[11][44][45][46][47][48][49]:

  • 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
  • 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 larger 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 provider should rule out other causes before attributing pain to scoliosis

Prognosis

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.[50][51][52][53][54]

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 such as conduct problems, ADHD, and psychological distress, passive coping strategies, and fear-avoidance behavior.[55][56][57][58][59]

Complications

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 select 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 60.1million years lived with disability worldwide. This data represents the most common cause of disability globally.[60] In the US low back pain accounts for the most common reason for disability.[61]

Deterrence and Patient Education

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 BMI less than 25, as higher BMI correlates with worse outcomes.[50] Patients of all ages should avoid smoking, as increases rates of back pain in all ages.[62][63] Continuing to engage in physical activity as fear-avoidant behaviors worsen disability.[50][54] 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.[64] There is mixed evidence about whether book bag weight plays a role in pediatric back pain,[65][22] but 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]

Pearls and Other Issues

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

For Adults[12][10][66][14][67][68][69][70][71][29][72][23][24][73][74][64]:

  • 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 acute 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 normal activity as soon as possible is effective in patients with nonspecific pain

For Children[75][59][76][11][12]:

  • 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 lateral plain 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 4 years and younger

Enhancing Healthcare Team Outcomes

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. The confusion lies within the way studies have been framed in the past, by isolating the pain away from the other factors that make up the patient. Disease-oriented medicine, with treating back pain as a primarily isolated issue has proven to have relatively poor outcomes in regards to chronic back pain.  Approaching the treatment of pain from a multi-disciplinary approach maximizes your chances of having better outcomes.  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 a multi-disciplinary 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.

Addition of early physical therapy has shown benefit more rapid improvement of health care utilization and opioid use.[77] [Level I] 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.[78] [Level I] Interventions aimed at lowering the patient's weight may also provide significant back pain relief; however, the evidence is not as compelling.[79] [Level IV] 


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Back Pain - Questions

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A 17-year-old male has had non-radiating back pain for several months. He experiences relief from pain while working out with his high school track team. He has no fevers, weakness, paresthesias, weight loss, or history of trauma. Which of the following factors would be helpful in establishing the diagnosis?



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In patients with chronic low back pain, what is the prevalence of facet joint involvement?



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Which of the following is the LEAST appropriate recommendation for a patient with low back pain?



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MRI is warranted in which of the following individuals experiencing low back pain?



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A patient experiences low back pain after moving a stack of bricks four days previously. His physical exam is positive only for tenderness to palpation of the lower paraspinal muscles. Which of the following treatment options is indicated in this patient?



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Which of the following is not in the differential diagnosis for low back pain?



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Which of the following would not be in the differential for low back pain?



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What is seen with overstretching and pain in rhomboid muscles?



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A patient has pain in the L5-S1 area without radiculopathy. There is no tenderness or pain with range of motion of the area. Pathology at what other structure is possible?



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A patient who is 26 weeks pregnant is referred for low back pain to PT. Select the exercise that would not be appropriate?



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A 51-year-old patient complains of 3 weeks of low back pain. Which of the following is a risk factor for serious spine pathology?



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Which of the following is the most effective approach used to relieve upper back pain in a 37-year-old male who smokes two packs of cigarettes per day?



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What is an inappropriate management for acute lower back pain?



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A patient is suspected of having inflammation of the psoas muscle as a cause of low back pain. Which study would be of most help?



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Severe musculoskeletal low back pain can often be mistaken for what entity?



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A 25-year-old male comes into the clinic complaining of lower back pain for one week. He was helping a friend move one week ago and felt pain when lifting a piece of heavy furniture. The pain is aching in nature and has gradually become constant, hindering his performance at work as a delivery driver. The patient has tried to decrease the level of his physical activity at work and has tried ice packs, but has concerns about the pain still being present. The patient has not had any recent weight loss or fatigue. The patient denies any intravenous drug use. He otherwise has no complaints and takes no medication. On physical exam, there is tenderness in the left lumbar paraspinal region, with no vertebral point tenderness. Straight leg raise test is negative. What is the next best step in management for this patient?



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Back Pain - References

References

Patrick N,Emanski E,Knaub MA, Acute and chronic low back pain. The Medical clinics of North America. 2014 Jul     [PubMed]
Balagué F,Mannion AF,Pellisé F,Cedraschi C, Non-specific low back pain. Lancet (London, England). 2012 Feb 4     [PubMed]
Hoy D,Brooks P,Blyth F,Buchbinder R, The Epidemiology of low back pain. Best practice & research. Clinical rheumatology. 2010 Dec     [PubMed]
Walker BF, The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. Journal of spinal disorders. 2000 Jun     [PubMed]
Leboeuf-Yde C,Kyvik KO, At what age does low back pain become a common problem? A study of 29,424 individuals aged 12-41 years. Spine. 1998 Jan 15     [PubMed]
Jeffries LJ,Milanese SF,Grimmer-Somers KA, Epidemiology of adolescent spinal pain: a systematic overview of the research literature. Spine. 2007 Nov 1     [PubMed]
Deyo RA,Rainville J,Kent DL, What can the history and physical examination tell us about low back pain? JAMA. 1992 Aug 12     [PubMed]
Patel DR,Kinsella E, Evaluation and management of lower back pain in young athletes. Translational pediatrics. 2017 Jul     [PubMed]
Downie A,Williams CM,Henschke N,Hancock MJ,Ostelo RW,de Vet HC,Macaskill P,Irwig L,van Tulder MW,Koes BW,Maher CG, Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ (Clinical research ed.). 2013 Dec 11     [PubMed]
Casazza BA, Diagnosis and treatment of acute low back pain. American family physician. 2012 Feb 15     [PubMed]
Feldman DS,Hedden DM,Wright JG, The use of bone scan to investigate back pain in children and adolescents. Journal of pediatric orthopedics. 2000 Nov-Dec     [PubMed]
Hollingworth P, Back pain in children. British journal of rheumatology. 1996 Oct     [PubMed]
Patel ND,Broderick DF,Burns J,Deshmukh TK,Fries IB,Harvey HB,Holly L,Hunt CH,Jagadeesan BD,Kennedy TA,O'Toole JE,Perlmutter JS,Policeni B,Rosenow JM,Schroeder JW,Whitehead MT,Cornelius RS,Corey AS, ACR Appropriateness Criteria Low Back Pain. Journal of the American College of Radiology : JACR. 2016 Sep     [PubMed]
Jarvik JG,Hollingworth W,Martin B,Emerson SS,Gray DT,Overman S,Robinson D,Staiger T,Wessbecher F,Sullivan SD,Kreuter W,Deyo RA, Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003 Jun 4     [PubMed]
Miller R,Beck NA,Sampson NR,Zhu X,Flynn JM,Drummond D, Imaging modalities for low back pain in children: a review of spondyloysis and undiagnosed mechanical back pain. Journal of pediatric orthopedics. 2013 Apr-May     [PubMed]
Borchers AT,Gershwin ME, Transverse myelitis. Autoimmunity reviews. 2012 Jan     [PubMed]
Kujala UM,Kinnunen J,Helenius P,Orava S,Taavitsainen M,Karaharju E, Prolonged low-back pain in young athletes: a prospective case series study of findings and prognosis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 1999     [PubMed]
Wang H,Cheng J,Xiao H,Li C,Zhou Y, Adolescent lumbar disc herniation: experience from a large minimally invasive treatment centre for lumbar degenerative disease in Chongqing, China. Clinical neurology and neurosurgery. 2013 Aug     [PubMed]
Gran JT,Husby G, HLA-B27 and spondyloarthropathy: value for early diagnosis? Journal of medical genetics. 1995 Jul     [PubMed]
Reveille JD, HLA-B27 and the seronegative spondyloarthropathies. The American journal of the medical sciences. 1998 Oct     [PubMed]
McGhee JL,Burks FN,Sheckels JL,Jarvis JN, Identifying children with chronic arthritis based on chief complaints: absence of predictive value for musculoskeletal pain as an indicator of rheumatic disease in children. Pediatrics. 2002 Aug     [PubMed]
Ejaz AA,Pourafshar N,Mohandas R,Smallwood BA,Johnson RJ,Hsu JW, Uric acid and the prediction models of tumor lysis syndrome in AML. PloS one. 2015     [PubMed]
Rosedale R,Rastogi R,May S,Chesworth BM,Filice F,Willis S,Howard J,Naudie D,Robbins SM, Efficacy of exercise intervention as determined by the McKenzie System of Mechanical Diagnosis and Therapy for knee osteoarthritis: a randomized controlled trial. The Journal of orthopaedic and sports physical therapy. 2014 Mar     [PubMed]
Dunsford A,Kumar S,Clarke S, Integrating evidence into practice: use of McKenzie-based treatment for mechanical low back pain. Journal of multidisciplinary healthcare. 2011     [PubMed]
Kamper SJ,Apeldoorn AT,Chiarotto A,Smeets RJ,Ostelo RW,Guzman J,van Tulder MW, Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ (Clinical research ed.). 2015 Feb 18     [PubMed]
Straube S,Harden M,Schröder H,Arendacka B,Fan X,Moore RA,Friede T, Back schools for the treatment of chronic low back pain: possibility of benefit but no convincing evidence after 47 years of research-systematic review and meta-analysis. Pain. 2016 Oct     [PubMed]
Shanthanna H,Gilron I,Rajarathinam M,AlAmri R,Kamath S,Thabane L,Devereaux PJ,Bhandari M, Benefits and safety of gabapentinoids in chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PLoS medicine. 2017 Aug     [PubMed]
Muehlbacher M,Nickel MK,Kettler C,Tritt K,Lahmann C,Leiberich PK,Nickel C,Krawczyk J,Mitterlehner FO,Rother WK,Loew TH,Kaplan P, Topiramate in treatment of patients with chronic low back pain: a randomized, double-blind, placebo-controlled study. The Clinical journal of pain. 2006 Jul-Aug     [PubMed]
Franke H,Franke JD,Fryer G, Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. BMC musculoskeletal disorders. 2014 Aug 30     [PubMed]
Buchmuller A,Navez M,Milletre-Bernardin M,Pouplin S,Presles E,Lantéri-Minet M,Tardy B,Laurent B,Camdessanché JP, Value of TENS for relief of chronic low back pain with or without radicular pain. European journal of pain (London, England). 2012 May     [PubMed]
Chou R,Loeser JD,Owens DK,Rosenquist RW,Atlas SJ,Baisden J,Carragee EJ,Grabois M,Murphy DR,Resnick DK,Stanos SP,Shaffer WO,Wall EM, Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine. 2009 May 1     [PubMed]
Staal JB,de Bie R,de Vet HC,Hildebrandt J,Nelemans P, Injection therapy for subacute and chronic low-back pain. The Cochrane database of systematic reviews. 2008 Jul 16     [PubMed]
Machado GC,Ferreira PH,Yoo RI,Harris IA,Pinheiro MB,Koes BW,van Tulder MW,Rzewuska M,Maher CG,Ferreira ML, Surgical options for lumbar spinal stenosis. The Cochrane database of systematic reviews. 2016 Nov 1     [PubMed]
Karatas AF,Dede O,Atanda AA,Holmes L Jr,Rogers K,Gabos P,Shah SA, Comparison of Direct Pars Repair Techniques of Spondylolysis in Pediatric and Adolescent Patients: Pars Compression Screw Versus Pedicle Screw-Rod-Hook. Clinical spine surgery. 2016 Aug     [PubMed]
Menga EN,Kebaish KM,Jain A,Carrino JA,Sponseller PD, Clinical results and functional outcomes after direct intralaminar screw repair of spondylolysis. Spine. 2014 Jan 1     [PubMed]
Helenius I,Lamberg T,Osterman K,Schlenzka D,Yrjönen T,Tervahartiala P,Seitsalo S,Poussa M,Remes V, Scoliosis research society outcome instrument in evaluation of long-term surgical results in spondylolysis and low-grade isthmic spondylolisthesis in young patients. Spine. 2005 Feb 1     [PubMed]
Lundine KM,Lewis SJ,Al-Aubaidi Z,Alman B,Howard AW, Patient outcomes in the operative and nonoperative management of high-grade spondylolisthesis in children. Journal of pediatric orthopedics. 2014 Jul-Aug     [PubMed]
Tsirikos AI,Jain AK, Scheuermann's kyphosis; current controversies. The Journal of bone and joint surgery. British volume. 2011 Jul     [PubMed]
Lim M,Green DW,Billinghurst JE,Huang RC,Rawlins BA,Widmann RF,Burke SW,Boachie-Adjei O, Scheuermann kyphosis: safe and effective surgical treatment using multisegmental instrumentation. Spine. 2004 Aug 15     [PubMed]
Parent S,Newton PO,Wenger DR, Adolescent idiopathic scoliosis: etiology, anatomy, natural history, and bracing. Instructional course lectures. 2005     [PubMed]
Will JS,Bury DC,Miller JA, Mechanical Low Back Pain. American family physician. 2018 Oct 1     [PubMed]
Hartvigsen J,Hancock MJ,Kongsted A,Louw Q,Ferreira ML,Genevay S,Hoy D,Karppinen J,Pransky G,Sieper J,Smeets RJ,Underwood M, What low back pain is and why we need to pay attention. Lancet (London, England). 2018 Jun 9     [PubMed]
Trecarichi EM,Di Meco E,Mazzotta V,Fantoni M, Tuberculous spondylodiscitis: epidemiology, clinical features, treatment, and outcome. European review for medical and pharmacological sciences. 2012 Apr     [PubMed]
Slipman CW,Patel RK,Botwin K,Huston C,Zhang L,Lenrow D,Garvan C, Epidemiology of spine tumors presenting to musculoskeletal physiatrists. Archives of physical medicine and rehabilitation. 2003 Apr     [PubMed]
Cohen MD,Harrington TM,Ginsburg WW, Osteoid osteoma: 95 cases and a review of the literature. Seminars in arthritis and rheumatism. 1983 Feb     [PubMed]
Azouz EM,Kozlowski K,Marton D,Sprague P,Zerhouni A,Asselah F, Osteoid osteoma and osteoblastoma of the spine in children. Report of 22 cases with brief literature review. Pediatric radiology. 1986     [PubMed]
Kang HM,Choi EH,Lee HJ,Yun KW,Lee CK,Cho TJ,Cheon JE,Lee H, The Etiology, Clinical Presentation and Long-term Outcome of Spondylodiscitis in Children. The Pediatric infectious disease journal. 2016 Apr     [PubMed]
Spencer SJ,Wilson NI, Childhood discitis in a regional children's hospital. Journal of pediatric orthopedics. Part B. 2012 May     [PubMed]
Ramirez N,Johnston CE,Browne RH, The prevalence of back pain in children who have idiopathic scoliosis. The Journal of bone and joint surgery. American volume. 1997 Mar     [PubMed]
Chou R,Shekelle P, Will this patient develop persistent disabling low back pain? JAMA. 2010 Apr 7     [PubMed]
Hendrick P,Milosavljevic S,Hale L,Hurley DA,McDonough S,Ryan B,Baxter GD, The relationship between physical activity and low back pain outcomes: a systematic review of observational studies. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2011 Mar     [PubMed]
Pinheiro MB,Ferreira ML,Refshauge K,Maher CG,Ordoñana JR,Andrade TB,Tsathas A,Ferreira PH, Symptoms of depression as a prognostic factor for low back pain: a systematic review. The spine journal : official journal of the North American Spine Society. 2016 Jan 1     [PubMed]
Wertli MM,Eugster R,Held U,Steurer J,Kofmehl R,Weiser S, Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review. The spine journal : official journal of the North American Spine Society. 2014 Nov 1     [PubMed]
Wertli MM,Rasmussen-Barr E,Weiser S,Bachmann LM,Brunner F, The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. The spine journal : official journal of the North American Spine Society. 2014 May 1     [PubMed]
Jones GT,Watson KD,Silman AJ,Symmons DP,Macfarlane GJ, Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Pediatrics. 2003 Apr     [PubMed]
Lynch AM,Kashikar-Zuck S,Goldschneider KR,Jones BA, Psychosocial risks for disability in children with chronic back pain. The journal of pain : official journal of the American Pain Society. 2006 Apr     [PubMed]
Korovessis P,Repantis T,Baikousis A, Factors affecting low back pain in adolescents. Journal of spinal disorders & techniques. 2010 Dec     [PubMed]
Ramond A,Bouton C,Richard I,Roquelaure Y,Baufreton C,Legrand E,Huez JF, Psychosocial risk factors for chronic low back pain in primary care--a systematic review. Family practice. 2011 Feb     [PubMed]
Mustard CA,Kalcevich C,Frank JW,Boyle M, Childhood and early adult predictors of risk of incident back pain: Ontario Child Health Study 2001 follow-up. American journal of epidemiology. 2005 Oct 15     [PubMed]
Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet (London, England). 2016 Oct 8     [PubMed]
Mokdad AH,Ballestros K,Echko M,Glenn S,Olsen HE,Mullany E,Lee A,Khan AR,Ahmadi A,Ferrari AJ,Kasaeian A,Werdecker A,Carter A,Zipkin B,Sartorius B,Serdar B,Sykes BL,Troeger C,Fitzmaurice C,Rehm CD,Santomauro D,Kim D,Colombara D,Schwebel DC,Tsoi D,Kolte D,Nsoesie E,Nichols E,Oren E,Charlson FJ,Patton GC,Roth GA,Hosgood HD,Whiteford HA,Kyu H,Erskine HE,Huang H,Martopullo I,Singh JA,Nachega JB,Sanabria JR,Abbas K,Ong K,Tabb K,Krohn KJ,Cornaby L,Degenhardt L,Moses M,Farvid M,Griswold M,Criqui M,Bell M,Nguyen M,Wallin M,Mirarefin M,Qorbani M,Younis M,Fullman N,Liu P,Briant P,Gona P,Havmoller R,Leung R,Kimokoti R,Bazargan-Hejazi S,Hay SI,Yadgir S,Biryukov S,Vollset SE,Alam T,Frank T,Farid T,Miller T,Vos T,Bärnighausen T,Gebrehiwot TT,Yano Y,Al-Aly Z,Mehari A,Handal A,Kandel A,Anderson B,Biroscak B,Mozaffarian D,Dorsey ER,Ding EL,Park EK,Wagner G,Hu G,Chen H,Sunshine JE,Khubchandani J,Leasher J,Leung J,Salomon J,Unutzer J,Cahill L,Cooper L,Horino M,Brauer M,Breitborde N,Hotez P,Topor-Madry R,Soneji S,Stranges S,James S,Amrock S,Jayaraman S,Patel T,Akinyemiju T,Skirbekk V,Kinfu Y,Bhutta Z,Jonas JB,Murray CJL, The State of US Health, 1990-2016: Burden of Diseases, Injuries, and Risk Factors Among US States. JAMA. 2018 Apr 10     [PubMed]
Hestbaek L,Leboeuf-Yde C,Kyvik KO, Are lifestyle-factors in adolescence predictors for adult low back pain? A cross-sectional and prospective study of young twins. BMC musculoskeletal disorders. 2006 Mar 15     [PubMed]
Leboeuf-Yde C, Smoking and low back pain. A systematic literature review of 41 journal articles reporting 47 epidemiologic studies. Spine. 1999 Jul 15     [PubMed]
Engers A,Jellema P,Wensing M,van der Windt DA,Grol R,van Tulder MW, Individual patient education for low back pain. The Cochrane database of systematic reviews. 2008 Jan 23     [PubMed]
Skaggs DL,Early SD,D'Ambra P,Tolo VT,Kay RM, Back pain and backpacks in school children. Journal of pediatric orthopedics. 2006 May-Jun     [PubMed]
Chou R,Qaseem A,Owens DK,Shekelle P, Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Annals of internal medicine. 2011 Feb 1     [PubMed]
Jarvik JG,Deyo RA, Diagnostic evaluation of low back pain with emphasis on imaging. Annals of internal medicine. 2002 Oct 1     [PubMed]
Saragiotto BT,Machado GC,Ferreira ML,Pinheiro MB,Abdel Shaheed C,Maher CG, Paracetamol for low back pain. The Cochrane database of systematic reviews. 2016 Jun 7     [PubMed]
Roelofs PD,Deyo RA,Koes BW,Scholten RJ,van Tulder MW, Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine. 2008 Jul 15     [PubMed]
van Tulder MW,Touray T,Furlan AD,Solway S,Bouter LM, Muscle relaxants for non-specific low back pain. The Cochrane database of systematic reviews. 2003     [PubMed]
Urquhart DM,Hoving JL,Assendelft WW,Roland M,van Tulder MW, Antidepressants for non-specific low back pain. The Cochrane database of systematic reviews. 2008 Jan 23     [PubMed]
Long A,May S,Fung T, The comparative prognostic value of directional preference and centralization: a useful tool for front-line clinicians? The Journal of manual & manipulative therapy. 2008     [PubMed]
Aina A,May S,Clare H, The centralization phenomenon of spinal symptoms--a systematic review. Manual therapy. 2004 Aug     [PubMed]
Clare HA,Adams R,Maher CG, Reliability of McKenzie classification of patients with cervical or lumbar pain. Journal of manipulative and physiological therapeutics. 2005 Feb     [PubMed]
Szpalski M,Gunzburg R,Balagué F,Nordin M,Mélot C, A 2-year prospective longitudinal study on low back pain in primary school children. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2002 Oct     [PubMed]
Feldman DS,Straight JJ,Badra MI,Mohaideen A,Madan SS, Evaluation of an algorithmic approach to pediatric back pain. Journal of pediatric orthopedics. 2006 May-Jun     [PubMed]
Arnold E,La Barrie J,DaSilva L,Patti M,Goode A,Clewley D, The Impact of Timing of Physical Therapy for Acute Low Back Pain on Health Services Utilization: A Systematic Review. Archives of physical medicine and rehabilitation. 2019 Jan 23     [PubMed]
Hajihasani A,Rouhani M,Salavati M,Hedayati R,Kahlaee AH, The Influence of Cognitive Behavioral Therapy on Pain, Quality of Life, and Depression in Patients Receiving Physical Therapy for Chronic Low Back Pain: A Systematic Review. PM & R : the journal of injury, function, and rehabilitation. 2018 Sep 25     [PubMed]
Roffey DM,Ashdown LC,Dornan HD,Creech MJ,Dagenais S,Dent RM,Wai EK, Pilot evaluation of a multidisciplinary, medically supervised, nonsurgical weight loss program on the severity of low back pain in obese adults. The spine journal : official journal of the North American Spine Society. 2011 Mar     [PubMed]

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