Mechanical Back Strain


Article Author:
Moustafa El Sayed


Article Editor:
Avery Callahan


Editors In Chief:
Sherri Murrell


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
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
5/30/2019 2:05:11 PM

Introduction

Back pain is one of the most common chief complaints in the emergency department. It is also a leading cause of disability and high healthcare expenses globally as it affects patients of all ages and backgrounds. Mechanical back strain is a subtype of back pain where the etiology is the spine, intervertebral discs, or the surrounding soft tissues. While the majority of cases of mechanical back strains that present to the emergency department can be managed conservatively, healthcare providers must be aware of the common red flags that signal more emergent causes of back pain and that are associated with high morbidity and mortality when the diagnosis is delayed.[1][2]

Etiology

Historically, references to mechanical back pain have used many other vague terms like "non-specific back pain," "lumbar strain," or "lumbago." This terminology was due to the absence of proper diagnostic methods in the past. However, more recent advances in imaging technology and a better clinical understanding of spinal anatomy and the body's innervation have allowed more accurate terminology and diagnoses, depending on the underlying cause. Hence, more specific diagnoses are made based on the etiology of mechanical back strain, which is typically due to pathology involving the anatomy of the spine. While the lower back is usually affected the most, mechanical back pathology may involve any part of the bones, spinal ligaments, intervertebral discs, facet joints, spinal cord, spinal nerves, or paraspinal muscles. Common examples of pathology involving these structures include the following diseases [3]

  • Spinal foraminal stenosis
  • Herniated discs
  • Spinal stenosis
  • Degenerative disc disease
  • Vertebral fractures
  • Sacroiliac joint dysfunction
  • Facet joint syndrome
  • Ligamentous and muscular injury
  • Myofascial pain syndrome

Epidemiology

Greater than 80% of people will suffer from low back pain during their lifetime. The global point prevalence of low back pain is 12 to 33%. There is a higher prevalence among women and people ages 40 to 80 years old. Due to missed work days and decreased wages, 100 to 200 billion dollars are estimated to be spent each year in the United States due to lower back pain.[2][4]

History and Physical

Obtaining a complete history and performing an in-depth physical exam is crucial to the diagnosis of mechanical back strains. The goal of evaluation in the acute setting is to ensure there are no red flags that warrant more advanced imaging and surgical consultation. These red flag symptoms include fevers, involuntary weight loss, night sweats, bladder or bowel incontinence, significant trauma, frequent falls, and history of cancer, anticoagulant use, chronic systemic steroid use, intravenous drug abuse, or an immunocompromised state. Physical exam red flags compromise assessing for focal neurologic deficits, including weakness, ataxia, saddle anesthesia, decreased deep tendon reflexes, and diminished rectal tone.[3][5]

Acute mechanical back strains may be triggered by physical or non-physical activity, with lifting being the most commonly recalled event. However, one-third of patients may not necessarily remember an inciting incident. More specific spinal pathology may have classically associated symptoms. For example, herniated discs will present with radicular pain that radiates from the lower back in L4 to S1 distribution, and pain may be reproducible to the affected side on straight leg raise. Spinal stenosis may demonstrate back pain and bilateral posterior leg pain that worsens with ambulation and spine extension but is relieved by rest and spine flexion. Patients on chronic steroids or at risk for osteoporosis are at increased risk for vertebral compression fractures even after seemingly minor trauma. Compression fractures tend to be focally tender on palpation.[1][6]

Evaluation

In the absence of the red flags discussed above, no laboratory or radiographic studies are necessary for the diagnosis or management of mechanical back strains in the acute setting. Inflammatory biomarkers, such erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), are useful for risk stratification of patients who have risk factors for infectious spinal pathology or malignancy but have no neurologic deficits on examination. Routine imaging for mechanical back strains is not recommended, as many may have incidental abnormal findings that are unrelated to their pain. More advanced imaging is needed in the setting of trauma, failure of conservative management, worsening of symptoms, and new neurologic deficits. Plain radiographs and computed tomography are useful when suspecting fractures. However, patients with signs of spinal cord compression or red flag symptoms need magnetic resonance imaging for making the diagnosis.[3][5][7] 

Treatment / Management

Management of mechanical back strains depends on the chronicity of symptoms, the patient's comorbidities, and the specific etiology. The American College of Physicians published an updated guideline in 2017 with recommendations regarding non-invasive options for treating low back pain. First-line nonpharmacologic therapy for acute low back pain includes spinal manipulation, acupuncture, massage, and superficial heat application, while first-line pharmacologic therapy for acute low back pain is nonsteroidal anti-inflammatory drugs and muscle relaxants. The use of acetaminophen and systemic corticosteroids showed no improvement of acute back pain when compared to placebo according to low-quality evidence. There was insufficient evidence to determine the benefits of other pharmacologic agents, such as benzodiazepines, antidepressants, antiepileptic medications, and opioids. According to the clinical policy by American College of Emergency Physicians, opioids should not be routine pharmaceutical therapy but saved for those whose pain is severe or uncontrolled with other medications.[8][9]

For chronic low back pain, non-pharmacologic approaches were recommended as the first-line agents, including exercise, tai-chi, yoga, multidisciplinary rehabilitation, spinal manipulation, acupuncture, psychotherapy, low-level laser therapy, and electromyogram biofeedback. Nonsteroidal anti-inflammatory drugs were again the first-line pharmacologic agents recommended followed by tramadol and duloxetine as the second-line treatments. Recommendations for opioid therapy are only if the previously mentioned therapies failed and based on an individualized decision to determine if the benefit outweighs the risk.[8]

The American Pain Society also has published recommendations by a multidisciplinary panel in 2009 regarding the use of more invasive procedures for diagnostic and therapeutic purposes to treat non-radicular low back pain, radicular low back pain, and spinal stenosis. The panel emphasized the use of intensive interdisciplinary rehabilitation for chronic non-radicular low back pain, as it has similar efficacy to fusion surgery. Epidural steroid injection showed variable evidence of short-term benefit for radicular low back pain; thus, the panel recommended a shared decision-making process for the appropriate patient.

For surgical management options, standard open discectomy and microdiscectomy have a moderate short-term benefit in treating persistent, debilitating radiculopathy secondary to herniated disc disease. Similarly, decompressive laminectomy has a moderate short-term benefit in treating severe, debilitating spinal stenosis. The panel noted that these benefits tend to decrease over time, and a shared decision-making process is also appropriate in these patients before surgical intervention. Lastly, spinal cord stimulation may be an option for patients who underwent surgery for herniated disc disease but continue to have debilitating radiculopathy.[10]

Differential Diagnosis

The differential diagnoses for mechanical back strains are other nonmechanical causes of back pain. These include but not limited to the following categories and diseases [1][5][11]

  • Rheumatologic - ankylosing spondylitis, Reiter syndrome, psoriatic spondylitis, polymyalgia rheumatica   
  • Oncologic - metastatic disease, spinal cord tumor, lymphomas, leukemia, multiple myeloma 
  • Infectious - spinal epidural abscess, osteomyelitis, discitis 
  • Gastrointestinal - pancreatitis, cholecystitis, bowel perforation 
  • Vascular - aortic aneurysm, spinal epidural hematoma, aortoiliac disease
  • Renal - pyelonephritis, nephrolithiasis, perinephric abscess
  • Genitourinary - endometriosis, prostatitis, pelvic inflammatory disease

Prognosis

While the majority of acute episodes of mechanical back pain resolve spontaneously within 12 weeks, up to one-third of patients may continue to have chronic symptoms. However, even those whose acute symptoms resolve have a 20 to 40% chance of symptom recurrence during the first year and 85% of lifetime recurrence.[2][8] Various environmental and psychosocial factors may influence the prognosis of mechanical back strains. These include a body mass index greater than 25, smoking, poor health, depression, fear avoidance, strenuous work demand, job dissatisfaction, and presence of compensation.[1][3][6]

Complications

The possible complications of mechanical back strains depend on the specific etiology, with the most common complication being the persistence of symptoms and the development of lasting disability. Rarer physical complications include cauda equina syndrome and physical deformities. Other health complications may arise as side effects from long-term pharmacologic therapies, such as NSAID use, or from more invasive therapeutic procedures, such as injections and surgeries. Many financial and social complications also exist for both the patients with chronic, disabling mechanical back pain and their employers due to lost wages and missed work days.[1][8] 

Deterrence and Patient Education

Reduction of strenuous physical requirements is the main primary prevention for mechanical back strains; however, secondary prevention rather than primary prevention is more practical due to the high prevalence of the condition and since the greatest risk factor is the recurrence of a previous episode. Some interventions by employers that may aid in injury prevention are stretching exercises at the workplace, appropriate rest breaks, and ergonomic modifications. Ergonomic modifications refer to adaptations in the work environment to reduce the physical stress of the employees. Also, educating patients regarding the importance of maintaining proper posture and correct lifting techniques may also aid in prevention. Other prevention techniques that can be used by patients aim at reducing the risk factors of having a poor prognosis, including exercising, smoking cessation, weight loss for obese patients, and resuming normal physical activity.[1][12][13][14]

Enhancing Healthcare Team Outcomes

Healthcare professionals of many specialties are involved in providing care for patients with mechanical back strains. Physicians and nurses, especially in the acute setting, must be familiar with red flag symptoms of back pain that may require more urgent interventions and possible surgical consultation. Conservative management of acute mechanical back strains after a complete assessment is reasonable as the course is usually self-limited; this includes superficial heat, nonsteroidal anti-inflammatory drugs, and muscle relaxants.[8] [Level II] 

Chronic mechanical back strains require an interprofessional approach due to the psychosocial factors involved. Initial non-pharmacologic therapy includes exercise, multidisciplinary rehabilitation, manipulation, and acupuncture. First-line pharmacologic therapy is nonsteroidal anti-inflammatory drugs followed by duloxetine or tramadol as second-line therapy.[8] [Level II] Patients with persistent disabling chronic non-radicular low back pain may benefit from interdisciplinary rehabilitation, described as rehabilitation along with a psychological, social, or occupational component. Patients with persistent chronic radicular pain due to herniated discs or spinal stenosis may benefit from surgical interventions.[10] [Level I] 

Mechanical back pain requires an interprofessional team approach, including physicians, specialists, specialty-trained nurses, physical therapists, chiropractors, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level V]


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Mechanical Back Strain - Questions

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A 65-year-old male with a history of prostate cancer presents with gradually worsening lower back pain over the past 2 months. He reports having episodes where he finds urine in his underwear more often recently. Upper extremities' deep tendon reflexes are 2+, but bilateral lower extremities' reflexes are 0. Which of the following characteristics below would be an indication for delayed imaging instead of early imaging?



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A 16-year-old male patient presents with a 5-day history of right-sided lower back pain that radiates down his posterior thigh. Raising the patient's leg at 70 degrees while he is supine reproduces both his back and right leg pain. His neurologic exam is otherwise unremarkable. Which of the following treatments is the best initial choice for pharmacologic management of his condition?



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A 45-year-old female suffers from bilateral lower back pain over the past 5 months since she was in a motor vehicle collision. CT scans at the time of the incident were negative for fractures. She has found no relief with yoga, ibuprofen, methocarbamol, and an interprofessional rehabilitation team, where she was referred to by her primary care provider. She is requesting another pharmacologic agent for relief. Which of the following medications is appropriate to add to treat her symptoms?



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A 25-year-old male presents to an urgent care for left-sided, non-radiating upper back pain that started the day prior after lifting a heavy desk. He has tried acetaminophen and naproxen with minimal relief. The patient's strength and sensation are intact. His pain is reproduced on palpation of his left upper back. Which of the following medications may be given to this patient to provide further relief of his symptoms?



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A 35-year-old female presents to her primary care physician's office with a chief complaint of constant, bilateral lower back pain over the past 1 week since moving furniture. The pain does not radiate, and she has not tried anything for relief except rest. Her vitals and physical examination are normal. Which of the following is the first-line non-pharmacological, non-invasive management for her condition?



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A 45-year-old male was lifting his groceries and suddenly developed low back pain. He presents a few hours later and is unable to find a comfortable position at rest. The pain is continuous but does not radiate to the back of the thigh or lower legs. He has no problems with voiding. He works as an accountant. The physical exam is unremarkable including a negative straight leg test. His urine is clear, and the lateral vertebral x-rays are unremarkable. Which of the following is an effective method for prevention of symptom recurrence for this patient?



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A 25-year-old patient with no prior medical problems is seen in an emergency room with bilateral, non-radiating lower back pain. The patient states that the pain started while he was competing for running and jumping. He denies any falls or trauma. Pain is reproduced by deep palpation over bilateral paraspinal muscles with no midline tenderness. What is the most likely underlying origin of his condition?



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A 35-year-old male presents to the office with a complaint of lower back pain. He states that he is a carpenter and has been working on a very strenuous job. The pain is most tender when he backward bends his spine. Which of the following muscles is most likely to be the source of the pain?



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A 17-year-old male presents to an urgent care clinic for constant, non-radiating, lower right sided back pain that has been constant over the past one week. He has no previous medical history and no focal neurologic deficits on examination. He is requesting education about his course of illness. Which of the following statements about his condition is true?



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Mechanical Back Strain - References

References

Casiano VE,De NK, Back Pain 2019 Jan;     [PubMed]
Freburger JK,Holmes GM,Agans RP,Jackman AM,Darter JD,Wallace AS,Castel LD,Kalsbeek WD,Carey TS, The rising prevalence of chronic low back pain. Archives of internal medicine. 2009 Feb 9;     [PubMed]
Chien JJ,Bajwa ZH, What is mechanical back pain and how best to treat it? Current pain and headache reports. 2008 Dec;     [PubMed]
Hoy D,Bain C,Williams G,March L,Brooks P,Blyth F,Woolf A,Vos T,Buchbinder R, A systematic review of the global prevalence of low back pain. Arthritis and rheumatism. 2012 Jun;     [PubMed]
Edlow JA, Managing Nontraumatic Acute Back Pain. Annals of emergency medicine. 2015 Aug;     [PubMed]
Maher C,Underwood M,Buchbinder R, Non-specific low back pain. Lancet (London, England). 2017 Feb 18;     [PubMed]
Hansen BB,Hansen P,Carrino JA,Fournier G,Rasti Z,Boesen M, Imaging in mechanical back pain: Anything new? Best practice     [PubMed]
Qaseem A,Wilt TJ,McLean RM,Forciea MA, Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Annals of internal medicine. 2017 Apr 4;     [PubMed]
Cantrill SV,Brown MD,Carlisle RJ,Delaney KA,Hays DP,Nelson LS,O'Connor RE,Papa A,Sporer KA,Todd KH,Whitson RR, Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department. Annals of emergency medicine. 2012 Oct;     [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]
Atlas SJ,Deyo RA, Evaluating and managing acute low back pain in the primary care setting. Journal of general internal medicine. 2001 Feb;     [PubMed]
Balagué F,Mannion AF,Pellisé F,Cedraschi C, Non-specific low back pain. Lancet (London, England). 2012 Feb 4;     [PubMed]
Shariat A,Cleland JA,Danaee M,Kargarfard M,Sangelaji B,Tamrin SBM, Effects of stretching exercise training and ergonomic modifications on musculoskeletal discomforts of office workers: a randomized controlled trial. Brazilian journal of physical therapy. 2018 Mar - Apr;     [PubMed]
Tariq RA,Toney-Butler TJ, Back Safety 2019 Jan;     [PubMed]

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