Back Pain: Steps To Take Before Referring To Neurosurgery

According to the American Association of Neurosurgical Surgeons, just about every adult in America will suffer from back pain including pulled muscles, degenerative disease and trauma. These patients are often first seen by a primary care physician, so it is important to realize key points in diagnosis treatment and referral.

Red Flags During Initial Assessment of Low Back Pain Patients

During the initial assessment of the patient, it is critical to rule out potentially serious conditions including: spinal tumors, fractures, infection, cauda equina syndrome, and spinal osteomyelitis. Red flags that require immediate attention include:

  1. Recent trauma
  2. Mild trauma or strain with a history of osteoporosis
  3. Unexplained weight loss
  4. History of cancer
  5. Fever
  6. Pain worse at night
  7. Bowel/bladder disfunction
  8. IV drug use
  9. Pain not relieved in the supine position/awakens patient from sleep

Patients exhibiting a combination or a single red flag without any obvious medical reason should have prompt evaluation and aggressive treatment.

Conservative Treatment Options

  1. For patients with pain for less than 4-6 weeks, treatment considerations include:
  2. Acetominophen and NSAID
  3. Decreased activity
  4. Opioids should be avoided
  5. Muscle relaxants, oral steroids, benzodiazpines and colchicine have not been proven effective.
  6. Manipulation is acceptable treatment for back pain without radiculopathy when used in the first month.

Criteria for Surgical Referral

If there is evidence of an initial red flag, an appropriate referral should be made immediately. Patients should also be referred for a surgical consult if they meet the following criteria:

  1. Sciatica is both severe and disabling;
  2. Symptoms of sciatica persist without improvement or with progression; and
  3. There is clinical evidence of nerve root compromise.

Pearls of Treatment

  1. Leg pain secondary to nerve root compression occurs during the first 60 degrees of straight leg raising; pain occurring thereafter is due to stretching the posterior leg muscles.
  2. If pain in the leg can be reproduced by direct compression or palpation of a part of the arm or leg, such as the shoulder joint, hip or SI joint, it is not referred nerve root pain, but is instead related to a localized problem.
  3. In patients presenting with back pain and sciatica, the presence of mild to moderate neurological findings (weakness, sensory changes, depressed reflex) does not contraindicate a trial of conservative therapy.
  4. Most patients with acute spinal pain improve spontaneously or after a brief period of conservative treatment, including physical therapy.
  5. For patients with little relief of symptoms after 4-6 weeks, imaging studies and the referral to a surgeon are warranted. We recommend MRI L-Spine to be available before neurosurgical evaluation. If the patient had prior back surgery or evidence of metastic spine tumor, MRI should be done with contrast.


Basic Neurological Exam to Screen for Nerve Root Compromise

Test
Result
Ipsilateral SLR
Crossed SLR
Ankle dorsiflexion
Great toe extensor weakness
Impaired ankle reflux
Sensory Loss
Quadriceps weakness
Pain at < 60 degrees indicates compromise
Absence of pain strongly indicates no compromise
Absence of weakness indicates no nerve root compromise
Weakness indicates possible compromise at L5-S1
Poor reflex indicates possible compromise at L5-S1
Decreased sensation indicates no L5-S1 weakness compromise
Absence of weakness indicates no L4 compromise