Low Back Pain Care Pathway

4. Differential Diagnosis Requiring Medical Attention

 

Note: Peripheral neuropathies may not present with low back pain but are key differentials for radicular pain/radiculopathy. Musculoskeletal peripheral neuropathy does not necessarily require referral to a medical provider, unlike other conditions in this section.

 

Red Flags: Immediate Referral to Emergency Care:

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1. Cauda Equina Syndrome

• Pain Location: Severe low back pain.

• Signs/Symptoms/Red Flags: Saddle anesthesia, bowel overflow incontinence, bladder retention or overflow incontinence, bilateral progressive radicular signs.

• Physical and Neurological Examination: Decreased perianal sensation, decreased anal sphincter tone, progressive lower extremity weakness.

• Action: Immediate referral to emergency care.

 

2. Spinal Infection (osteomyelitis, discitis, epidural abscess)

• Pain Location: Localized severe back pain.

• Signs/Symptoms/Red Flags: Constitutional (fever, chills, fatigue), localized pain, swelling, redness, immunosuppression, recent infection or surgery, TB (tuberculosis) history, IV drug use, poor living conditions.

• Physical and Neurological Examination: Tenderness over the affected area, possible erythema and warmth, possible neurological deficits.

• Action: Immediate referral to emergency care.

 

3. Traumatic Spinal Fracture

• Pain Location: Localized pain in the mid or lower back.

• Signs/Symptoms/Red Flags: Sudden onset of severe pain following severe trauma.

• Physical and Neurological Examination: Point tenderness.

• Action: Immediate referral to emergency care.

 

Refer to Medical Provider:

 

1. Non-traumatic Spinal Fracture

• Pain Location: Localized pain in the mid or lower back.

• Signs/Symptoms: Sudden onset of severe pain following minor trauma or spontaneous in osteoporotic patients, corticosteroid use, female sex, older age (>60), history of spinal fracture or cancer.

• Physical and Neurological Examination: Point tenderness over the affected vertebra, kyphosis in severe cases.

• Action: Referral to appropriate medical provider.

 

2. Spinal Malignancy

• Pain Location: Severe, progressive, localized back pain, often with radiation to the chest or abdomen.

• Signs/Symptoms: History of cancer; persistent pain, worse at night, not relieved by rest; constitutional symptoms (night sweats, unexplained weight loss, fatigue).

• Physical and Neurological Examination: Localized tenderness, possible neurological deficits.

• Action: Referral to appropriate medical provider.

 

3. Inflammatory Arthritides

1. Spondyloarthropathies (e.g., ankylosing spondylitis, psoriatic arthritis, reactive arthritis):

• Pain Location: Lower back, may radiate to buttocks and thighs.

• Signs/Symptoms: Morning stiffness >1 hour, pain improves with activity, pain worse at night, presence of other inflammatory signs (e.g., uveitis, psoriasis), systemic symptoms (fatigue, weight loss, fever).

• Physical Examination: Possible reduced spinal mobility, positive Schober’s test, tenderness over joints.

• Action: Referral to appropriate medical provider.

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2. Rheumatoid Arthritis

• Pain Location: Diffuse joint pain, may include lower back.

• Signs/Symptoms: Symmetrical joint pain, morning stiffness >1 hour, systemic symptoms (fatigue, weight loss, fever).

• Physical Examination: Joint swelling, tenderness, and deformity.

• Action: Referral to appropriate medical provider.

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3. Systematic Lupus Erythematosus (SLE)

• Pain Location: May include lower back and other joints.

• Signs/Symptoms: Joint pain and swelling, fatigue, butterfly-shaped rash on the face, photosensitivity, systemic symptoms (fatigue, weight loss, fever).

• Physical Examination: Joint tenderness and swelling, skin rashes, signs of organ involvement such as kidney issues or pleuritis.

• Action: Referral to appropriate medical provider.

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4. Referred Pain (from abdominal/pelvic visceral conditions)

 (e.g., aortic aneurysm, endometriosis, kidney stones, pancreatitis)

• Pain Location: Varies depending on the condition, often radiating to the back.

• Signs/Symptoms: Specific to the underlying condition, may include abdominal pain, gastrointestinal symptoms, urinary symptoms, systemic symptoms (fever, chills, weight loss).

• Physical Examination: Abdominal or pelvic tenderness, palpable mass, and other specific signs related to the condition (e.g., Murphy's sign for kidney stones, Cullen's sign for pancreatitis).

• Action: Referral to appropriate medical provider.

 

5. Non-Musculoskeletal Peripheral Neuropathy

(e.g., diabetic neuropathy, Guillain-Barré syndrome)

• Pain Location: Burning, tingling, or numbness in the feet and legs distally and bilaterally.

• Signs/Symptoms: Stocking-like distribution of sensory loss, muscle weakness.

• Physical Examination: Reduced sensation, absent reflexes, muscle weakness, balance difficulty.

• Action: Referral to appropriate medical provider.

 

6. Musculoskeletal Peripheral Neuropathy

(e.g., meralgia paresthetica, tarsal tunnel syndrome, peroneal nerve entrapment)

• Pain Location: Burning, tingling, or numbness in the feet and legs distally.

• Signs/Symptoms: Follows peripheral nerve distribution, unilateral.

• Physical Examination: Reduced sensation, absent reflexes, muscle weakness, balance difficulty.

• Action: Does not necessarily require referral to a medical provider.