When to Worry About Low Back Pain

There are several serious and acute causes of low back pain, which you need to watch out for. These include trauma, urine or bowel difficulties, numbness, motor deficits, and several others. Keep reading to find out whether you should worry about low back pain.

Low back pain is the 5th most common reason that drive people to the doctor ‘s office. It’s also typically a benign and self-limiting condition. However, there are some uncommon but more serious causes of low back pain. So how do you know when you should worry about it? What are some of those concerning red flags? How can you best prepare for your doctor’s visit? And how can you treat lower back pain?

I will address these questions and more in a two-part episode dedicated to this highly common medical ailment.

Let’s take Lori as an example. She’s a 46-year-old female bakery owner who came to see me for three days of low back pain, severe enough to prevent her from working. Lori is very healthy and rarely comes in to see me, so I knew she must not be well if she’d visited the office. What happened to Lori? And how can we help fix her lower back?

Anatomy of the Low Back

The low back is divided into the two segments referred to as the “lumbar” and “sacrum” of the spine, hence “lumbosacral” for short. The lumbar section of the spine refers to the vertebrae that typically cave in when looking at the lower back, located directly above the buttocks. And the sacrum sits directly below, located between the buttocks and often referred to as the “tailbone.”

History of Present Illness

In today’s episode, I’d like to focus on acute low back pain specifically, one that develops in recent history, typically 4-6 weeks. Chronic low back pain is another ball game altogether and we will attack it in a future episode.

If you recall from some of my previous episodes, physicians are trained to gather the patient “history of present illness” and build a detailed story of the symptoms. Let's do that with Lori.

But first, may I ask what you had for lunch yesterday? How many of you cannot recall or require some serious thinking to answer this question? You're not alone.

In the same way, Lori, like many other patients who see me for an acute low back pain, doesn’t remember any significant event that triggered the pain: no accidents, no falls, and no injuries. Unfortunately, pain sometimes develops 24 to 48 hours after an event. Think of the last time you started a new, rigorous exercise regimen; you felt sore the day after your workout, not the same day of the event. So if it wasn’t a memorable event, many people will be unable to recall their activity details.

Here’s what I wanted to know about Lori’s pain, and what your doctor may want to know about your pain. So get yourself ready to answer the following questions:

Onset: When did it begin?

Duration: Is it constant? How long does it last?

Frequency:  If the pain comes and goes, how often does it occur?

Location: Where exactly does it hurt? Left or right? Low back, mid-back, or upper back?

Radiation: Does the pain travel anywhere, like down the leg?

Quality: Can you describe the type of pain (i.e., is it like “pressure,” “soreness,” “ache,” “sharp”)?

Severity: On a scale from 1 to 10 (with 10 being the most severe pain you could ever imagine, think childbirth; or for those without the pleasure, just imagine childbirth). 10 out of 10 pain is typically so severe that it would require hospitalization.

Alleviating or Aggravating Factors: Anything make it better or worse? Does sitting or standing affect it, for instance?

Treatment Attempted: Did you try ice or heat? Stretching? How about any over-the-counter pain relievers? Which ones, what dose, and how many times a day?

Prior History: Have you ever had these symptoms before? If so, how did it resolve?

Lori tells me that her constant 6 out of 10 “achy” left low back pain began upon awakening two days ago. A “sharp” pain stemming from the same side also travels down her leg, which is what bothers her most. Sitting makes it worse, and standing and walking alleviates it. She’s tried ice and ibuprofen 200mg OTC 2 tabs only once daily. She “hates” pills, she tells me. She has had a similar low back pain episode 4 years ago when she had gained 15 pounds. She lost the weight, but admits to having gained almost all of it back in recent months. She also mentions that she's been working longer hours since she's been short-staffed for the last week.

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Low Back Pain Red Flags

Thankfully, acute low back pain is common and typically self-resolving. Studies show that up to 90% of low back pain resolves within weeks.  

Thankfully, acute low back pain is common and typically self-resolving.

Despite its relatively benign nature, however, there are several rare and serious causes of acute low back pain that I must keep in mind when evaluating Lori:

Trauma:  If she had trauma precipitating the pain, I have to make sure there are no fractures or injuries.

Urine or bowel difficulties: Incontinence of either origin is especially important to know, so is a diminished ability to urinate.

Saddle anesthesia: Numbness or changes in sensation of the genitals or buttocks (which is why it's called saddle anesthesia).

Motor deficits:  Weakness with movement of either leg.

Fevers:  Infectious causes of back pain can cause fevers.

Unintentional weight loss:  Whether sudden or gradual weight loss, malignancy is a consideration (albeit a very rare cause of low back pain and more common in those with a history of cancer)..

History of cancer:  If you’ve had breast cancer, melanoma, prostate, lung, kidney, thyroid, and any cancer for that matter, it’s vital that you discuss your low back pain with your doctor right away.

Thankfully, Lori hasn't experienced any of this. These red flags are more worrisome and truly warrant an urgent and/or possibly emergent evaluation. 

And of course any pain that is persistent, becomes chronic, or becomes more severe throughout time warrants a doctor visit, as well. It's always better to get checked out.

So we’ve gathered the vital components of Lori’s low back pain experience, we’ve reviewed the anatomy of the lumbarsacral spine, and the more serious red flags that require immediate attention. In the next episode, I’ll review the causes of low back pain, explain how sciatica can play a role, discuss imaging considerations, and finally the treatment grand finale.

Please note that all content here is strictly for informational purposes only.  This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider.  Please always seek a licensed physician in your area regarding all health related questions and issues. 

Image courtesy of Shutterstock.