›NSAIDs: contraindicated in third trimester
›Risk of premature closure of ductus arteriosus
›Use with caution in second trimester
›Avoid entirely after 30 weeks gestation
›Muscle relaxants: avoid in pregnancy
›Cyclobenzaprine: insufficient safety data
›Opioids: avoid unless severe refractory pain
›Risk of neonatal opioid withdrawal syndrome
›Imaging in pregnancy
›MRI without gadolinium: safe in all trimesters
›Avoid CT unless life-threatening indication (AAA, dissection)
›Plain radiographs: low fetal radiation exposure; use if indicated for fracture
›Epidemiology in elderly patients
›Prevalence of LBP increases with age >40 years
›More likely to have specific pathoanatomical cause compared to younger adults
›Higher prevalence of vertebral compression fracture, spinal stenosis, malignancy
›Red flags more prevalent in elderly
›Vertebral compression fracture: LR+ with osteoporosis and minor trauma
›Minor trauma with age >75 has significant fracture risk
›Malignancy: increasing incidence with age
›AAA: higher prevalence in males over 65 who smoke
›Pharmacologic considerations
›NSAIDs: increased risk of adverse effects
›GI bleeding risk higher: consider PPI co-prescription
›Renal impairment common: check eGFR before prescribing
›Cardiovascular risk: use lowest dose for shortest duration
›Muscle relaxants: avoid per Beers Criteria
›High risk of falls, confusion, sedation in elderly
›Cyclobenzaprine explicitly listed on Beers Criteria
›Opioids: significantly increased sensitivity and risk
›Start low (25-50% of standard dose), go slow
›Falls and fracture risk
›Constipation, urinary retention, delirium
›Gabapentin and pregabalin: avoid; increased fall risk
›Imaging in elderly
›Lower threshold for imaging vs. younger patients
›Age >65 is ACR Appropriateness Criteria indication for imaging in some scenarios
›Osteoporotic fracture screening with low threshold
›Prefer MRI over CT for soft tissue assessment
›CT for fracture characterization
›DEXA scan referral for osteoporosis assessment
›Physical therapy considerations
›Core strengthening with attention to comorbidities
›Balance training to reduce fall risk
›Aquatic therapy for arthritis comorbidity
›Epidemiology in children and adolescents
›Prevalence of LBP in school-aged children 10-32%
›Increases significantly through adolescence
›JAMA Pediatrics 2017 review (MacDonald et al.)
›Most pediatric LBP is musculoskeletal and self-limited
›Specific pediatric diagnoses to consider
›Spondylolysis and spondylolisthesis
›Common in young athletes (gymnastics, football, dance)
›Extension-worsened pain in lumbar region
›Plain radiograph oblique views; CT or MRI for confirmation
›Scheuermann kyphosis
›Thoracic or thoracolumbar kyphosis >45 degrees
›Multiple (>3) consecutive vertebrae with >5 degrees anterior wedging
›Vertebral discitis or osteomyelitis
›Higher incidence in young children (<5 years)
›Refusal to walk, fever, localized spinal tenderness
›Leukemia and pediatric malignancy
›Higher index of suspicion for constitutional symptoms
›Functional pain disorders
›Anxiety, school avoidance, behavioral components
›Physical examination in children
›Growth assessment and pubertal staging
›Scoliosis screening: Adam forward bend test
›Hamstring tightness frequently associated with spondylolysis
›Hip examination to exclude Perthes or slipped capital femoral epiphysis
›Pharmacologic dosing in pediatrics
›Ibuprofen: 5-10 mg/kg orally every 6-8 hours
›Maximum 40 mg/kg per day
›Age >6 months
›Naproxen: 5 mg/kg orally every 12 hours
›Age >2 years
›Acetaminophen: 10-15 mg/kg orally every 4-6 hours
›Maximum 75 mg/kg per day
›Note: limited evidence for LBP efficacy even in children
›Avoid muscle relaxants: insufficient pediatric safety data
›Avoid opioids unless severe trauma or surgical indication
›Imaging in pediatrics
›AP and lateral lumbar spine radiographs first-line if imaging needed
›MRI preferred for neurologic symptoms or infection concern
›Limit CT to bone detail questions when MRI unavailable
›ALARA principle: minimize radiation exposure