Usual adult dose	Cost per 14-day course*	Comments
Drug Diflunisal (Dolobid)	500 mg q12h	$17.50	Low potential for GI upset. Anti-inflammatory effect not as beneficial as some of the other NSAIDs
Indomethacin (Indocin-SR)	75 mg qd-bid	$10-20	High potential gor GI and CNS side effects. Not the first drug of choice for elderly.
Naproxyn (Naprosyn)	200-500 mg q 12h 250 mg q 12h 375 mg q 12h 500 mg q 12h	$14 $17.50 $21.75	Also approved for ankylosing spondylitis, tendinitis, bursitis
Piroxicam (Feldene)	10-20 mg qd 10 mg qd 20 mg qd	$11 $16.75	10 mg is more appropriate for elderly patients
Sulidac (Clinoril)	150-200 mg q 12h 150 mg q 12h 200 mg q 12h	$14.25 $16.25	May have fewer renal side effects
Salsalate (Disalcid)	1.5G q 12h	$15.75	Least likely to cause GI irritation, smallest potential for renal side effects and fluid retention. Probably less evvective in sacroiliitis tahn other conditions

* Based on current California retail prices.

Disorder	Symptoms	Physical signs	Diagnostic Techniques	Treatment
Diskogenic
Disk herniation	Low back pain with radiculopathy and paravertebral muscle spasm;pain aggravated by sitting, Valsalva's maneuver, and sciatic stretch	Restricted spinal movement; restricted spinal segment; and positive League's test	EMG/NCS and CT or myelogram	(beyond scope of discussion)
Lateral entrapment syndrome (spinal stenosis)	Buttock and leg pain with radiculopathy and paravertebral muscle spasm;pain often relieved by sitting, aggravated by extension of spine	Similar to Disk herniation	EMG/NCS and CT with or without myelogram	(beyond scope of discussion)
NonDiskogenic
Sacroiliitis	Low back and Buttock pain	Tender SI joint; compression test; positive Patrick's test often associated with peripheral arthritis	X-Ray of the pelvis and the frog leg view of the SI joint and bone CRP may be elevated	Non steroidal and anti-inflammatory drugs; SI joint injection
Pyriformis syndrome	Low back and Buttock pain with the referred pain down the leg	Pain and weakness on resisted abduction/external rotation of thigh	Injection of muscle with local anesthetics	Injection of muscle with local anesthetics and corticosteroid
Iliolumbar syndrome	Pain in Iliolumbar ligament area(posterior iliac crest); referred pain down the leg	Tender iliac crest and increased pain with lateral bending	Local injection to iliac crest area	Local injection at insertion of iliac crest
Trochanteric bursitis	Buttock and lateral thigh pain; worse at night with activity	Tender greater trochanter; R/O associated with leg length discrepancy	--	Local injection of trochanteric bursa; NSAIDs
Ischiogluteal bursitis	Buttock and posterior thigh pain; worse with sitting	Tender ischial tuberosity; straight-leg raising test and Patrick's test positive; R/O associated with leg length discrepancy	--	Bed rest and local injections; NSAIDs
Posterior facet syndrome	Low back pain	Lateral bending in spinal extension increases pain	CT	Referral for local injection under fluoroscopy. Manipulation, NSAIDs
Meralgia paresthetica	Lateral thigh paresthesia	No motor findings, tenderness below antesuperior iliac spine	--	Local infiltration around the nerve
Fibrositis syndrome	Difficulty sleeping, anxiety and depression; multiple trigger points	Trigger-point tenderness maximal at defined sites	--	Antidepressants and trigger-point injections; aerobic exercise, stretching

History Pain: Time of onset, duration, chracter, factors that relieve or exacerbate pain Family history of back pain History of related diseases(colitis, psoriasis, peripheral arthritis, recent venereal infection) Physical Examination Observation of patient's gait Sacroiliac palpation Inspection of lumbar paraspinal spasm Anterior bending with Schöber test Lateral bending Patrick's test(two stage) Palpation of ischial and trochanteric bursae Palpation of sciatic notch Inspection of piriformis sign and performance of piriformis test Leg length measurement Pressure on floating rib Inspection of non-spinal and spinal points Rectal examination (loss of sphincter tone indicates nerve compression) Pelvic examination in women Inspection of shoes for abnormal wear. This is an important clue to both leg length discrepancy and altered gait, which may suggest a chronic underlying problem Laboratory Evaluation SMAC-20 ESR C-reactive protein Radiographs* : A film of the pelvis * In selected patients. See text for Indications.

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