low back pain: case based evaluation and management patrick kortebein, m.d. departments of pm&r...
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Low Back Pain:Case Based Evaluation
and Management
Low Back Pain:Case Based Evaluation
and Management
Patrick Kortebein, M.D.Departments of PM&R and GeriatricsUniversity of Arkansas for Medical
Sciences5/31/09
Slides: www.uams.edu/pmr
ObjectivesObjectives
• Understand the evaluation and management of common sources of low back and related pain
• Understand the significance of abnormal findings on lumbar spine MRI in individuals with low back and related pain.
• Understand the evaluation and management of chronic low back pain.
Low Back PainLow Back Pain
• Common; 2nd primary care visits• 5-15% per year • 60-80% lifetime
• Acute episodes • 75-90% recover w/in 3 months• 25-75% will have recurrence w/in 6 months
LBP: AnatomyLBP: Anatomy
• Bone / Vertebrae• Disc
• Annulus• Nucleus Pulposus
• Muscles / Ligaments
• Spinal Nerve Roots
Case #1Case #1
28 yo M presents with CC: LBP • Started 4 days ago while bending over to pick up his 14 mo old child
• PMHX: L knee arthroscopy• Meds: Acetaminophen• NKDA• Social Hx: Married, insurance salesman
What other information is important?
Acute LBP: HistoryAcute LBP: History
• Location• Axial or Radiating (Sciatica) ?
• Onset: Traumatic, Insidious• Duration:
• Acute: < 12 weeks• Chronic: > 12 weeks
• Character/Quality: Ache, Burning, etc
• Exacerbating / Alleviating Factors
Acute LBP: HistoryAcute LBP: History
“Red Flags” (AHCPR 1994)• Fracture:
• Major/minor trauma• Age > 70 yrs (~50 yrs)• Chronic corticosteroids
• Cauda Equina• B/B dysfunction• Saddle Anesthesia• LE weakness
Acute LBP: HistoryAcute LBP: History
“Red Flags” (AHCPR 1994)• Infection
• Fever• Steroids / Immunosuppression / IV Drug Use
• UTI / Systemic Infection
• Cancer • Hx of Cancer • Unintentional Weight Loss• Supine/Night Pain • Age > 50
Acute LBP: Physical ExamAcute LBP: Physical Exam
• Lumbar Spine:• Inspection• Palpation• ROM: Flexion / Extension
• +/- LE Neurologic Exam
Acute LBP: ImagingAcute LBP: Imaging
When?• Minimum 6 weeks• + “Red Flags”
What?• X-ray3-view:
•AP / Lat / L5 Spot
Obliques:•Limited information
•Radiation exposure
Acute LBP: ImagingAcute LBP: Imaging
Abnormal findings• “Degenerative disc disease”
• “Bulging disc”
• “Herniated disc”
LBP: ImagingLBP: Imaging
MRI Abnormalities in Normals / No LBP
• Boden et al (N=67) JBJS 1990• HNP: 21-36%• Bulging Disc: 50-80%• Degenerative Disc Changes: 34-93%
• Jensen et al (N= 98) NEJM 1994• Bulging Disc: 52% (28-100%)• Disc Protrusion: 27% (21-30%)
Case #1Case #1
History• Onset: 4 days ago, constant• Location: R lumbosacral junction• No radiation / neurological symptoms• No clear exacerbating / alleviating factors
Physical Exam• Mild tenderness R low lumbar region• Increased pain with flexion• Normal LExt neuro exam
Case # 1Diagnosis: “Mechanical” LBP
Case # 1Diagnosis: “Mechanical” LBP
• Education / Activity Modification• Bedrest: ~ 2 days (Deyo NEJM 1986)
• Analgesics: • Acetaminophen• NSAID’s• Tramadol
• Muscle Relaxants• Cyclobenzaprine
“Mechanical” LBP“Mechanical” LBP
• Physical Therapy• Exercise• Modalities• Lumbar Support
• Chiropractic• Acupuncture
Back Heat
LBP: Zygapophyseal (Facet) joint LBP: Zygapophyseal (Facet) joint
• History/Examination• Axial LBP +/- post thigh
• No neuro sxs• Worse w/ static posture•Lumbar Extension•Stand / Walk
• Neuro exam normal
LBP: Zygapophyseal (Facet) jointLBP: Zygapophyseal (Facet) joint
Management• Analgesics
• Tylenol, NSAID
• Physical Therapy• Injections
• Diagnostic • Therapeutic
LBP: Sacroiliac (SI) JointLBP: Sacroiliac (SI) Joint
• History• Atraumatic > Traumatic
• Axial; Lumbosacral• Uni- > Bilateral• No radiation / neuro sxs
• Physical Exam• ~ Normal• Tender SI region
LBP: DiscogenicLBP: Discogenic
History / Exam• Axial LBP• No radiation / neuro sxs
• Aggravating: • Static posture- Sitting or Sit to stand
• Normal neurological exam
LBP: DiscogenicLBP: Discogenic
Management• Physical Therapy
• Core Strength
• Surgery:• Fusion• Artificial Disc
•Not yet
Case # 2Case # 2
• 38 yo with left LE radicular pain > LBP for ~6 weeks. Also left foot tingling and weakness.
• PMHx: HTN, Hyperlipidemia• Meds: HCTZ, Atorvastatin• Allergies: Sulfa• Social Hx: Divorced, Landscaper
Case # 2Case # 2
Physical Exam• L-spine: Non-tender• Left LExt: + SLR / Crossed SLR
• Neuro• Motor: 5/5 except Plantar Flexion
• Reflex: KJ +2/+2, AJ +2 / 0• Sensory: Dec to LT lateral heel
LBP: RadiculopathyLBP: Radiculopathy
Diagnosis • Physical Exam• MRI• EMG• CT Myelogram
* Correlate anatomy w/ sxs and exam
LBP: RadiculopathyLBP: Radiculopathy
Neurological Exam:Motor Reflex SensoryL2/3: Hip Flex/Add Knee Med Thigh /Knee
L4: Knee Ext/DFlex Knee Med AnkleL5: Great toe/EHL Int. HS Dorsum Foot
S1: Plantarflex Ankle Lat Heel
Functional: Squat, Heel / Toe Walk, Heel Raise
LBP: RadiculopathyLBP: Radiculopathy
Management• Medications
• NSAID’s• Acetaminophen• Tramadol• Neuropathic
• Steroids; • Oral (? dose) vs epidural
LBP: RadiculopathyLBP: Radiculopathy
Management• Physical Therapy
• McKenzie Extension therapy• TENS ~ No benefit
LBP: RadiculopathyLBP: Radiculopathy
Surgery• Indications
• Cauda equina• Progressive neuro deficits
• No relief w/ conservative treatment
• SPORT trial• JAMA 2006
LBP: Spinal StenosisLBP: Spinal Stenosis
• History (Neurogenic claudication)• Prox LE Pain +/- Neuro sxs • Walk / Stand• Uphill > Downhill• Grocery Cart
• Physical Exam• ~ Normal• Stand / Walk
LBP: Spinal StenosisLBP: Spinal Stenosis
• Diagnosis• MRI• EMG
• Management• Medications
•Neuropathic
• PT• Epidural Injection • Surgery: (SPORT trial)
Case # 3Case # 3
• 51 yo M truck driver injured at work 2 years ago lifting a 30# box, and applying for disability
• Continued axial LBP and “numb” R LE
• No “Red Flags”• Treatments to date:
• Medications: NSAIDs, Tramadol, Hydrocodone
• Physical Therapy: 24 sessions• Work restrictions; not working• Injections: Epidural / Facet / Sacroiliac
Case # 3Case # 3
Physical Examination• Lumbar: Diffuse tenderness to light palpation
• Exaggerated pain behavior w/ trunk rotation
• Lower Extremity Neurologic• 50% decreased sensation entire LExt • Normal strength / reflexes• Supine SLR: LBP; Seated SLR: No pain
Case # 3Case # 3
• Lumbar MRI: • Mild DD changes with diffuse disc bulge at L4-5 and L5-S1
• Diagnosis?
• Treatment?
Chronic LBPChronic LBP
• Strong Association• Depression
• Anxiety
• Poor Coping Skills
“My back hurts, but I’m here because I can’t cope with this episode, as well as the turmoil at home (or work)”- N Hadler “Last Well Person”
Chronic LBPChronic LBP
**Goal** • Improve Function• Minimize focus on treating pain itself
• Biopsychosocial Model of Pain• Maladaptive Behavior • Neuroplasticity
Case # 3Case # 3
Multidisciplinary Pain Management
• Education• Medications
• Chronic Opioids ?
• PT Functional Restoration
• Psychology• Pain Management
Recommended ReadingRecommended Reading
• Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician 2007; 75:1181-8, 1190-2.
• Deyo et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22:62-8.
• LBP Handbook 2003• Cole & Herring
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