clinical assessment of backpain cmc
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CLINICAL ASSESSMENT CLINICAL ASSESSMENT OF BACKPAINOF BACKPAIN
Dr. Anupam MahajanDr. Anupam Mahajan
LecturerLecturer
Department of OrthopaedicsDepartment of Orthopaedics
““Back Pain is an Illness Back Pain is an Illness in search of a Disease”in search of a Disease”
Williams ME, Haddler NM. N Engl J Med 1983;308:1357-Williams ME, Haddler NM. N Engl J Med 1983;308:1357-6060
Fact or Fiction
The work I do is the main cause of my bad back
FICTION
.
• Physical demands of work are a risk fact in the onset of back pain BUT overall the non work, individual and unidentified factors are more important.
Fact or Fiction
I have back pain I will get worse and may ultimately have to have an operation !
FICTION
•Most adults (60-80%) experience back pain at some time and it frequently reoccurs, but acute attacks are usually brief and self limiting.
Fact or FictionIf I hurt my back I should go to bed
and rest until I feel better ( I should rest and let pain be my guide!)
FICTION
• Prolonged resting weakens the muscles which support the back and can hinder recovery. Bed rest for 2-7 days is worse than no treatment
Fact or FictionFact or FictionThe way I feel about my bad back will determine The way I feel about my bad back will determine
how likely it is to get worse !how likely it is to get worse !
FACT
• If you think of yourself as a victim of the work you do you are more likely to get worse. Being positive about getting back to normal helps you to recover.
Fact or Fiction
X Rays and scans will not always show up the causes of back pain.
FACT
• In patients with non specific low back pain X ray and MRI findings do not match well with symptoms or work capacity
ANATOMY Anterior Column
-- anterior disc and vertebra, ant. long. ligament
Middle column-- posterior disc and vertebra, post. long. ligament
Posterior column-- bones: facet joints, pedicles, transverse processes, laminae, spinous processes-- ligaments: lig. flavum, interspinous, others
ANATOMY
Definitions
Acute LBP: <6 weeksSubacute LBP: >6 weeks but <3
months Chronic LBP: >3 monthsRecurrent LBP: Acute LBP in a patient
who has had previous episodes of LBP from a similar location, with asymptomatic intervening intervals.
Epidemiology – quick stats
90% of people experience back pain in their 90% of people experience back pain in their lifetime, and at least 50% have a recurrent lifetime, and at least 50% have a recurrent episodeepisode
80% of people seek care at some point for ALBP80% of people seek care at some point for ALBP
fifth most common reason to visit a physician fifth most common reason to visit a physician
50% of working persons have back pain every year
number one cause of disability under 45yrs
85% have no definitive diagnosisDeyo et al. JAMA 1992;268:760
<2% have disc herniation, <1% have malignancy
Causes of low back pain of low back pain
Why do we want to know the cause?
Guide our treatmentPatients want to know whyWe want to know why
Pain sensitive structures
Muscles & ligaments
Vertebral body periosteum
Dura Facet Joints Discs - AF Nerves Epidural veins
Common Sources of LBP
Disc 1. posteriorly - sinu vertebral nn. 2. laterally - gray rami communicantes a. branches of ventral rami 3. various types of nerve endings up to ½ annulus depth
Targets for dorsal primary ramus 1. facet joints
2. interspinous ligaments
3. back muscles
VPR
DPR
GRCSVN
Acute Back PainAcute Back Pain
Differential Differential Diagnosis
Mechanical Low Back or Leg Pain 97%
Nonmechanical Spinal Conditions 1%
Visceral Diseases 2%
Mechanical Low Back or Leg Pain (97%)
Lumbar strain/sprain Lumbar strain/sprain 70% 70% Degenerative process Degenerative process 10%10%Herniated discsHerniated discs 4% 4%Spinal stenosisSpinal stenosis 3% 3%Compression fxCompression fx 4% 4%SpondylolisthesisSpondylolisthesis 2% 2%Traumatic fracture Traumatic fracture <1%<1%Congenital Congenital <1%<1%SpondylolysisSpondylolysis Internal disc disruptionInternal disc disruption
Nonmechanical Spinal Conditions (1%)
Neoplasia 0.7%Neoplasia 0.7% multiple myelomamultiple myeloma metsmets lymphoma/leukemialymphoma/leukemia spinal cord tumorsspinal cord tumors retroperitoneal tumorsretroperitoneal tumors primary vert. Tumorsprimary vert. Tumors
Infection 0.01%Infection 0.01% osteomyelitisosteomyelitis septic diskitisseptic diskitis paraspinous abscessparaspinous abscess shinglesshingles
Inflammatory arthritis Inflammatory arthritis 0.3%0.3% ankylosing spondylitisankylosing spondylitis psoriatic spondylitispsoriatic spondylitis Reiter’s syndromeReiter’s syndrome Inflammatory bowel Inflammatory bowel
diseasedisease Paget’s disease Paget’s disease Scheuermann’s Scheuermann’s
diseasedisease
Visceral Disease (2%)Visceral Disease (2%)
Disease of pelvic Disease of pelvic organsorgans prostatitisprostatitis endometriosisendometriosis chronic PIDchronic PID
Renal diseaseRenal disease nephrolithiasisnephrolithiasis pyelonephritispyelonephritis perinephric abscessperinephric abscess
Aortic aneurysmsAortic aneurysms Gastrointestinal Gastrointestinal
diseasesdiseases pancreatitispancreatitis cholecystitischolecystitis penetrating ulcerpenetrating ulcer
Causes of low back painCauses of low back pain
Things that need:Things that need:
URGENT workupURGENT workupURGENT referralURGENT referralURGENT treatmentURGENT treatment
““Red Flag”Red Flag” signs signs
Watch out forWatch out for
History of traumaHistory of traumaWeight loss, malaise, feverWeight loss, malaise, feverNumbness, weakness,Numbness, weakness, incontinenceincontinence
Fracture
Tumor,infection
Cauda equina
HISTORY HISTORY • Onset, Duration, ProgressionOnset, Duration, Progression• LocationLocation• CharacterCharacter• Exacerbating and relieving factorsExacerbating and relieving factors• RadiationRadiation
• Previous episodes (course, treatment)Previous episodes (course, treatment)• Any other joint inv, morning stiffnessAny other joint inv, morning stiffness• Medical history (CA, osteoporosis, infections, Medical history (CA, osteoporosis, infections,
etc…)etc…)• Drugs/medications (IVDU, steroids)Drugs/medications (IVDU, steroids)• Systemic symptoms (fever, sweats, wt. loss, etc…)Systemic symptoms (fever, sweats, wt. loss, etc…)• Function (ability to work, care for self)Function (ability to work, care for self)
RED FLAGS – HISTORYRED FLAGS – HISTORY
BB – bowel/bladder – bowel/bladder AA – awakening (night-time), accident (trauma) – awakening (night-time), accident (trauma) CC – cancer, constitutional symptoms – cancer, constitutional symptoms KK – chronic disease – chronic disease
PP – parasthesia, pharmacy (steroids, IVDU) – parasthesia, pharmacy (steroids, IVDU) AA – age >55 or <20 – age >55 or <20 II -- infection, inactivity (worse at rest) -- infection, inactivity (worse at rest) NN – neurologic deficit – neurologic deficit SS – subacute (lasting >6wks), surgery (previous) – subacute (lasting >6wks), surgery (previous)
PHYSICAL EXAMPHYSICAL EXAM1. Inspection1. Inspection2. ROM2. ROM3. Palpation3. Palpation4. Motor4. Motor5. Sensation5. Sensation6. Reflexes6. Reflexes7. Straight leg raise7. Straight leg raise8. Abdominal exam8. Abdominal exam9. Vascular exam9. Vascular exam10. Other (as guided by above e.g. chest 10. Other (as guided by above e.g. chest
expansion)expansion)
INSPECTIONINSPECTION
GaitGait
PosturePosture-- head/shoulders, -- head/shoulders, listing, flxn/extn, pelvic listing, flxn/extn, pelvic tilt tilt
Muscle balance, Muscle balance, HabitusHabitus
AlignmentAlignment
Appley’s Textbook of Orthopaedics, 8th edn
PALPATION AND PERCUSSIONPALPATION AND PERCUSSION
Bones Bones -- tenderness or deformity over -- tenderness or deformity over spinous processesspinous processes
JointsJoints
-- facet and sacroiliac joint -- facet and sacroiliac joint tendernesstenderness
MusclesMuscles
-- paraspinal tension and -- paraspinal tension and trigger pointstrigger points
RANGE OF MOTIONRANGE OF MOTION
often very limited globally often very limited globally secondary to pain -- secondary to pain -- perform slowly with perform slowly with physical supportphysical support
FlexionFlexion (normal = 90 (normal = 90 degrees , >5 cm by degrees , >5 cm by Modified Schober’s Modified Schober’s method)method)
Lateral bendingLateral bending (normal = 45 degrees, (normal = 45 degrees, hand to knee) hand to knee)
RotationRotation (normal = (normal = 90 degrees, stabilize 90 degrees, stabilize hips)hips)
RANGE OF MOTIONRANGE OF MOTION ExtensionExtension (normal = 30 degrees) (normal = 30 degrees)
-- narrows canal, loads facet joints-- narrows canal, loads facet joints
CombinationsCombinations
-- extension + rotation loads ipsilateral facet-- extension + rotation loads ipsilateral facet
Hip ROM should also be assessedHip ROM should also be assessed
-- to r/o articular disorders, identify muscular -- to r/o articular disorders, identify muscular problems (e.g. flexion contracture may problems (e.g. flexion contracture may increase disc pressure)increase disc pressure)
NEUROLOGIC TESTINGNEUROLOGIC TESTING Motor examMotor exam (screen = squat, heel/toe (screen = squat, heel/toe
walks)walks)
Sensory examSensory exam (screen = light touch of foot, (screen = light touch of foot, knee)knee)
ReflexesReflexes (ankle, patellar, Babinski)(ankle, patellar, Babinski)
SLRSLR (sensitive but not specific for (sensitive but not specific for herniation of disc herniation of disc
+/- Others+/- Others (e.g. femoral stretch, auton, etc )(e.g. femoral stretch, auton, etc )
Straight Leg Raise -- SLRStraight Leg Raise -- SLR
positive SLR produces positive SLR produces radicular radicular painpain that radiates below one or that radiates below one or both knees, both knees, notnot pain in the pain in the buttock, thigh or backbuttock, thigh or back
improved by decreasing improved by decreasing elevation, and worsened by elevation, and worsened by ankle dorsiflexionankle dorsiflexion
crossed SLR) is much more crossed SLR) is much more specific (but not sensitive) for specific (but not sensitive) for disc herniationdisc herniation
Motor examMotor exam Bulk and ToneBulk and Tone
Power (1 to 5)Power (1 to 5)-- squat (L3,-- squat (L3,44), heel walk (L4,), heel walk (L4,55), toe walk (S1), ), toe walk (S1), -- more detailed testing if any neurologic deficit:-- more detailed testing if any neurologic deficit:no motor at L1no motor at L1hip addn (L2)hip addn (L2)hip flexn (L2,3) hip flexn (L2,3) knee extn (L3,4)knee extn (L3,4)ankle dorsiflexn (L4,5)ankle dorsiflexn (L4,5)hallucis extn (L5)hallucis extn (L5)hip extn (S1)hip extn (S1)ankle extn (S1,2)ankle extn (S1,2)
Sensory examSensory exam
light touch to light touch to medial foot (L4), medial foot (L4), first web space (L5) first web space (L5)
and and lateral foot (S1) lateral foot (S1)
will detect most clinically will detect most clinically significant deficits significant deficits
UMN vs. LMNUMN vs. LMNUpper Motor NeuronUpper Motor Neuron
increased toneincreased tone hyper-reflexiahyper-reflexia up going Babinskiup going Babinski diffuse weakness diffuse weakness
no fasciculationsno fasciculations normal bulknormal bulk
Lower Motor NeuronLower Motor Neuron
decreased tonedecreased tone decreased reflexesdecreased reflexes down going Babinskidown going Babinski focal weaknessfocal weakness
fasciculations fasciculations muscle atrophymuscle atrophy
Red Flags – Physical findingsRed Flags – Physical findings(things that make you go hmmm….)(things that make you go hmmm….)
feverfever saddle anaesthesiasaddle anaesthesia urinary retention or loss of rectal tone urinary retention or loss of rectal tone positive Babinski, other UMN signs positive Babinski, other UMN signs
bilateral, severe, progressive, or persistent (<1mo.) bilateral, severe, progressive, or persistent (<1mo.) neurologic deficitsneurologic deficits
bony tenderness to palpation or percussionbony tenderness to palpation or percussion abnormal abdominal or respiratory examabnormal abdominal or respiratory exam
Tests for SI Joint Tests for SI Joint
FABER test
Pelvic rock/ Compression test
Distraction test
Pump Handle test
Ganslens test
Other testsOther testsMilgram test- hold heels 2 in. off
table for 30 sec., if can hold intrathecal pathology ruled out
Tests for MalingeringPhlip’s testAird’s TestMagnuson TestHoover test
Signs of Non-organic Pain (Waddell)Signs of Non-organic Pain (Waddell)
1. Superficial tenderness (e.g. skin rolling)1. Superficial tenderness (e.g. skin rolling)
2. Pain with simulated testing (e.g. axial 2. Pain with simulated testing (e.g. axial loading)loading)
3. Inconsistent responses with distraction (e.g. 3. Inconsistent responses with distraction (e.g. clenched fist) clenched fist)
4. Non-anatomic neurologic deficits4. Non-anatomic neurologic deficits
5. Over-reaction and “pain behaviours”5. Over-reaction and “pain behaviours”
3 of 5 criteria present is suggestive of non-3 of 5 criteria present is suggestive of non-organic painorganic pain
Approach to DiagnosisApproach to DiagnosisBack pain
Localised to back Radiation Red Flag
Primarily back pain Referred
transient intermitent
claudication
Strain /sprainHip path
Facet jointIVD
<20 listhesis
20-40 Disc prol
Elderly Comp #
OA
Spinal stenosis
Constitutional symp
Trauma Neuro+ bowel bladder
Tumorinfection
fracture Cauda equina
Relieved by rest Not relieved by restRelieved by exercise
AS
Criteria for Radiographs (A/P, lateral)Criteria for Radiographs (A/P, lateral)
basically, basically, any red flags on history or any red flags on history or physicalphysical::
loss of lumbar lordosisloss of lumbar lordosis
scoliosis / kyphosis/ listhesis/ lysisscoliosis / kyphosis/ listhesis/ lysis
osteopenia / bone destruction osteopenia / bone destruction (30%)(30%)
disc spacedisc space
pediclespedicles
Blood WorkBlood Work
Blood work (with red flags only… be specific)Blood work (with red flags only… be specific)CBC, ESR CBC, ESR Blood cultures (+/- Montoux)Blood cultures (+/- Montoux)Alkaline Phosphatase, calcium, Phos, TP, albuminAlkaline Phosphatase, calcium, Phos, TP, albuminSerum protein electrophoresis, PSASerum protein electrophoresis, PSAHLA-B27HLA-B27
Other non-MSK-related tests as indicatedOther non-MSK-related tests as indicated
Initial Investigations -- findingsInitial Investigations -- findings
ConditionCondition RadiographsRadiographs Blood WorkBlood Work
Disc Disc
HerniationHerniation
narrowed disc space(s)narrowed disc space(s)
(not an acute change)(not an acute change)
NilNil
OsteoarthritisOsteoarthritis narrow joint space, cysts narrow joint space, cysts osteophytes, erosionsosteophytes, erosions
Nil (normal ESR)Nil (normal ESR)
SpondylolisthesisSpondylolisthesis Abnormal movement on Abnormal movement on flexion/extension viewsflexion/extension views
NilNil
Initial Investigations -- findingsInitial Investigations -- findings
ConditionCondition RadiographsRadiographs Blood WorkBlood Work
InfectionInfection often normal often normal
+/- changes at 10-14days +/- changes at 10-14days
CBC (WBC), ESR CBC (WBC), ESR
blood culture (60-80%)blood culture (60-80%)
TumourTumour erosions or blastic lesions,erosions or blastic lesions,
mets may invade pediclesmets may invade pedicles
(winking owl sign on AP)(winking owl sign on AP)
CBC (anemia), ESRCBC (anemia), ESR
PSA, electrophoresis, PSA, electrophoresis, alkaline phosphatasealkaline phosphatase
AnkylosingAnkylosing
SpondylitisSpondylitis
sacroiliac joints sacroiliac joints
(sclerosis, narrowing),(sclerosis, narrowing),
bamboo spine (squared)bamboo spine (squared)
ESRESR
HLA-B27 (90% +)HLA-B27 (90% +)
Criteria for CT/MRICriteria for CT/MRI
Significant neurologic findingsSignificant neurologic findings Unstable fracture or otherwise suspicious XRUnstable fracture or otherwise suspicious XR Significant red flags (despite normal XR, blood Significant red flags (despite normal XR, blood
work)work) No improvement after 6wksNo improvement after 6wks
CT better for bone, +/- tumour,CT better for bone, +/- tumour, MRI better for restMRI better for rest
Criteria for Bone ScanCriteria for Bone Scan
11.. MalignancyMalignancy
-- find early lesions (especially blastic)-- find early lesions (especially blastic)
2.2. InfectionInfection
-- Gallium scan most specific (pos. early)-- Gallium scan most specific (pos. early)
3. Occult fracture3. Occult fracture
Other InvestigationsOther Investigations
DensitometryDensitometryosteoporosisosteoporosis
ElectromyographyElectromyographysubtle, persistent neurologic symptoms e.g. subtle, persistent neurologic symptoms e.g.
spinal stenosis or spinal cord myelopathyspinal stenosis or spinal cord myelopathysuspected peripheral nerve lesion suspected peripheral nerve lesion sx of myopathysx of myopathy
EmergenciesEmergencies
Cauda Equina Syndrome / Spinal Cord Cauda Equina Syndrome / Spinal Cord CompressionCompression
only difference between the two is level affectedonly difference between the two is level affected
Etiology:Etiology: tumour, hematoma, abscess, fracture, tumour, hematoma, abscess, fracture, trauma, Spondylolisthesis, trauma, Spondylolisthesis,
HistoryHistory: : back pain is usually mild/mod.back pain is usually mild/mod.Numbness, paresthesiasNumbness, paresthesias fecal/urinary retention/incontinencefecal/urinary retention/incontinence
Cauda Equina Syndrome / Spinal Cord Cauda Equina Syndrome / Spinal Cord CompressionCompression
Physical examPhysical exam: : gait changes, gait changes, significant bilateral motor/sensory loss (e.g. saddle significant bilateral motor/sensory loss (e.g. saddle
anesthesia), anesthesia), Ankle areflexiaAnkle areflexialong tract signs, long tract signs, diminished rectal tone (60-80%), diminished rectal tone (60-80%), large post void residual (negative predictive value 99.99%)large post void residual (negative predictive value 99.99%)
Management:Management: XR, full spine MRI, XR, full spine MRI,
+/- steroids, surgery+/- steroids, surgery
Abdominal Aortic Aneurysm (AAA)Abdominal Aortic Aneurysm (AAA)
uncommon, but potentially lethal uncommon, but potentially lethal
RF: elderly, FHx, PVD (i.e.atherosclerosis)RF: elderly, FHx, PVD (i.e.atherosclerosis)
palpation for pulsatile mass is surprisingly palpation for pulsatile mass is surprisingly sensitive and specific, +/- bruit sensitive and specific, +/- bruit
Mechanical and Mechanical and Musculoligamentous Musculoligamentous
Back PainBack Pain
Diagnosis -- HistoryDiagnosis -- History
Disc Disc FacetFacet RootRoot StenosisStenosis
OnsetOnset (hrs—days)(hrs—days) (min--hrs)(min--hrs) (seconds)(seconds) (minutes)(minutes)
PainPain Back Back (radiates to (radiates to posterior posterior thigh(s))thigh(s))
Back Back (radiates to (radiates to buttock(s), buttock(s), lateral leg)lateral leg)
LegLeg
(unilateral, (unilateral, dermatome)dermatome)
Legs Legs
(bilateral)(bilateral)
DurationDuration wks—monthswks—months days--wksdays--wks sec-- minsec-- min minutesminutes
Activity Activity which which worsensworsens
bending, bending, lifting, lifting, ValsalvaValsalva
standing, standing, walkingwalking
as with discas with disc exercise, exercise, standingstanding
Diagnosis – physical examDiagnosis – physical exam
Disc Disc FacetFacet Root Root StenosisStenosis
ROMROM flexn hurts, flexn hurts, poor hip flexpoor hip flex
extn hurts, extn hurts, esp. with rotn esp. with rotn
flexn hurtsflexn hurts extn hurtsextn hurts
PalpnPalpn truncal tilt, truncal tilt, fxnl scoliosisfxnl scoliosis
pain over pain over facet jointfacet joint
pain with pain with nerve press.nerve press.
NilNil
NeuroNeuro NilNil NilNil dermatomaldermatomal
(sens/motor, (sens/motor, decr. reflex)decr. reflex)
(+ SLR)(+ SLR)
only if acute only if acute or v. severe or v. severe (UMN signs)(UMN signs)
PATHOPHYSIOLOGY OF DDDPATHOPHYSIOLOGY OF DDD
discs degenerate discs degenerate
compress the nerve root (compress the nerve root (sciaticasciatica) or spinal cord) or spinal cord
fissures and cracks occur in the annulus, and herniations of nucleusfissures and cracks occur in the annulus, and herniations of nucleus
reactive reactive osteophytesosteophytes
spinal stenosisspinal stenosis
spondylolisthesisspondylolisthesis
DISC HERNIATIONDISC HERNIATION 95% of disc herniations occur 95% of disc herniations occur
at L4/5 or L5/S1 because at L4/5 or L5/S1 because pressure is greatest therepressure is greatest there
disc most commonly herniate disc most commonly herniate posterolaterally, impinging on posterolaterally, impinging on the motor and sensory rami the motor and sensory rami (LMN signs) (LMN signs)
disc may also (rarely) herniate disc may also (rarely) herniate centrally, impinging on the centrally, impinging on the spinal cord itself (UMN signs)spinal cord itself (UMN signs)
DEGENERATIVE DISC DEGENERATIVE DISC DISEASEDISEASE
pain frompain from: : 1. disc damage (variable btw individuals) or 1. disc damage (variable btw individuals) or
2. root irritation by herniated discs2. root irritation by herniated discs
3. muscular inflammation/spasm3. muscular inflammation/spasm
therapy aimed at therapy aimed at pain controlpain control and and gentle ROMgentle ROM to to promote healing and prevent stiffness/weakeningpromote healing and prevent stiffness/weakening
secondary preventionsecondary prevention (improved flexibility, muscle (improved flexibility, muscle stabilizing, avoiding precipitating events, etc…) stabilizing, avoiding precipitating events, etc…)
FACET DISEASEFACET DISEASE
pain frompain from:1. pinching of synovium :1. pinching of synovium
2. underlying OA 2. underlying OA
3. secondary muscular 3. secondary muscular inflammation/spasminflammation/spasm
responds well to responds well to physical therapiesphysical therapies (stretch/relax (stretch/relax muscle spasm and move joint to allow realignment) muscle spasm and move joint to allow realignment)
secondary preventionsecondary prevention (prevent misalignment) (prevent misalignment)
SPONDYLOLISTHESISSPONDYLOLISTHESIS
Six typesSix types:: congenital /dysplasticcongenital /dysplastic 20%20% Lytic / isthmicLytic / isthmic 50%50% DegenerativeDegenerative 25%25% Post-traumaticPost-traumatic PathologicalPathological Post-opPost-op
SxSx: local pain : local pain oror radiculopathy radiculopathy oror cord compression (rare)cord compression (rare)
Spinal StenosisSpinal StenosisEtiology:Etiology:
DDD (i.e. typically elderly patients), DDD (i.e. typically elderly patients), trauma, trauma, congenital defectscongenital defectsfacet joint arthropathyfacet joint arthropathybony or lig thickening bony or lig thickening
History:History: most patients have hx of chronic back most patients have hx of chronic back
painpain 90% have predominantly leg 90% have predominantly leg
symptoms symptoms claudication (pain with exercise) claudication (pain with exercise) Must distinguish from vascular Must distinguish from vascular
Physical:Physical: signs are unreliable – may signs are unreliable – may
have thigh pain with sustained lumbar have thigh pain with sustained lumbar extension (>30 sec)extension (>30 sec)
Vascular Vs. Neurogenic Vascular Vs. Neurogenic ClaudicationClaudication
NeurogenicNeurogenic
ppt’d by extensionppt’d by extension onset variable with onset variable with
walkingwalking relief after 2-10 relief after 2-10
minutesminutes bilateral parasthesia bilateral parasthesia
+/- neuro deficit+/- neuro deficit
VascularVascular
no positional effectno positional effect onset after set onset after set
distancedistance relief under 2 minutesrelief under 2 minutes muscular cramping, muscular cramping,
often lateralizesoften lateralizes
OSTEOPOROSISOSTEOPOROSIS
Etiology: Etiology: primary (post-menopausal or elderly)primary (post-menopausal or elderly) secondary secondary
drugs—steroids, anticonvulsants; drugs—steroids, anticonvulsants; endocrine– thyroid/parathyroid xs,hypoestrogenism; endocrine– thyroid/parathyroid xs,hypoestrogenism; hepatic or renal disease; hepatic or renal disease; MalabsorptionMalabsorption rheumatoidrheumatoid
History: History: acute or chronic back pain (ache) with or without fracture acute or chronic back pain (ache) with or without fracture
or traumaor trauma may have history of other fractures (long bones)may have history of other fractures (long bones)
OsteoporosisOsteoporosis
Physical examn: loss of height, kyphosis loss of height, kyphosis
and/or scoliosis and/or scoliosis +/- bony tenderness or +/- bony tenderness or
neurologic sx neurologic sx
Investigations: plain XR (look for fracture, or plain XR (look for fracture, or
late changes)late changes) Densitometry (1-2 = Densitometry (1-2 =
osteopenia, >2.0 = osteopenia, >2.0 = osteoporosis)osteoporosis)
FracturesFractures
Etiology: Etiology: trauma, tumour, osteomalacia, trauma, tumour, osteomalacia, osteoporosisosteoporosis
History: History: sudden/localized pain +/- radicular sx, sudden/localized pain +/- radicular sx, trauma, old age, hx CA, steroid use or other RF trauma, old age, hx CA, steroid use or other RF for osteoporosis for osteoporosis
PhysicalPhysical: bony tenderness +/- neurologic deficit: bony tenderness +/- neurologic deficit
InvestigationsInvestigations: plain films, +/- CT, +/- bone scan: plain films, +/- CT, +/- bone scan
TuberculosisTuberculosis 50% of skeletal 50% of skeletal
tuberculosistuberculosis Mostly affects the dorsal Mostly affects the dorsal
and dorsolumbar spineand dorsolumbar spine Children and adolescentsChildren and adolescents Constitutional symptomsConstitutional symptoms Paradiscal most commonParadiscal most common
X-ray – loss of disc spaceX-ray – loss of disc space MRI- cord inv, abscesses MRI- cord inv, abscesses
OsteomyelitisOsteomyelitis Etiology:Etiology: usu. usu. hematogenous spread -- S.aureus hematogenous spread -- S.aureus
and gram negatives most common in vertebrae and gram negatives most common in vertebrae
HistoryHistory: : usually oldusually old immunocompromised (DM, steroids, chemotherapy, HIV, immunocompromised (DM, steroids, chemotherapy, HIV,
transplant, etc… )transplant, etc… ) pain aching, constant, varying severity, usu. pain aching, constant, varying severity, usu. SubacuteSubacute +/- constitutional symptoms +/- constitutional symptoms +/- history of recent infection (skin, UTI, bacteremia)+/- history of recent infection (skin, UTI, bacteremia)
OsteomyelitisOsteomyelitisPhysical:Physical: bony tenderness, painful bony tenderness, painful
ROM, fever (only 30%)ROM, fever (only 30%)
Diagnosis:Diagnosis:Gallium scanGallium scan positive earlier than XR (by positive earlier than XR (by
2-3days?) 2-3days?) blood cultureblood culture positive 60-80% positive 60-80% XRXR findings late – osteopenia, disc findings late – osteopenia, disc
space loss, soft tissue shadowsspace loss, soft tissue shadows
TumoursTumours Back pain may result fromBack pain may result from
tumours in the bony spine tumours in the bony spine or the adjacent soft tissues (fracture or pressure)or the adjacent soft tissues (fracture or pressure)
Primary MalignancyPrimary Malignancy-- sarcoma more common in children/young adults -- sarcoma more common in children/young adults -- multiple myeloma more common in adults (anemia, -- multiple myeloma more common in adults (anemia, renal failure, bone pain, constitutional sx) renal failure, bone pain, constitutional sx)
MetastasisMetastasis-- much more common than primary malignancy-- much more common than primary malignancy-- -- prostateprostate, thyroid, , thyroid, breastbreast, lung, kidney, lung, kidney
TumoursTumours
risk factors for malignancyrisk factors for malignancy (identify virtually all (identify virtually all pts): pts):
-- age over 50 (80%) -- age over 50 (80%) -- previous hx CA (33%) -- previous hx CA (33%) -- constitutional sx-- constitutional sx -- no relief with bed rest -- no relief with bed rest -- duration greater than one month-- duration greater than one month
TumoursTumours
x raysx rays
CTCT
Bone ScanBone Scan
Investigations for primaryInvestigations for primary
SpondyloarthropathiesSpondyloarthropathies
seronegative rheumatic diseasesseronegative rheumatic diseases may cause may cause sacroilitissacroilitis or or spondylitisspondylitis as well as peripheral arthritis as well as peripheral arthritis and enthesopathyand enthesopathy
extra-articular featuresextra-articular features – incl. – incl. iritisiritis, conjuctivitis, , conjuctivitis, apthous ulcers, aortitis, resp/kidney involvement, apthous ulcers, aortitis, resp/kidney involvement, etc…) etc…)
Ankylosing spondylitisAnkylosing spondylitis >> Reiter’s syndrome > >> Reiter’s syndrome > Inflammatory Bowel Disease > Reactive arthritis > Inflammatory Bowel Disease > Reactive arthritis > Psoriatic arthritisPsoriatic arthritis
Ankylosing SpondylitisAnkylosing Spondylitis History:History:
insidious onset back/buttock pain at insidious onset back/buttock pain at rest (better with activity), rest (better with activity),
prolonged am stiffness (hours), prolonged am stiffness (hours), peripheral arthritis (20-30%), peripheral arthritis (20-30%), extra-articular features, extra-articular features, FHxFHx
Physical:Physical: decreased back ROM (all directions), decreased back ROM (all directions), loss of lumbar lordosis, loss of lumbar lordosis, decreased chest expansion decreased chest expansion sacroiliac joint tendernesssacroiliac joint tenderness
Diagnosis:Diagnosis: plain XR, plain XR, HLA-B27 (90%)HLA-B27 (90%)
MUSCULOLIGAMENTOUS PAINMUSCULOLIGAMENTOUS PAIN
may mimic mechanical back pain or occur may mimic mechanical back pain or occur along with italong with it
may perpetuate mechanical pathology, may perpetuate mechanical pathology,
lifestyle measureslifestyle measures especially important in especially important in secondary preventionsecondary prevention
Musculoligamentous PainMusculoligamentous Pain
MYOFASCIAL SYNDROMESMYOFASCIAL SYNDROMEScharacterized clinically by restricted characterized clinically by restricted
ROM, muscle tenderness, and trigger ROM, muscle tenderness, and trigger pointspoints
e.g. Piriformis, Gluteal, Iliopsoas, e.g. Piriformis, Gluteal, Iliopsoas, Quadratus lumborumQuadratus lumborum
Trigger PointsTrigger Points
taut bands/knots of muscle fibrestaut bands/knots of muscle fibres that that referrefer pain pain along the sensory nerve innervating the musclealong the sensory nerve innervating the muscle
result of result of primaryprimary muscle strain or muscle strain or secondarysecondary to an adjacent bony or soft tissue to an adjacent bony or soft tissue
inflammation/injury (i.e. non-specific)inflammation/injury (i.e. non-specific)
pressure may be a pressure may be a diagnostic and therapeuticdiagnostic and therapeutic* * maneuver (30 – 60 sec)maneuver (30 – 60 sec)
TREATMENT STRATEGIESTREATMENT STRATEGIES1. Activity
2. Stretching, ROM
3. Heat and cold
4. Analgesia +/- anti-inflammatory
5. Consider physiotherapy referral
6. Patient education
7. Put in a plug for prevention -- including smoking cessation, weight loss loss
Activity
Bed rest longer than 48hrs is contraindicated Avoiding irritating activities may shorten
episode
-- minimize lifting
-- avoid prolonged sitting if it aggravates (soft support in small of back while sitting to minimize)
-- change position often
Stretching and ROM ExercisesStretching and ROM Exercises
speed recovery and prevent recurrence
specific examples include:
-- gentle ROM in all directions
-- “cat” stretch (20-30x), esp. in am, lubricates facet jts
-- pelvic tilt exercises
-- “scissors” stretch for paraspinals, hamstrings
-- “rocker” stretch to lengthen iliopsoas muscles
Heat/ColdHeat/Cold
Cold in first 48 hrs -- 10 min on/off, or 20-30 min q2h-- analgesia and limits edema
Heat after 48hrs-- similar application as above-- analgesia, improves spasm/exercise
tolerance
contraindicated in circulatory or cognitive compromise
AcetaminophenAcetaminophen
first line therapy for ALBP (along with NSAID)
fewer side effects than other analgesics
equal analgesia to NSAIDS, but no anti-inflammatory
analgesia with NSAIDS is cumulative
NSAIDS
first line agents
excellent for analgesia +/- anti-inflammatory
side effects are relatively common (GI, renal, others)
regularity needed for anti-inflammatory effect
NSAIDSNSAIDS ibuprofen
indomethicin more potent, but also more toxic
ketorolac is $$, toxic, over-rated for non-colicky pain
naproxen is fairly $$, but has a longer half-life (12-24hrs) allowing for BID dosing
cox-2 inhibitors reasonable, less studied, less costly
Narcotics
analgesia may be no better than with NSAIDS
dependence/abuse
constipation
drowsiness, clouded judgment, decr. reaction time may limit use
Muscle Relaxants
some benefit if used as monotherapy acutely,
not for extended use, not first line
primary side effect is drowsiness (often BDZ, anti-H)
dependence may occur
Physiotherapy
modest benefit during acute episode of LBP
significant benefit in chronic LBP (decreases need for surgery) and in the prevention of ALBP
not indicated for patients with neurologic deficits
Chiropracty
some benefit in the management of acute mechanical back pain without radiculopathy or red flags
no proven benefit in chronic pain
Surgery
evidence of significant spinal cord compression
persistent neurologic deficit after 1 month of conservative therapy, plus CT/MRI pathology
severe, limiting spinal stenosis
success depends on selection – if above criteria strictly applied, long-term benefit in 70-80%
Other therapies
traction, traction, transcutaneous electrical nerve stimulation,transcutaneous electrical nerve stimulation, biofeedback, biofeedback, diathermy, diathermy, ultrasound, ultrasound, acupuncture, acupuncture, facet joint injectionsfacet joint injections trigger point injectionstrigger point injections
PreventionPrevention
Weight loss, Smoking cessationWeight loss, Smoking cessation Aerobic exerciseAerobic exercise
Postural change (neck/shoulders back, pelvic tilt)Postural change (neck/shoulders back, pelvic tilt) Back and hip stretchingBack and hip stretching Strengthening abdominal, back musculatureStrengthening abdominal, back musculature
Workplace ergonomicsWorkplace ergonomics Avoid precipitating activities (e.g. heavy lifting, Avoid precipitating activities (e.g. heavy lifting,
especially while bending, reaching, or twisting)especially while bending, reaching, or twisting)
History, exam, risk fs for RED FLAG
FU at 2 wksReturn to normal activity
No diag. testsReassurance
Patient educationPain relief necessary?
Symp trearment optionsEarly return to usual activityActivity alterationsNSAIDsShort- ms relaxant/opoidsBed rest optional- <2 dSpinal manipulation/physical therapy optional
Resume normal activity
Yes
No
No
Yes
No
FU at 2 weeksReturn to activity tolerance?
No Yes
Review response to initial treatmentReview risk factorsModify symptomatic treratment
Resume normal activity
FU at 2 weeksReturn to normal activity?
Yes
No
Acute back pain >4 weeks
NoYes
EMG/MCV radiculopathy?Imaging study [MRI,CT, myelography]Are imaging and neurologic evaluations concordant?
Specialist FU; nerve root, plexus or CNS problem?
Appropiate intervention
Consult specialistNeurological exam.
Clear nerve root level?
Consult spinal surgeon
Yes
No
No
Yes Yes
Yes
Risk factor for serious etiology present
Rapidly progresive neurological deficit
Immediate consutlation specialist
Spine fracture Cancer Infection
Plain X ray
Fracture + Fracture-
CBC, ESRCBC, ESR, DLC, UA
Other labHigh suspicion after 10 days
– MRI, bone scan
Evidence of serious disease?
SummarySummary
ALBP is extremely prevalent and preventableALBP is extremely prevalent and preventable
A good history and physical exam are highly A good history and physical exam are highly sensitivesensitive
While uncommon, serious etiologies must be While uncommon, serious etiologies must be identified (red flags) and investigatedidentified (red flags) and investigated
Most ALBP is secondary to soft tissue injury and is Most ALBP is secondary to soft tissue injury and is amenable to conservative physical therapiesamenable to conservative physical therapies
Chronic BackpainChronic Backpain
When it become chronicWhen it become chronic
More psychological disturbanceMore psychological disturbanceMore social consequencesMore social consequencesMore behavioral changesMore behavioral changes
More difficult to treatMore difficult to treat
Watch out for…Watch out for…
Mood problemsMood problems
DepressionDepressionAnxietyAnxietyPost-traumatic stressPost-traumatic stressSuicidal riskSuicidal risk
Watch out for…Watch out for…
Thought problemsThought problems
Mal-adaptative ideasMal-adaptative ideasBlaming themselves / othersBlaming themselves / othersWrong (even no) coping skillsWrong (even no) coping skills
Watch out for…Watch out for…
Behavioral problemsBehavioral problems
Interaction with othersInteraction with others
Compensation issuesCompensation issues
Watch out for…Watch out for…
Substance use problemsSubstance use problems
AlcoholAlcoholSedativesSedativesOpioidsOpioids
Pain can be a withdrawal symptomPain can be a withdrawal symptom
When it become chronicWhen it become chronic
Established treatment: multi-Established treatment: multi-modalitymodality
‘‘golden standard’golden standard’1 + 1 = 31 + 1 = 3ExpensiveExpensive
Applicable for all sorts of chronic painApplicable for all sorts of chronic pain
PhysiotherapyPhysiotherapy
Established treatmentEstablished treatment
Aerobic exerciseAerobic exerciseStrengthening exerciseStrengthening exerciseStretching exerciseStretching exercise
Some exercise is better than nothingSome exercise is better than nothing
Epidural steroidEpidural steroid
RadiculopathyRadiculopathy
Good previous responseGood previous response
Relatively simple and safeRelatively simple and safe
Spine surgerySpine surgery
Presence of pathologyPresence of pathology
Correlate with painCorrelate with pain
Neurological symptomsNeurological symptoms
Works well in selected casesWorks well in selected cases
Facet joint injectionFacet joint injectionDiagnostic criteriaDiagnostic criteria
Use of steroidUse of steroid
Joint v.s. nerve injectionJoint v.s. nerve injection
Technical difficultiesTechnical difficulties
No consensus in its roleNo consensus in its role
Trigger point injectionTrigger point injectionShort lastingShort lasting
Simple and safeSimple and safe
BotoxBotox
No consensus in its roleNo consensus in its role
AntidepressantsAntidepressants
Better pain reliefBetter pain reliefCan treat depressionCan treat depressionFunctionally unchangedFunctionally unchangedMore side effectsMore side effects
Can try, but watch out for side Can try, but watch out for side effectseffects
Behavioral therapyBehavioral therapy
Better than nothingBetter than nothingTime consumingTime consumingNeed expertiseNeed expertise
Limited availabilityLimited availability
ChymopapainChymopapain
SimpleSimpleConflicting outcome dataConflicting outcome dataCatastrophic side effectsCatastrophic side effects
Only for selected cases (and in good Only for selected cases (and in good hands)hands)
AccupunctureAccupuncture
Patients believe in itPatients believe in itDoctors’ blind spotDoctors’ blind spotNo outcome dataNo outcome data
As good (and expensive) as anything As good (and expensive) as anything elseelse
ChiropracticsChiropractics
Doubtful treatment:Doubtful treatment:Patients like itPatients like itDoctor’s don’t like itDoctor’s don’t like itSimpleSimple
No better than conventional therapyNo better than conventional therapy
Useless treatment:Useless treatment:
MagnetMagnet Can TV games treat low Can TV games treat low
back pain?back pain?
AromatherapyAromatherapy Can Dior treat low back Can Dior treat low back
pain?pain?
Useless treatment can cause harmUseless treatment can cause harm
ExpensiveExpensiveDefeating experienceDefeating experienceEnhance mal-adaptive behaviour eg: Enhance mal-adaptive behaviour eg:
doctor shopping, fixation on physical doctor shopping, fixation on physical causecause
Special casesSpecial cases
Failed back surgeryFailed back surgery
Avoid further surgeryAvoid further surgeryEpidural SteroidEpidural SteroidSpinal Cord StimulatorSpinal Cord Stimulator
Strict patient selection for better Strict patient selection for better outcomeoutcome
ConclusionsConclusions
We know too little about itWe know too little about itTreatment remained empiricalTreatment remained empiricalSimple is beautifulSimple is beautiful
Don’t work too hard (try it on your Don’t work too hard (try it on your boss)boss)