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

LBPLBP

• Facet joint• Zygopophyseal joint

• Synovial

LBPLBP

• Sacroiliac Joint• Tight, Synovial• Ligaments• “SI Dysfunction”

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

“Red Flag” Evaluation“Red Flag” Evaluation

Acute LBP: Physical ExamAcute LBP: Physical Exam

• Lumbar Spine:• Inspection• Palpation• ROM: Flexion / Extension

• +/- LE Neurologic Exam

Acute LBP: ImagingAcute LBP: Imaging

• When?

• What imaging?

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

• Lumbar MRI

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 # 1Case # 1

• Diagnosis ?

• Management ?

LBP: Differential DiagnosisLBP: Differential Diagnosis

Deyo NEJM 2001

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- SI JointLBP- SI Joint

• Diagnosis / Treatment• Physical Therapy• Injection

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

Case # 2Case # 2

•Diagnosis ?

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: EvaluationLBP: Evaluation

• SLR / Dural Tension

Case # 2Case # 2

• MRI: Left L5-S1 disc herniation impinging on S1 nerve root

Management?

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

• Injections

Epidural Selective

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

• Duration• > 12 weeks

• Poor Correlation • Symptoms• Objectives Finding

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

Chronic LBPChronic LBP

**Goal** • Improve Function• Minimize focus on treating pain itself

• Biopsychosocial Model of Pain• Maladaptive Behavior • Neuroplasticity

Chronic LBPChronic LBP

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

LBPLBP

Questions ?Questions ?

OtherOther

LBP: EvaluationLBP: Evaluation

• Waddell’s Signs (Non-organic PE)• Tenderness• Overreaction• Regional • Distraction• Simulation• > 3/5

* Behavioral Component of PainSpine 1980