Low Back Pain

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Low Back Pain

• Rural Track Didactic Series
• Philip J Fracica MD FACP

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Epidemiology

• 75 of adults will experience LBP at some point
  in their lives
• 5th most common cause of all physician visits
• Peak incidence 20-40 years old More severe in
  older patients
• 85 of patients have no definitive anatomic cause
  or imaging finding
• Most cases are self limited with serious problems
  in lt 5
• Most common cause of work-related disability for
  individuals lt 45 years old

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Anatomy Review
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lbp
Ligamentum flavum
Superior articular process
Transverse process
Intervertebral foramen
Pars interarticularis
Normal canal
Intervertebral disk
Herniated Nucleus pulposus
Defect in Pars interarticularis (spondylolysis)
Sacrum
Anterior displacement of L5 on sacrum (spondylolis
thesis)
Anulus fibrosus
Herniated disk
Articular surface (sacroiliac)
Thickened ligamentum flavum
Deyo RA, Weinstein JN NEJM 3445 363-370 2001
Spinal stenosis
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Spondylolysthesis

• Spondylos (spine or vertebra)
• listhesis (to slip or slide)
• a condition where one bone slips forward on
  another

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Spondylolysis

• Spondylos (spine or vertebra)
• lysis (a break or loosening)
• Loosening of the pars interarticularis fracture

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Anatomy Review
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LBP Risk Factors

• Heavy lifting and twisting
• Obesity
• Poor physical fitness/conditioning
• History of low back trauma
• Psychiatric history(chronic LBP)

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LBP Classification

• Etiologic
• Mechanical (97)
• Non-Mechanical (1)
• Visceral (2)
• Temporal
• Acute
• Chronic

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Mechanical LBP/Leg PainEtiologies (97)

• usually attributable to musculoligamentous
  injuries or age-related degenerative disease in
  intervertebral disks and facet joints
• Lumbar strain (70)
• Degenerative disk and facets (10)
• Herniated disk (4)
• Spinal Stenosis (3)
• Osteoporotic compression fracture (4)
• Spondylolisthesis
• Traumatic fracture (lt1)
• Congenital disease (lt1)
• Kyphosis
• Scoliosis
• Transitional vertebrae
• Spondylolysis
• Internal disk disruption / diskogenic pain
• Presumed instability

Deyo RA, Weinstein JN NEJM 3445 363-370 2001
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Non Mechanical LBP Etiologies (1)

• Inflamatory, infectious our systemic disease
  effecting vertebral musculoskeletal structures
• Neoplasia (0.7)
• Multiple myeloma
• Metastatic carcinoma
• Lymphoma / Leukemia
• Spinal cord tumors
• Primary vertebral tumors
• Infection (lt0.01)
• Osteomyelits
• Septic diskitis
• Paraspinous abcess
• Epidural abcess
• Shingles
• Inflammatory arthritis (often HLA-B27 associated)
  (0.3)
• Ankylosing spondylitis
• Psoriatic spondylitis
• Reiters syndrome
• Inflammatory bowel disease

Deyo RA, Weinstein JN NEJM 3445 363-370 2001
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Visceral Disease Induced LBPEtiologies (2)

• Process involving anatomic site other that
  vertebral musculoskeletal structures
• Disease of pelvic organs
• Prostatitis
• Endometriosis
• Chronic Pelvic Inflammatory Disease
• Renal disease
• Nephrolithiasis
• Pyelonephritis
• Perinephric abcess
• Aortic aneurysm
• Gastrointestinal disease
• Pancreatitis
• Cholecystitis
• Penetrating ulcer

Deyo RA, Weinstein JN NEJM 3445 363-370 2001
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Mechanical LBP Differential Diagnosis Clinical
Features

• Herniated disk
• Usually occurs in adults aged 30 to 55 years
• Sciatica, often associated with leg numbness or
  paresthesias, is a
• highly sensitive (95) and specific (88) finding
  for herniated disk
• Exacerbation of pain may occur with
• coughing
• sneezing
• Valsalva maneuvers
• Spinal Stenosis
• usually occurs in older adults
• characterized by neurogenic claudication
• radiating back pain and lower extremity numbness
• exacerbated by walking and spinal extension
• improved by sitting

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Clinical Assessment Serious Illness

• Is this likely to represent a serious illness?

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Clinical Assessment Serious Illness

• Is this likely to represent a serious illness?
• Systemic
• Inflammatory
• Infectious
• Severe mechanical injury

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Clinical Assessment Serious Illness

• Is this likely to represent a serious illness?
• Major trauma
• Possible fracture
• Corticosteroid use
• Greater risk for osteoporotic fracture
• Age gt50 y
• Greater risk for malignancy, osteoporotic
  fracture
• History of cancer
• Greater risk for underlying malignancy
• Unexplained weight loss
• Greater risk for malignancy or infection
• Fever, immunosuppression, immunodeficiency,
  injection drug use, or active infection
• Risk for spinal infection

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Clinical Assessment Neurologic

• Is there neurologic compromise?
• Patterns of neurologic impairment worrisome for
  serious neurologic compromise

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Clinical Assessment Neurologic

• Is there neurologic compromise?
• Saddle anesthesia, bowel or bladder incontinence
  
• Possible cauda equina syndrome
• Severe or progressive neurologic deficit
• Possible cauda equina syndrome or severe nerve
  root compression

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Cauda Equina Syndrome History

• Low back pain
• Acute or chronic radiating pain
• Unilateral or bilateral lower extremity motor
  and/or sensory abnormality
• Bowel and/or bladder dysfunction
• Usually with associated perineal (saddle)
  anesthesia
• Bladder dysfunction
• impaired emptying
• difficulty starting or stopping a stream of urine
• may present as incontinence due to overflow

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Cauda Equina Syndrome Physical

• local tenderness to palpation or percussion
• loss or diminution of reflexes
• Hyperactive reflexes suggest spinal cord
  involvement rather than CES.
• Pain in (or radiating to) the legs
• Sensory abnormality (light touch) in the perineal
  area or lower extremities.
• Muscle weakness
• Poor anal sphincter tone is characteristic of
  CES.
• Babinski sign not consistent with CES, suggests
  spinal cord lesion.
• Anesthetic areas may show skin breakdown.
• Alteration in bladder with increased postvoid
  residual

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Clinical Assessment Psychosocial

• Are there complicating psychosocial factors that
  may impede treatment or prolong pain and predict
  poor outcomes?
• history of failed treatment,
• depression, and somatization.
• Substance abuse,
• job dissatisfaction
• ongoing litigation or compensation claims

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Low Back Pain Classification (Temporal)

• Acute Low Back Pain
• lt 6 week duration
• Chronic Low Back Pain
• gt 6 week duration

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Acute LBP

• History
• Time-course of onset (associated activity time
  of day)
• Pain
• Location (site, radiation)
• Nature (sharp, throbbing, dull, etc.)
• Severity
• Aggravating/relieving factors
• Prior injuries
• Age

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Acute Low Back Pain

• Three clinical groups of Acute LBP
• Symptoms of potentially serious spinal condition
  (tumor, infection, fracture)
• Sciatica or neurogenic claudication (discomfort
  radiating to legs)
• Nonspecific back symptoms (most common is strain
  of soft tissue elements)

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Acute LBP

• Physical Exam
• Should be comprehensive, but focus on
• Neurologic? DTRs, sensation, muscle
  strength(dorsiflexion of foot and great toe)
• Peripheral pulses
• Stance and gait
• Flexibility
• Focal tenderness
• Straight leg raise
• Non-physiologic symptoms
• consider depression, mental illness

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Differential Diagnoses

• Acute low back pain
• Strain
• Acute herniation
• Spinal stenosis
• Osteoarthritis
• Spondylolisthesis
• Ankylosing spondylitis
• Infection
• Malignancy

Fracture of L1 with vertebral compression
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Persistent (Chronic) LBP

• History
• Additionally consider
• History of cancer
• Age gt 50 (malignancy, osteoporotic fracture)
• Recent unexplained weight loss (underlying
  malignancy)
• Recent IV drug use (Osteomyelits, Septic
  diskitis,Paraspinous or Epidural abcess)
• Presence of chronic infection (as above)
• Prior treatments and their effectiveness
• Pain unrelieved with positional changes?consider
  infection, cancer (not specific, however)

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LBP Nerve Root Syndromes

• S1 (L5-S1 disc)
• Pain and paresthesias in buttock, posterior
  thigh, calf and heel and lateral foot and 4-5th
  digits.
• Weakness of toe flexors and gastrocs ankle jerk
  absent
• L5 (L4-L5 disc)
• Pain in backleg.
• Pain to posterolateral thigh, groin, lateral
  calf, dorsomedial foot and 1st 2nd digits.
• Weakness in dorsiflexion foot drop
• L4 (L3-L4 disc)
• Back pain gt leg pain.
• Pain radiates to anterior thigh and knee.
• Weakness in quad muscles and iliopsoas.
• Decreased or absent knee jerk

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Labs

• Rarely necessary
• CBC, ESR and PSA, alkaline phosphatase and UPEP
  and SPEP for those with h/o or suspected cancer

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When to use radiology?

• Age gt50 years
• Recent significant trauma
• Neurologic deficits
• Systemic symptoms
• Fever
• Unexplained weight loss
• History of cancer, substance abuse, chronic
  corticosteroid use
• Suspicion of ankylosing spondylitis

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What imaging modalities?

• Plain films very rarely helpful
• Some aid if trauma history elicited
• Consider plain films if h/o prolonged
  corticosteroid use, osteoporosis and patient gt 70
• CT and MRI
• Mainstay of imaging for LBP that meets criteria
• Good visualization of spinal canal and
  intervertebral disk spaces
• However, disease seen in asymptomatic patients
• MRI more sensitive for soft tissue abnormalities
  (cancer, abscess, tumors)
• Bone scan if suspect osteomyelitis despite
  (-)MRI/CT

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Significance of radiographic abnormalities
L5
L5

• Herniation of the lumbar disk
• found in 25 to 50 of asymptomatic subjects
• extrusion of the disk material found in 1 to 18

Carragee NEJM 35218 2005
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Significance of radiographic abnormalities
L5
L5

• Degeneration of the lumbar disk
• increases with age
• found in 25 to 70 of asymptomatic subjects

Carragee NEJM 35218 2005
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Significance of radiographic abnormalities
L5
L5
Signal changes in vertebral end plates found in
10 of asymptomatic subjects
Carragee NEJM 35218 2005
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Significance of radiographic abnormalities

• Annular fissure with high-intensity signals
• represents degenerative changes
• found in 14 to 33 of asymptomatic subjects

Carragee NEJM 35218 2005
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LBP Treatment

• Nonspecific LBP
• NSAIDs and muscle relaxants for symptomatic
  relief
• Sedation from relaxants may reduce utility
• Bed rest not effective
• A tincture of time best remedy
• Back exercises not effective acutely
• Most popular general therapies
• Spinal manipulation, massage, acupuncture (the
  latter not proven effective)
• Surgery only effective for sciatica, lysthesis,
  spinal canal stenosis

Corsets not effective
Electrostimulation Not effective
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Treatment (cont.)

• Acute LBP
• Superficial heat, deep heat, cold packs
• NSAIDs mainstay, narcotics only if severe pain
  and only for short duration
• Reevaluate treatment after 4 weeks
• 90 get better within 4 weeks
• Physical Therapy
• Persistent LBP
• Intensive exercise (poor compliance)
• Treatment of concomitant mental illness if
  present
• Tricyclics also good vs neuropathic pain
• Patient education
• Referral to pain center (combination of
  modalities

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Indications for Surgery

• Primary indication
• Severe or increasing neurologic deficit
• Sciatica and herniated disk
• Cauda equina syndrome
• Neurologic deficits not responding to
  non-invasive therapy
• Persistent sciatica symptoms
• Spinal stenosis
• Elective surgery if symptoms definitively
  associated with spinal stenosis and/or low back
  flexion/extension
• Spondylolysthesis
• Spinal stenosis symptoms
• Severe, persistent pain or sciatica for 12 months
  or more

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Prevention Strategies

• Exercise and strengthening exercises
• Weight loss?
• Smoking cessation?
• Improvement of strenuous and stressful working
  conditions
• Back braces are ineffective in prevention

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Case 1

• 41 y/o presents with cc of low back pain.
  Lifting heavy objects previous night, twisting a
  lot and felt twinge, then increasing pain. Also
  with R testicular pain returning after Rx for
  presumed prostatitis. Neg. straight leg raise,
  limited ROM and muscle spasms in perispinous
  muscles.

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Case 1

• 2 weeks later returns with right calf pain and
  numbness in right foot, particularly 1st and 2nd
  digit. 4/5 strength with dorsiflexion right
  foot. Back pain better.

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Case 1

• MRI showed L4-L5 disc herniation with impingement
  of L5 nerve root.
• Neurosurgeon performed Microdiscectomy and
  patients symptoms improved.

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Case 2

• 51 y/o with past medical history significant for
  back surgery fell at work. Now c/o back and left
  leg pain radiating to bottom of feet. Exam
  reveals no sensory deficit and strength testing
  unreliable d/t pain. No DTRs noted bilateral
  ankles. Some pain radiation down right leg as
  well.
• Previous h/o back pain and depression/anxiety

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Case 2

• MRI showed disc herniation at L5-S1 centrally
  with impingement on left nerve root at S1.
• Microdiscetomy performed with little improvement.
  
• Patient disabled and did not return to work.

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Case 3

• 62 y/o with acute low back pain. Gradual onset
  x 2 weeks, then sudden increase in pain after he
  hit a shot on hole 4 of the local golf course.
  I took a lot of turf with that shot and the pain
  hit me like a ton of bricks. Some pain
  radiation into left buttock and thigh. No n/t or
  weakness, no change in b b function. Pain not
  completely resolved with supine, but worse with
  standing or sitting.

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Case 3

• X-ray done in ER normal. No improvement with 1
  week Skelaxin and Tylenol 3s.
• At repeat visit, developed left lateral thigh
  numbness.
• MRI showed disc extrusion on the left with
  compression of L3 nerve root and broad-based disc
  protrusion at L4-L5 with no root compression.
• Labs normal

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Case 3

• Treated with NSAIDs, physical therapy and
  epidural steroid injections x 2 and pain resolved
  within 8 weeks of onset.

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Case 4

• 71 y/o with complaint of left lower acute back
  pain x 1 week in duration. Noted pain after
  lifting watermelon out of her trunk. Worse with
  standing and sitting, relieved with supine
  position. PMHx significant for osteoporosis
  and hypothyroidism. OTC alleve helps some as
  does heat. Flexeril ineffective. No n/t or
  alarm symptoms.

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Case 4

• Treated with NSAIDs, activity limitations and
  heat prn.
• RTC in 4 weeks for follow up.
• Diazepam 2mg po BID prn, 20 with no refills

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Case 5

• 46 y/o with complaint of right lower acute back
  pain x 1 week in duration. Noted pain after
  lifting bookshelf while standing on ladder.
  PMHx unremarkable. OTC naproxen helps some.
  Pain not too severe but now notes anterolateral
  thigh anesthesia and quadricps fasiculation.
  Absent patellar reflex and diminished knee
  extensor motor strength. Extensive
  paravertebral muscle spasm.

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Case 5

• MRI unremarkable
• Treated with
• brief period of bed rest and
• oral corticosteroid therapy
• PRN ambulation and back strengthening exercises
  initiated several weeks later
• Progressive improvement