Low Back Pain: Case Based Evaluation and Management

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Low Back PainCase Based Evaluation and
Management

• Patrick Kortebein, M.D.
• Departments of PMR and Geriatrics
• University of Arkansas for Medical Sciences
• 5/31/09
• Slides www.uams.edu/pmr

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Objectives

• 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.

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Low 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

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LBP Anatomy

• Bone / Vertebrae
• Disc
• Annulus
• Nucleus Pulposus
• Muscles / Ligaments
• Spinal Nerve Roots

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LBP

• Facet joint
• Zygopophyseal joint
• Synovial

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LBP

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

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Case 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?

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Acute LBP History

• Location
• Axial or Radiating (Sciatica) ?
• Onset Traumatic, Insidious
• Duration
• Acute lt 12 weeks
• Chronic gt 12 weeks
• Character/Quality Ache, Burning, etc
• Exacerbating / Alleviating Factors

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Acute LBP History

• Red Flags (AHCPR 1994)
• Fracture
• Major/minor trauma
• Age gt 70 yrs (50 yrs)
• Chronic corticosteroids
• Cauda Equina
• B/B dysfunction
• Saddle Anesthesia
• LE weakness

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Acute 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 gt 50

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Red Flag Evaluation
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Acute LBP Physical Exam

• Lumbar Spine
• Inspection
• Palpation
• ROM Flexion / Extension
• /- LE Neurologic Exam

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Acute LBP Imaging

• When?
• What imaging?

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Acute LBP Imaging

• When?
• Minimum 6 weeks
• Red Flags
• What?
• X-ray
• 3-view
• AP / Lat / L5 Spot
• Obliques
• Limited information
• Radiation exposure

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Acute LBP Imaging

• Lumbar MRI

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Acute LBP Imaging

• Abnormal findings
• Degenerative disc disease
• Bulging disc
• Herniated disc

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LBP Imaging

• MRI Abnormalities in Normals / No LBP
• Boden et al (N67) 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)

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Case 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

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Case 1

• Diagnosis ?
• Management ?

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LBP Differential Diagnosis

Deyo NEJM 2001
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Case 1Diagnosis Mechanical LBP

• Education / Activity Modification
• Bedrest 2 days (Deyo NEJM 1986)
• Analgesics
• Acetaminophen
• NSAIDs
• Tramadol
• Muscle Relaxants
• Cyclobenzaprine

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Mechanical LBP

• Physical Therapy
• Exercise
• Modalities
• Lumbar Support
• Chiropractic
• Acupuncture

Back Heat
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LBP Zygapophyseal (Facet) joint

• History/Examination
• Axial LBP /- post thigh
• No neuro sxs
• Worse w/ static posture
• Lumbar Extension
• Stand / Walk
• Neuro exam normal

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LBP Zygapophyseal (Facet) joint

• Management
• Analgesics
• Tylenol, NSAID
• Physical Therapy
• Injections
• Diagnostic
• Therapeutic

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LBP Sacroiliac (SI) Joint

• History
• Atraumatic gt Traumatic
• Axial Lumbosacral
• Uni- gt Bilateral
• No radiation / neuro sxs
• Physical Exam
• Normal
• Tender SI region

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LBP- SI Joint

• Diagnosis / Treatment
• Physical Therapy
• Injection

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LBP Discogenic

• History / Exam
• Axial LBP
• No radiation / neuro sxs
• Aggravating
• Static posture- Sitting or Sit to stand
• Normal neurological exam

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LBP Discogenic

• Management
• Physical Therapy
• Core Strength
• Surgery
• Fusion
• Artificial Disc
• Not yet

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Case 2

• 38 yo with left LE radicular pain gt LBP for 6
  weeks. Also left foot tingling and weakness.
• PMHx HTN, Hyperlipidemia
• Meds HCTZ, Atorvastatin
• Allergies Sulfa
• Social Hx Divorced, Landscaper

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Case 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

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Case 2

• Diagnosis ?

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LBP Radiculopathy

• Diagnosis
• Physical Exam
• MRI
• EMG
• CT Myelogram
• Correlate anatomy w/ sxs and exam

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LBP Radiculopathy

• Neurological Exam
• Motor Reflex Sensory
• L2/3 Hip Flex/Add Knee Med Thigh
  /Knee
• L4 Knee Ext/DFlex Knee Med Ankle
• L5 Great toe/EHL Int. HS Dorsum
  Foot
• S1 Plantarflex Ankle Lat Heel
• Functional Squat, Heel / Toe Walk, Heel Raise

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LBP Evaluation

• SLR / Dural Tension

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Case 2

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

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LBP Radiculopathy

• Management
• Medications
• NSAIDs
• Acetaminophen
• Tramadol
• Neuropathic
• Steroids
• Oral (? dose) vs epidural

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LBP Radiculopathy

• Management
• Physical Therapy
• McKenzie
• Extension therapy
• TENS
• No benefit

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LBP Radiculopathy

• Injections
• Epidural Selective

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LBP Radiculopathy

• Surgery
• Indications
• Cauda equina
• Progressive neuro deficits
• No relief w/ conservative treatment
• SPORT trial
• JAMA 2006

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LBP Spinal Stenosis

• History (Neurogenic claudication)
• Prox LE Pain /- Neuro sxs
• Walk / Stand
• Uphill gt Downhill
• Grocery Cart
• Physical Exam
• Normal
• Stand / Walk

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LBP Spinal Stenosis

• Diagnosis
• MRI
• EMG
• Management
• Medications
• Neuropathic
• PT
• Epidural Injection
• Surgery (SPORT trial)

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Case 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

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Case 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

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Case 3

• Lumbar MRI
• Mild DD changes with diffuse disc bulge at L4-5
  and L5-S1
• Diagnosis?
• Treatment?

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Chronic LBP

• Duration
• gt 12 weeks
• Poor Correlation
• Symptoms
• Objectives Finding

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Chronic LBP

• Strong Association
• Depression
• Anxiety
• Poor Coping Skills

My back hurts, but Im here because I cant cope
with this episode, as well as the turmoil at home
(or work)- N Hadler Last Well Person
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Chronic LBP
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Chronic LBP

• Goal
• Improve Function
• Minimize focus
• on treating pain itself
• Biopsychosocial Model of Pain
• Maladaptive Behavior
• Neuroplasticity

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Chronic LBP
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Case 3

• Multidisciplinary Pain Management
• Education
• Medications
• Chronic Opioids ?
• PT
• Functional Restoration
• Psychology
• Pain Management

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Recommended Reading

• Kinkade S. Evaluation and treatment of acute low
  back pain. Am Fam Physician 2007 751181-8,
  1190-2.
• Deyo et al. Overtreating chronic back pain time
  to back off? J Am Board Fam Med 2009 2262-8.
• LBP Handbook 2003
• Cole Herring

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LBP
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Questions ?
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Other
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LBP Evaluation

• Waddells Signs (Non-organic PE)
• Tenderness
• Overreaction
• Regional
• Distraction
• Simulation
• gt 3/5
• Behavioral Component of Pain

Spine 1980