Diagnosing Low Back Pain

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Diagnosing Low Back Pain

• FARIS HAZIM ALHAFID
• ORTHOPAEDIC SURGEON

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I. History
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• Mechanism of injury
• Associated symptoms
• Bladder / bowel function
• Fevers / chills
• Sleep disturbance
• Numbness / tingling
• Prior injuries, treatment and outcomes
• Medications
• Family history
• Social history
• Vocational
• Education
• Tobacco / ETOH / Illicit drugs
• Function ADLs Mobility
• Litigation

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Pain Specifics

• Quality sharp, dull, shooting, burning, etc.
• Location / Distribution
• Radicular Dermatomal distribution, dysesthesias
  
• Radiating Nondermatomal
• Onset
• Gradual DDD
• Acute Disc abnormality, strain, compression
  fractures
• Severity / Intensity
• Frequency Constant vs. Intermittent
• Duration
• Exacerbating and Alleviating Factors
• Time of Day If nocturnal, consider malignancy

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Red Flags

• Significant trauma history, or minor in older
  adults
• Nocturnal pain in supine position with history of
  cancer
• Bladder or bowel incontinence or dysfunction
• Constitutional symptoms
• Fever / chills
• Weight loss
• Lymph node enlargement
• Risk factors for spinal infection
• Recent infection
• IV drug use
• Immunosuppression
• Major motor weakness

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II. Examination
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A. Physical

• Posture
• Splinting
• Body language
• Gait
• Antalgia
• Heel / Toe pattern
• Trendelenberg
• Musculoskeletal
• ROM
• Leg length
• Vascular
• Atrophy

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• Abdomen
• Presence of masses
• Back
• Inspection
• Palpation
• ROM
• Scoliosis
• Neurological
• Sensation
• Motor
• DTRs
• Rectal if indicated
• Evaluation of sphincter tone

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B. Symptom Magnification Examination

• Waddell signs Presence of nonorganic signs
  suggesting symptom magnification and
  psychological distress
• Superficial or nonanatomic distribution of
  tenderness
• Nonanatomic or regional disturbance of motor or
  sensory impairment
• Inconsistency on positional SLR
• Inappropriate/excessive verbalization of pain or
  gesturing
• Pain with axial loading or rotation of spine
• Give-away weakness Inconsistent effort on
  manual motor testing with ratcheting rather
  than smooth resistance

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C. Pathological Examination

• Spurlings maneuver Lateral rotation and
  extension of spine resulting in neuroforaminal
  narrowing and nerve root encroachment, clinically
  reproducing extremity pain, usually in
  dermatomal distribution
• Straight-leg raise (SLR) Elevation of lower
  extremity, seated or standing, resulting in
  neural tension at S1 nerve root with extremity
  pain
• Patricks maneuver Crossed leg with unilateral
  pain indicative of sacro-iliac (SI) joint
  dysfunction
• Femoral stretch Hip extension stretch with
  heel pushed to buttock in lateral supine or
  prone position resulting in anterior thigh pain

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III. Low Back Pain
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A. Epidemiology

• Incidence of LBP
• 60-90 lifetime incidence
• 5 annual incidence
• 90 of cases of LBP resolve without treatment
  within 6-12 weeks
• 40-50 LBP cases resolve without treatment in 1
  week
• 75 of cases with nerve root involvement can
  resolve in 6 months
• LBP and lumbar surgery are
• 2nd and 3rd highest reasons for physician visits
• 5th leading cause for hospitalization
• 3rd leading cause for surgery

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B. Disability

• Age and LBP
• Leading cause of disability of adults lt 45 years
  old
• Third cause of disability in those gt 45 years old
• Prevalence rate
• Increased 140 from 1970 to 1981 with only125
  population growth
• Nearly 5 million people in the U.S. are
  ondisability for LBP

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C. Lifetime Return to Work

• Success of less than 50 if off work greater
  than 6 months
• 25 success rate if off work greater than 1 year
• Nearly 0 success if return to work has not
  occurred in 2 years

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D. Occupational Risk Factors

• Low job satisfaction
• Monotonous or repetitious work
• Educational level
• Adverse employer-employee relations
• Recent employment
• Frequent lifting
• Especially exceeding 25 pounds
• Utilization of poor body mechanics in technique

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E. Differential Diagnoses

• Lumbar strain
• Disc bulge / protrusion / extrusion producing
  radiculopathy
• Degenerative disc disease
• Spinal stenosis
• Spondyloarthropathy
• Spondylosis
• Spondylolisthesis
• Sacro-iliac dysfunction

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F. Diagnostic Tools

• 1. Laboratory
• Performed primarily to screen for other disease
  etiologies
• Infection
• Cancer
• Spondyloarthropathies
• No evidence to support value in first 7 weeks
  unless with red flags
• Specifics
• WBC
• ESR or CRP
• HLA-B27
• Tumor markers Kidney Breast Lung
  Thyroid Prostate

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• 2. Radiographs
• Pre-existing DJD is most common diagnosis
• Usually 3 views adequate with obliques only if
  equivocal findings
• Indications
• History of trauma with continued pain
• Less than 20 years or greater than 55 years with
  severe or persistent pain
• Noted spinal deformity on exam
• Signs / symptoms suggestive of spondyloarthropathy
  
• Suspicion for infection or tumor

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• 3. EMG / NCV ( Electrodiagnostics)
• Can demonstrate radiculopathy or peripheral nerve
  entrapment, but may not be positive in the
  extremities for the first 3-6 weeks and
  paraspinals for the first 2 weeks
• Would not be appropriate in clinically obvious
  radiculopathy
• 4. Bone scan
• Very sensitive but nonspecific
• Useful for
• Malignancy screening
• Detection for early infection
• Detection for early or occult fracture

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• 5. Myelogram
• Procedure of injecting contrast material into the
  spinal canal with imaging via plain radiographs
  versus CT
• In past, considered the gold standard for
  evaluation of the spinal canal and neurological
  compression
• With potential complications, as well as advent
  of MRI and CT, is less utilized
• More common Headache, nausea / vomiting
• Less common Seizure, pain, neurological change,
  anaphylaxis
• Myelogram alone is rarely indicated
• Hitselberger study 1968 Journal of Neurosurgery
• 24 of asymptomatic subjects with defects

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• 6. CT with myelogram
• Can demonstrate much better anatomical detail
  than myelogram alone
• Utilized for
• Demonstrating anatomical detail in multi-level
  disease in pre- operative state
• Determining nerve root compression etiology of
  disc versus osteophyte
• Surgical screening tool if equivocal MRI or CT

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• 7. CT
• Best for bony changes of spinal or foraminal
  stenosis
• Also best for bony detail to determine
• Fracture
• DJD
• Malignancy
• SW Wiesel study 1984 Spine
• 36 of asymptomatic subjects had HNP at
  L4-L5and L5-S1 levels

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• 8. Discography (Diagnostic disc injection)
• Less utilized as initial diagnostic tool due to
  high incidence of false positives as well as
  advent of MRI
• Utilizations
• Diagnose internal disc derangement with normal
  MRI / myelo
• Determine symptomatic level in multi-level
  disease
• Criteria for response
• Volume of contrast material accepted by the disc,
  with normals of 0.5 to 1.5 cc
• Resistance of disc to injection
• Production of pain---MOST SIGNIFICANT
• Usually followed by CT to evaluate internal
  architecture, but also may utilize MRI
• As outcome predictor (Coulhoun study 1988 JBJS)
• 89 of those with pain response received benefit
  from surgery
• 52 of those with structural change received
  surgical benefit

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• 9. MRI
• Best diagnostic tool for
• Soft tissue abnormalities
• Infection
• Bone marrow changes
• Spinal canal and neural foraminal contents
• Emergent screening
• Cauda equina syndrome
• Spinal cored injury
• Vascular occlusion
• Radiculopathy
• Benign vs. malignant compression fractures
• Osteomyelitis evaluation
• Evaluation with prior spinal surgery

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• Has essentially replaced CT and myelograms for
  initial evaluations
• Boden study 1990 JBJS
• 20 of asymptomatic population less than 60
  years with HNP
• 36 of asymptomatic population of 60 years
• Jensen study 1995 NEJM
• 52 of asymptomatic patients with disc bulge at
  one or more levels
• 27 of asymptomatic patients with disc
  protrusion
• 1 of asymptomatic patients with disc extrusion

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• MRI with Gadolinium contrast
• Gadolinium is contrast material allowing
  enhancement of intrathecal nerve roots
• Utilization
• Assessment of post-operative spine---most
  frequent use
• Identifying tumors / infection within /
  surrounding spinal cord
• Diagnosis of radiculitis
• Post-operatively can take 2-6 months for
  reduction of mass effect on posterior disc and
  anterior epidural soft tissues which can
  resemble pre-operative studies
• Only indications in immediate post-operative
  period
• Hemorrhage
• Disc infection

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• 10. Psychological tools
• Utilized in case scenarios where psychological or
  emotional overlay of pain is suspected
• Symptom magnification
• Grossly abnormal pain drawing
• Non-responsive to conservative interventions but
  with essentially normal diagnostic studies
• Includes
• Pain Assessment Report, which combines
• McGill Pain Questionnaire
• Mooney Pain Drawing Test
• MMPI
• Middlesex Hospital Questionnaire
• Cornell Medical Index
• Eysenck Personality Inventory

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MRI Nomenclature (PER NASS)

• Anular fissure Focal disruption of anular
  fibers in concentric, radial or transverse
  distribution
• Disc bulge Circumferential, diffuse, symmetric
  extension of anulus beyond the adjacent
  vertebral end plates by 3 or more mm, usually due
  to weakened or lax anular fibers
• Disc protrusion Focal, asymmetric extension of
  disc segment beyond margin of vertebral end
  plates into the spinal canal with most of anular
  fibers intact
• Disc extrusion Focal, asymmetric extension of
  disc segment and / or nucleus pulposis through
  the anular containment into the epidural space
• Disc sequestration Extruded disc segment that is
  detached from original with migration into the
  canal
• Disc degeneration Irreversible structural and
  histiological changes in nucleus seen on MRI T2WI
  images (commonly associated with bulge)

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Specificity / Sensitivity
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G. Treatment

• Medications
• NSAIDS
• Membrane stabilizers
• TCA / Neurontin
• re-establish sleep pain
• reduce radicular dysesthesias
• Muscle relaxers
• re-establish sleep patterns
• more useful in myofascial/muscular pain
• Narcotics rarely indicated
• Steroids more useful for radiculitis
• Non-narcotic analgesics Ultram

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• Physical therapy
• Modalities
• electrical stimulation/TENS
• Postural education / body mechanics
• Massage / mobilization / myofascial release
• Stretching / body work
• Exercise / strengthening
• Traction
• Pre-conditioning / work-conditioning
• Injections
• Epidural blocks
• Facet blocks
• Trigger point
• SNRB
• SI joint

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• Surgery
• Laminectomy
• Fusion
• Discectomy
• Percutaneous Lumbar Discectomy
• Success rate variable 50 -85
• Low rate of complications
• Infection
• Peripheral nerve injury
• Benefits
• Outpatient procedure
• Minimal to no epidural scarring
• No general anesthesia
• Spine stability preservation
• Decreased cost

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• Chemonucleolysis
• IDET Intradiscal Electrotherapy or Spine CATH
• Alternative
• Chiropractic
• Clinical studies show benefit only in first 3
  weeks of symptoms
• Acupuncture
• Biofeedback

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IV. Specific Disorder Considerations
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A. Sacroiliitis

• History
• Trauma is very common
• Repetitive LS motion--lumbar rotation or axial
  loading
• No specific correlation with exacerbating
  activities
• Commonly have leg length discrepancy or condition
  contributing
• Biomechanics
• Movement of the SIJ is involuntary, usually from
  muscle imbalances
• Can occur at multiple levels lower extremities,
  hip, LS spine
• Motion is complex and not single-axis based

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• Differential Diagnosis
• a. Fracture
• Traumatic
• Insufficiency stress fractures elderly patient
  with osteoporosis without history of trauma
• Fatigue stress fractures usually athletes /
  soldiers
• b. Infection
• Hematogenous spread with predisposing history
• Usually unilateral symptoms present
• c. Degenerative joint disease
• d. Metabolic disease
• e. Referred pain

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• f. Seronegative spondyloarthropathies
• RA--usually not until late in course of disease
• Ankylosing spondylitis
• Psoriatic arthritis
• g. Primary SI tumor
• Rare and usually synovial villoadenomas
• h. Iatrogenic instability
• Via pelvic tumor resection or bone graft site
• i. Osteitis condensans ilii
• Prevalence of 2.2 , primarily in multiparous
  women
• Usually self-limiting and bilateral
• j. Reactive disease as sequellae of PID

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• Diagnostic Tools
• X-rays Up to 25 of asymptomatic adults over
  50 years can have abnormalities
• MRI / CT Only if looking for tumor
• Bone scan Good for fractures but less favorable
  for inflammation
• Treatment
• Medications NSAIDS
• Physical therapy
• Correct limb discrepancy
• Injection Fluoroscopy-guided vs. local
• Surgical fusion Few figures for efficacy

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B. Cauda Equina Syndrome

• History
• Sudden, partial or complete loss of voluntary
  bladder function due to massive disc
  impingement on spinal nerves
• Can include loss of sensation as well as
  sphincter tone
• Treatment
• Urgent decompression is mandatory for prevention
  of irreparable / irreversible bladder damage
• 12 hours is the maximum time prior to
  irreversible changes

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C. DDD and Spondylosis

• Clinical
• Up to 75 of involvement of the spine occurs at
  2 levels L5-S1 and L4-L5
• Possible factors that contribute to development
• Changes with maturation in
• Nutrition
• Disc chemistry
• Hormones
• Occupational forces
• Progression of disc narrowing leads to
  degenerative changes of bony structures,
  especially posterior components, leading to
  spondylosis

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• Treatment
• Medications
• Physical therapy
• Lifestyle changes
• Smoking cessation
• Weight loss
• Vocational changes
• Injections
• Less helpful if pain is limited to central low
  back only
• Surgery
• Laminectomy
• Fusion

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D. Spinal Stenosis

• Clinical
• Results from narrowing of spinal canal and / or
  neural foramina (CONGENITAL OR DEGENERATIVE)
• Most common complaint is leg pain limiting
  walking
• Neurogenic / Pseudoclaudication pain in lower
  extremities with gait
• Relief can occur with
• stopping activity
• sitting, stooping or bending forward
• Common are complaints of weakness and numbness of
  extremities
• Usually becomes symptomatic in 6th decade

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• Diagnosis
• CT and MRI may yield false-positive results,
  therefore EMG / NCV can be helpful to confirm
  diagnosis
• Myelography also can be confirmatory and
  pre-surgical screening tool
• Treatment
• Medications
• Physical therapy
• TENS
• Epidural injections
• Surgical decompression laminectomy

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E. HNP

• Clinical
• Low back pain wit associated leg symptoms
• Positions can induce radicular symptoms
• Posterolateral disc pathology most common
• Area where anular fibers least protected by PLL
• Greatest shear forces occur with forward or
  lateral bend
• Central disc pathology
• Usually with LBP only without radicular symptoms,
  unlessa large defect is present

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• Treatment
• Conservative treatment
• Saul and Saul study 1989 Spine
• gt 90 success rate of symptom resolution
  withnon-operative management
• Bozzao study 1992 Radiology
• 69 patients with HNP studied longitudinally
  with MRI
• 63 with gt30 reduction with 48 gt 70
  reductionover time
• Medications
• Physical therapy
• Injections
• Surgery

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F. Pars Interarticularis Defects

• Spondylolysis
• Anatomic defect in the bony pars interarticularis
  within the lamina
• May uni- or bilateral
• Can be congenital or induced
• Usually without clinical symptoms with incidental
  findings on radiographs

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• Spondylolisthesis
• Progression of spondylolysis with separation
• Grades assigned I-IV for level of translation
• Most common levels are L5-S1 (70 ) and L4-L5 (25
  )
• May be asymptomatic, but can result in
• Spondylosis
• DDD
• Radiculopathy
• Treatment
• Medication
• Physical Therapy
• Injections
• Surgery

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V. Chronic Pain Issues
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A. Pain Reinforcing Factors

• Secondary gain Support system allows passive /
  inactive role for patient via catering to needs
  and hence fostering dependency
• Environmental Inadequate opportunity or skills
  to compete in the professional community
• Physician knowledge deficit In areas of
  diagnosis and appropriate treatment, can prolong
  symptoms and validate pain behavior
• Workers compensation Laws have become
  counterproductive-- financial compensation or
  open claim may discourage desire for return work
  and impede recovery
• Litigation Anticipation of large financial
  settlement can reinforce pain behavior and
  develop into learned pain behavior

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B. Risk Factors for Delayed Recovery

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C. Discouraging Chronic Pain

• Requiring employer to accommodate restrictions to
  allow continued working during treatment and
  recovery
• Rapid abjudication of disability and compensation
  claims
• Physician education re appropriate treatments
  and limiting use of potentially addictive
  medications
• Ergonomic work environments
• Patient education re disease process and
  treatment options

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• D. Considerations ofPM R Treatment
• Physical therapy is initially usually one of
  modalities with progression into more active
  exercise
• Pre-conditioning therapy is more functional with
  transition into Work Conditioning (Work
  Hardening) program
• Always consider return to work, whether modified
  duty with restrictions or limiting hours worked
• If patients poorly tolerate standard therapy,
  consider pool therapy intervention which
  allows elimination of gravity effects
• Functional Capacity Evaluations utilized if
  patients are not progressing through therapy or
  if have reached a plateau and abilities as
  well as restrictions need to be assessed
• Job site evaluations appropriate if concerns re
  ergonomics

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E. Final Thoughts

• It is the patient, not the diagnostic test, that
  is treated
• 80 of patients will recover from acute low back
  pain within 3 days to 3 weeks, with or without
  treatment, with up to 90 resolved in 6-12 weeks