1. Back and Hip Pain
M. Andrew Greganti, MD

2. Back Pain
Accounts for 2.5% of medical visits – second most common reason for office visits in US
Prevalence varies widely – 1.2 to 43%
Risk factors:
Obesity
Smoking
Female gender
Physically strenuous or sedentary work – lifting over 25 lbs
Low educational level
Job dissatisfaction
Somatization disorder, anxiety, depression
Workers’ Compensation Insurance
Genetic background
Cultural differences

3. Prognosis
Generally good, especially if expectation is to improve – most do get better with no intervention
Less than 5% have serious underlying pathology
A cause can be found only in a minority of patients
Chronicity seems to correlate with:
Female gender
Increasing age
Pre-existing psychosocial factors

5. Clinical Evaluation Key concepts:
Most patients have mechanical low back pain – no infectious, inflammatory, or neoplastic cause.
Degenerative disc disease plays a substantial role but exactly how much of one is unclear. Many patients without pain have discs on MRI.
Muscular and ligamentous sources of pain are probably equally important.
Tender fibro-fatty nodules (back mice) may play some role but correlation with back pain remains in question.

6. History Consider 3 major concerns:
Evidence for a systemic process – hx of cancer, age over 50, weight loss, nocturnal pain, unresponsiveness to Rx
Evidence for neurologic compromise – cauda equina syndrome, radiation of pain below the knee, pseudoclaudication as in spinal stenosis, focal weakness
Social or psychological distress contributing to chronic, disabling pain

7. Physical Examination
Check for spinal curvature – kyphosis, scoliosis, etc.
Check for spinal tenderness
Straight leg raising and crossed straight leg raising
Evaluate for deficits in L4, L5, and S1 distributions.
Lymph node, breast, and prostate exams if neoplasia is suspect
Check peripheral pulses

8. Diagnostic Imaging Special situations:
Imaging is essential in these situations:
Progression of neurological findings
History of trauma
History of neoplasia
Age <18 or >50
Special situations:
Injection drug use
Immunosuppression
Indwelling Foley catheter or recent GU procedure
Concomitant steroid use

9. Plain Films, MRI, CT
If symptoms persist for 4 to 6 wks with no improvement, order two views of plain films without obliques
Implications of spondylosis, spondylolisthesis, spondylolysis
Order MRI or CT to evaluate progressive neurologic deficits, to evaluate for cancer, or to evaluate patients with refractory symptoms – greater than 12 wks of persistent pain

10. Treatment of Back Pain
Bed rest is not indicated – may actually delay recovery
NSAIDS and narcotics have similar efficacy – use of NSAIDS should be limited to 2 to 4 wks
Adverse effects more common in older patients
Acetaminophen is probably as good as NSAIDS.
Muscle relaxers are more effective than placebo for short-term relief
NSAIDS + muscle relaxants may be better - based on observational data.

11. Treatment of Back Pain
Opioids are effective in acute back pain but obviously have multiple side effects and are addicting
Tramadol is a non-opioid and works on the opioid receptor – is worth a trial.
Oral glucocorticoids probably are not beneficial for acute pain.
Lidocaine patches, anticonvulsants, antidepressants are of limited effectiveness in acute pain.

12. Treatment of Back Pain Epidural injection:
Efficacy remains unclear – conflicting results from controlled trials
Probably best in radiculopathy secondary to HNP – has short-term (at 6 wks) but no long-term benefit at 3 , 6, or 12 months
Not of proven benefit in spinal stenosis and nonspecific pain
No difference in translaminar, transforaminal, and caudal approaches
2 of 7 trials found epidural injection vs placebo associated with lower rates of subsequent surgery.
Adverse events: dural puncture, bleeding, infection

13. Treatment of Back Pain Local or trigger point injection rarely works
Facet joint steroid injection doesn’t help at 1 and 3 months
Medial branch of dorsal ramus nerve blocks are of unknown efficacy
Sacroiliac joint steroid injection was more effective than anesthetic injection in one small trial
Probably does work for spondyloarthropathies
Rx effectiveness of piriformis syndrome using injected steroids remains unclear

14. Treatment of Back Pain
Chemonucleolysis for HNP should only be used in patients who do not want surgery – not often done in US
Paravertebral botulinum toxin injection was superior to placebo at 3 and 8 weeks
Evidence for the efficacy of radiofrequency nerve ablation remains inconsistent – would only consider in the most refractory situations
Prolotherapy should not be used

15. Treatment of Back Pain
Exercise is not good for acute pain in contrast to more chronic pain.
Encourage mobilization as soon as possible.
Physical therapy is, in general, very helpful but no difference in heat/cold, ultrasound, electrical stimulation
TENS effectiveness is very questionable at best.
Spine manipulation by chiropractors may be helpful.
Accupuncture is probably equivalent to NSAIDS.
Traction does not help lumbar pain.

16. Hip Pain
Basic issues:
The major dilemma is to differentiate among gluteus medius superficial and deep bursitis and osteoarthritis
The hip is “fixed” by the pelvic girdle, making it more difficult to differentiate pain originating in the lumbar spine and knee from hip pain.
The gluteus medius and gluteus minimus muscles abduct the hip and attach at the greater trochanter.
The gluteus maximus extends the hip and attaches just distal to the greater trochanter
The iliopsoas muscle, the major hip flexor, attaches at the lesser trochanter.

18. Clinical Presentation of Hip Pain
Hip pain with weight bearing and improvement with rest is most compatible with DJD.
Constant pain and pain while supine are more likely with infectious, inflammatory, and neoplastic processes.
Lateral hip pain is often from the joint or from the greater trochanteric bursa, especially if there is point tenderness.
Hip joint pain is more often anterior
Lateral paresthesias raise the possibility of meralgia paresthetica.

19. Clinical Presentation of Hip Pain
Anterior hip or groin pain is most often seen in DJD of the hip joint.
Important to differentiate DJD from osteonecrosis
If not worse with repetitive hip flexion, have to consider inguinal hernia and intraabdominal process.
Anterior thigh pain just above the knee presents the most difficulty
Posterior hip pain is not usually from the hip. More commonly is secondary to lumbar disc, sacroiliac disease, facet joint disease.

20. Clinical Presentation of Hip Pain
Trochanteric bursitis is caused by exaggerrated movement of the gluteus medius tendon and tensor fascia lata over the lateral femur.
More likely to develop with leg length discrepancy, knee arthritis, ankle sprain, LS spine stiffness
Point tenderness over trochanteric bursa
Hip DJD presents with groin pain worse with movement, limited internal rotation (<15 º), limited flexion (<115 º)
Osteonecrosis presents in the groin, thigh, or buttock
Rest pain is common as is nocturnal pain

21. Hip Examination
Observe patient’s gait - ? antalgic, short leg limp, Trendelenburg gait
Passive internal and external rotation - ? endpoint stiffness – endpoint pain raises osteonecrosis, occult fracture, acute synovitis, metastatic disease
Fabere or Patrick test
Straight leg raising to evaluate lumbar origin
Check sensation lateral thigh - ? meralgia
Evaluate L4, L5, and S1 nerve root distribution
Check for tenderness over the sacroiliac joint
Check leg pulses

23. Evaluation of Hip Pain AP of pelvis and hip films
MRI if occult hip or pelvic fracture is suspected – also to evaluate early osteonecrosis
Local anesthetic blocks of sacroiliac joint, trochanteric area below gluteus medius tendon, lateral femoral cutaneous nerve

24. Treatment of Hip Pain Very similar to Rx of back pain
Acetaminaphen, tramadol, NSAIDS
Physical therapy
Joint replacement