2 Back PainAccounts for 2.5% of medical visits – second most common reason for office visits in USPrevalence varies widely – 1.2 to 43%Risk factors:ObesitySmokingFemale genderPhysically strenuous or sedentary work – lifting over 25 lbsLow educational levelJob dissatisfactionSomatization disorder, anxiety, depressionWorkers’ Compensation InsuranceGenetic backgroundCultural differences
3 PrognosisGenerally good, especially if expectation is to improve – most do get better with no interventionLess than 5% have serious underlying pathologyA cause can be found only in a minority of patientsChronicity seems to correlate with:Female genderIncreasing agePre-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 RxEvidence for neurologic compromise – cauda equina syndrome, radiation of pain below the knee, pseudoclaudication as in spinal stenosis, focal weaknessSocial or psychological distress contributing to chronic, disabling pain
7 Physical ExaminationCheck for spinal curvature – kyphosis, scoliosis, etc.Check for spinal tendernessStraight leg raising and crossed straight leg raisingEvaluate for deficits in L4, L5, and S1 distributions.Lymph node, breast, and prostate exams if neoplasia is suspectCheck peripheral pulses
8 Diagnostic Imaging Special situations: Imaging is essential in these situations:Progression of neurological findingsHistory of traumaHistory of neoplasiaAge <18 or >50Special situations:Injection drug useImmunosuppressionIndwelling Foley catheter or recent GU procedureConcomitant steroid use
9 Plain Films, MRI, CTIf symptoms persist for 4 to 6 wks with no improvement, order two views of plain films without obliquesImplications of spondylosis, spondylolisthesis, spondylolysisOrder 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 PainBed rest is not indicated – may actually delay recoveryNSAIDS and narcotics have similar efficacy – use of NSAIDS should be limited to 2 to 4 wksAdverse effects more common in older patientsAcetaminophen is probably as good as NSAIDS.Muscle relaxers are more effective than placebo for short-term reliefNSAIDS + muscle relaxants may be better - based on observational data.
11 Treatment of Back PainOpioids are effective in acute back pain but obviously have multiple side effects and are addictingTramadol 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 trialsProbably best in radiculopathy secondary to HNP – has short-term (at 6 wks) but no long-term benefit at 3 , 6, or 12 monthsNot of proven benefit in spinal stenosis and nonspecific painNo difference in translaminar, transforaminal, and caudal approaches2 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 monthsMedial branch of dorsal ramus nerve blocks are of unknown efficacySacroiliac joint steroid injection was more effective than anesthetic injection in one small trialProbably does work for spondyloarthropathiesRx effectiveness of piriformis syndrome using injected steroids remains unclear
14 Treatment of Back PainChemonucleolysis for HNP should only be used in patients who do not want surgery – not often done in USParavertebral botulinum toxin injection was superior to placebo at 3 and 8 weeksEvidence for the efficacy of radiofrequency nerve ablation remains inconsistent – would only consider in the most refractory situationsProlotherapy should not be used
15 Treatment of Back PainExercise 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 stimulationTENS 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 PainBasic issues:The major dilemma is to differentiate among gluteus medius superficial and deep bursitis and osteoarthritisThe 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 trochanterThe 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 anteriorLateral 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 osteonecrosisIf not worse with repetitive hip flexion, have to consider inguinal hernia and intraabdominal process.Anterior thigh pain just above the knee presents the most difficultyPosterior 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 stiffnessPoint tenderness over trochanteric bursaHip DJD presents with groin pain worse with movement, limited internal rotation (<15 º), limited flexion (<115 º)Osteonecrosis presents in the groin, thigh, or buttockRest pain is common as is nocturnal pain
21 Hip ExaminationObserve patient’s gait - ? antalgic, short leg limp, Trendelenburg gaitPassive internal and external rotation - ? endpoint stiffness – endpoint pain raises osteonecrosis, occult fracture, acute synovitis, metastatic diseaseFabere or Patrick testStraight leg raising to evaluate lumbar originCheck sensation lateral thigh - ? meralgiaEvaluate L4, L5, and S1 nerve root distributionCheck for tenderness over the sacroiliac jointCheck 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 osteonecrosisLocal 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, NSAIDSPhysical therapyJoint replacement