Presentation on theme: "Low Back Pain: Case Based Evaluation and Management Patrick Kortebein, M.D. Departments of PM&R and Geriatrics University of Arkansas for Medical Sciences."— Presentation transcript:
Low Back Pain: Case Based Evaluation and Management Patrick Kortebein, M.D. Departments of PM&R and Geriatrics University of Arkansas for Medical Sciences 5/31/09 Slides:
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.
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
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?
Acute LBP: History “Red Flags” (AHCPR 1994) Fracture: Major/minor trauma Age > 70 yrs (~50 yrs) Chronic corticosteroids Cauda Equina B/B dysfunction Saddle Anesthesia LE weakness
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 > 50
LBP: Imaging MRI Abnormalities in Normals / No LBP Boden et al (N=67) 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%)
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
Case # 2 38 yo with left LE radicular pain > LBP for ~6 weeks. Also left foot tingling and weakness. PMHx: HTN, Hyperlipidemia Meds: HCTZ, Atorvastatin Allergies: Sulfa Social Hx: Divorced, Landscaper
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
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
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
Case # 3 Lumbar MRI: Mild DD changes with diffuse disc bulge at L4-5 and L5-S1 Diagnosis? Treatment?
Chronic LBP Strong Association Depression Anxiety Poor Coping Skills “My back hurts, but I’m here because I can’t cope with this episode, as well as the turmoil at home (or work)”- N Hadler “Last Well Person”
**Goal** Improve Function Minimize focus on treating pain itself Biopsychosocial Model of Pain Maladaptive Behavior Neuroplasticity
Recommended Reading Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician 2007; 75:1181-8, Deyo et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22:62-8. LBP Handbook 2003 Cole & Herring