Presentation is loading. Please wait.

Presentation is loading. Please wait.

Low Back Pain: Case Based Evaluation and Management Patrick Kortebein, M.D. Departments of PM&R and Geriatrics University of Arkansas for Medical Sciences.

Similar presentations


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:

1 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:

2 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.

3 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

4 LBP: Anatomy Bone / Vertebrae Disc Annulus Nucleus Pulposus Muscles / Ligaments Spinal Nerve Roots

5 LBP Facet joint Zygopophyseal joint Synovial

6 LBP Sacroiliac Joint Tight, Synovial Ligaments “SI Dysfunction”

7 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?

8 Acute LBP: History Location Axial or Radiating (Sciatica) ? Onset: Traumatic, Insidious Duration: Acute: < 12 weeks Chronic: > 12 weeks Character/Quality: Ache, Burning, etc Exacerbating / Alleviating Factors

9 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

10 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

11 “Red Flag” Evaluation

12 Acute LBP: Physical Exam Lumbar Spine: Inspection Palpation ROM: Flexion / Extension +/- LE Neurologic Exam

13 Acute LBP: Imaging When? What imaging?

14 Acute LBP: Imaging When? Minimum 6 weeks + “Red Flags” What? X-ray 3-view: AP / Lat / L5 Spot Obliques: Limited information Radiation exposure

15 Acute LBP: Imaging Lumbar MRI

16 Acute LBP: Imaging Abnormal findings “Degenerative disc disease” “Bulging disc” “Herniated disc”

17 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%)

18 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

19 Case # 1 Diagnosis ? Management ?

20 LBP: Differential Diagnosis Deyo NEJM 2001

21 Case # 1 Diagnosis: “Mechanical” LBP Education / Activity Modification Bedrest: ~ 2 days (Deyo NEJM 1986) Analgesics: Acetaminophen NSAID’s Tramadol Muscle Relaxants Cyclobenzaprine

22 “Mechanical” LBP Physical Therapy Exercise Modalities Lumbar Support Chiropractic Acupuncture Back Heat

23 LBP: Zygapophyseal (Facet) joint History/Examination Axial LBP +/- post thigh No neuro sxs Worse w/ static posture Lumbar Extension Stand / Walk Neuro exam normal

24 LBP: Zygapophyseal (Facet) joint Management Analgesics Tylenol, NSAID Physical Therapy Injections Diagnostic Therapeutic

25 LBP: Sacroiliac (SI) Joint History Atraumatic > Traumatic Axial; Lumbosacral Uni- > Bilateral No radiation / neuro sxs Physical Exam ~ Normal Tender SI region

26 LBP- SI Joint Diagnosis / Treatment Physical Therapy Injection

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

28 LBP: Discogenic Management Physical Therapy Core Strength Surgery: Fusion Artificial Disc Not yet

29 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

30 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

31 Case # 2 Diagnosis ?

32 LBP: Radiculopathy Diagnosis Physical Exam MRI EMG CT Myelogram * Correlate anatomy w/ sxs and exam

33 LBP: Radiculopathy Neurological Exam: Motor ReflexSensory 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

34 LBP: Evaluation SLR / Dural Tension

35 Case # 2 MRI: Left L5-S1 disc herniation impinging on S1 nerve root Management?

36 LBP: Radiculopathy Management Medications NSAID’s Acetaminophen Tramadol Neuropathic Steroids; Oral (? dose) vs epidural

37 LBP: Radiculopathy Management Physical Therapy McKenzie Extension therapy TENS ~ No benefit

38 LBP: Radiculopathy Injections EpiduralSelective

39 LBP: Radiculopathy Surgery Indications Cauda equina Progressive neuro deficits No relief w/ conservative treatment SPORT trial JAMA 2006

40 LBP: Spinal Stenosis History (Neurogenic claudication) Prox LE Pain +/- Neuro sxs Walk / Stand Uphill > Downhill Grocery Cart Physical Exam ~ Normal Stand / Walk

41 LBP: Spinal Stenosis Diagnosis MRI EMG Management Medications Neuropathic PT Epidural Injection Surgery: (SPORT trial)

42 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

43 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

44 Case # 3 Lumbar MRI: Mild DD changes with diffuse disc bulge at L4-5 and L5-S1 Diagnosis? Treatment?

45 Chronic LBP Duration > 12 weeks Poor Correlation Symptoms Objectives Finding

46 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”

47 Chronic LBP

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

49 Chronic LBP

50 Case # 3 Multidisciplinary Pain Management Education Medications Chronic Opioids ? PT  Functional Restoration Psychology Pain Management

51 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

52 LBP

53 Questions ?

54 Other

55 LBP: Evaluation Waddell’s Signs (Non-organic PE) Tenderness Overreaction Regional Distraction Simulation > 3/5 * Behavioral Component of Pain Spine 1980


Download ppt "Low Back Pain: Case Based Evaluation and Management Patrick Kortebein, M.D. Departments of PM&R and Geriatrics University of Arkansas for Medical Sciences."

Similar presentations


Ads by Google