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Low Back Pain: Case Based Evaluation and Management

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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 Acute episodes
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 Muscles / Ligaments
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 Onset: Traumatic, Insidious Duration:
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: Cauda Equina
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 Cancer 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? What? Minimum 6 weeks + “Red Flags” 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 Chiropractic Acupuncture 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 Surgery: Core Strength
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 Reflex Sensory
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

36 LBP: Radiculopathy Management Medications Steroids; 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 Epidural Selective

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

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

41 LBP: Spinal Stenosis Diagnosis Management MRI EMG Medications PT
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 Lower Extremity Neurologic
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: Diagnosis? Treatment?
Mild DD changes with diffuse disc bulge at L4-5 and L5-S1 Diagnosis? Treatment?

45 Chronic LBP Duration Poor Correlation > 12 weeks 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 Chronic LBP **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 PT
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

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