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Diagnosing Low Back Pain

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1 Diagnosing Low Back Pain
Eden Wheeler, M.D. Physical Medicine and Rehabilitation Rockhill Orthopaedics, P.C.

2 I. History:

3 Prior injuries, treatment and outcomes Medications Family history
Mechanism of injury Associated symptoms: Bladder / bowel function Fevers / chills Sleep disturbance Numbness / tingling Prior injuries, treatment and outcomes Medications Family history Social history: Vocational Education Tobacco / ETOH / Illicit drugs Function: ADLs & Mobility Litigation

4 Pain Specifics: Quality: sharp, dull, shooting, burning, etc.
Location / Distribution: Radicular: Dermatomal distribution, dysesthesias Radiating: Nondermatomal Onset: Gradual: DDD Acute: Disc abnormality, strain, compression fractures Severity / Intensity Frequency: Constant vs. Intermittent Duration Exacerbating and Alleviating Factors Time of Day: If nocturnal, consider malignancy

5 Red Flags: Significant trauma history, or minor in older adults
Nocturnal pain in supine position with history of cancer Bladder or bowel incontinence or dysfunction Constitutional symptoms: Fever / chills Weight loss Lymph node enlargement Risk factors for spinal infection Recent infection IV drug use Immunosuppression Major motor weakness

6 II. Examination:

7 A. Physical: Posture: Gait: Musculoskeletal: Splinting Body language
Antalgia Heel / Toe pattern Trendelenberg Musculoskeletal: ROM Leg length Vascular Atrophy

8 Abdomen: Back: Neurological: Rectal if indicated: Presence of masses
Inspection Palpation ROM Scoliosis Neurological: Sensation Motor DTRs Rectal if indicated: Evaluation of sphincter tone

9 B. Symptom Magnification Examination:
Waddell signs: Presence of nonorganic signs suggesting symptom magnification and psychological distress Superficial or nonanatomic distribution of tenderness Nonanatomic or regional disturbance of motor or sensory impairment Inconsistency on positional SLR Inappropriate/excessive verbalization of pain or gesturing Pain with axial loading or rotation of spine Give-away weakness: Inconsistent effort on manual motor testing with “ratcheting” rather than smooth resistance

10 C. Pathological Examination:
Spurling’s maneuver: Lateral rotation and extension of spine resulting in neuroforaminal narrowing and nerve root encroachment, clinically reproducing extremity pain, usually in dermatomal distribution Straight-leg raise (SLR): Elevation of lower extremity, seated or standing, resulting in neural tension at S1 nerve root with extremity pain Patrick’s maneuver: Crossed leg with unilateral pain indicative of sacro-iliac (SI) joint dysfunction Femoral stretch: Hip extension stretch with heel pushed to buttock in lateral supine or prone position resulting in anterior thigh pain

11 III. Low Back Pain:

12 A. Epidemiology: Incidence of LBP: 60-90 % lifetime incidence
5 % annual incidence 90 % of cases of LBP resolve without treatment within weeks 40-50 % LBP cases resolve without treatment in 1 week 75 % of cases with nerve root involvement can resolve in 6 months LBP and lumbar surgery are: 2nd and 3rd highest reasons for physician visits 5th leading cause for hospitalization 3rd leading cause for surgery

13 B. Disability: Age and LBP: Prevalence rate:
Leading cause of disability of adults < 45 years old Third cause of disability in those > 45 years old Prevalence rate: Increased 140 % from to 1981 with only 125 % population growth Nearly 5 million people in the U.S. are on disability for LBP

14 C. Lifetime Return to Work:
Success of less than 50 % if off work greater than 6 months 25 % success rate if off work greater than 1 year Nearly 0 % success if return to work has not occurred in 2 years

15 D. Occupational Risk Factors:
Low job satisfaction Monotonous or repetitious work Educational level Adverse employer-employee relations Recent employment Frequent lifting Especially exceeding 25 pounds Utilization of poor body mechanics in technique

16 E. Differential Diagnoses:
Lumbar strain Disc bulge / protrusion / extrusion producing radiculopathy Degenerative disc disease Spinal stenosis Spondyloarthropathy Spondylosis Spondylolisthesis Sacro-iliac dysfunction

17 F. Diagnostic Tools: 1. Laboratory:
Performed primarily to screen for other disease etiologies Infection Cancer Spondyloarthropathies No evidence to support value in first 7 weeks unless with red flags Specifics: WBC ESR or CRP HLA-B27 Tumor markers: Kidney Breast Lung Thyroid Prostate

18 2. Radiographs: Pre-existing DJD is most common diagnosis
Usually 3 views adequate with obliques only if equivocal findings Indications: History of trauma with continued pain Less than 20 years or greater than 55 years with severe or persistent pain Noted spinal deformity on exam Signs / symptoms suggestive of spondyloarthropathy Suspicion for infection or tumor

19 3. EMG / NCV ( Electrodiagnostics):
Can demonstrate radiculopathy or peripheral nerve entrapment, but may not be positive in the extremities for the first 3-6 weeks and paraspinals for the first 2 weeks Would not be appropriate in clinically obvious radiculopathy 4. Bone scan: Very sensitive but nonspecific Useful for: Malignancy screening Detection for early infection Detection for early or occult fracture

20 5. Myelogram: Procedure of injecting contrast material into the spinal canal with imaging via plain radiographs versus CT In past, considered the gold standard for evaluation of the spinal canal and neurological compression With potential complications, as well as advent of MRI and CT, is less utilized: More common: Headache, nausea / vomiting Less common: Seizure, pain, neurological change, anaphylaxis Myelogram alone is rarely indicated Hitselberger study 1968 Journal of Neurosurgery: 24 % of asymptomatic subjects with defects

21 6. CT with myelogram: Can demonstrate much better anatomical detail than myelogram alone Utilized for: Demonstrating anatomical detail in multi-level disease in pre- operative state Determining nerve root compression etiology of disc versus osteophyte Surgical screening tool if equivocal MRI or CT

22 7. CT: Best for bony changes of spinal or foraminal stenosis
Also best for bony detail to determine: Fracture DJD Malignancy SW Wiesel study 1984 Spine: 36 % of asymptomatic subjects had “HNP” at L4-L5 and L5-S1 levels

23 8. Discography (Diagnostic disc injection):
Less utilized as initial diagnostic tool due to high incidence of false positives as well as advent of MRI Utilizations: Diagnose internal disc derangement with normal MRI / myelo Determine symptomatic level in multi-level disease Criteria for response: Volume of contrast material accepted by the disc, with normals of 0.5 to 1.5 cc Resistance of disc to injection Production of pain---MOST SIGNIFICANT Usually followed by CT to evaluate internal architecture, but also may utilize MRI As outcome predictor (Coulhoun study 1988 JBJS): 89 % of those with pain response received benefit from surgery 52 % of those with structural change received surgical benefit

24 9. MRI: Best diagnostic tool for: Soft tissue abnormalities:
Infection Bone marrow changes Spinal canal and neural foraminal contents Emergent screening: Cauda equina syndrome Spinal cored injury Vascular occlusion Radiculopathy Benign vs. malignant compression fractures Osteomyelitis evaluation Evaluation with prior spinal surgery

25 Has essentially replaced CT and myelograms for initial evaluations
Boden study 1990 JBJS: 20 % of asymptomatic population less than 60 years with “HNP” 36 % of asymptomatic population of 60 years Jensen study 1995 NEJM: 52 % of asymptomatic patients with disc bulge at one or more levels 27 % of asymptomatic patients with disc protrusion 1 % of asymptomatic patients with disc extrusion

26 MRI with Gadolinium contrast:
Gadolinium is contrast material allowing enhancement of intrathecal nerve roots Utilization: Assessment of post-operative spine---most frequent use Identifying tumors / infection within / surrounding spinal cord Diagnosis of radiculitis Post-operatively can take 2-6 months for reduction of mass effect on posterior disc and anterior epidural soft tissues which can resemble pre-operative studies Only indications in immediate post-operative period: Hemorrhage Disc infection

27 10. Psychological tools: Utilized in case scenarios where psychological or emotional overlay of pain is suspected Symptom magnification Grossly abnormal pain drawing Non-responsive to conservative interventions but with essentially normal diagnostic studies Includes: Pain Assessment Report, which combines: McGill Pain Questionnaire Mooney Pain Drawing Test MMPI Middlesex Hospital Questionnaire Cornell Medical Index Eysenck Personality Inventory

28 MRI Nomenclature: (PER NASS)
Anular fissure: Focal disruption of anular fibers in concentric, radial or transverse distribution Disc bulge: Circumferential, diffuse, symmetric extension of anulus beyond the adjacent vertebral end plates by 3 or more mm, usually due to weakened or lax anular fibers Disc protrusion: Focal, asymmetric extension of disc segment beyond margin of vertebral end plates into the spinal canal with most of anular fibers intact Disc extrusion: Focal, asymmetric extension of disc segment and / or nucleus pulposis through the anular containment into the epidural space Disc sequestration: Extruded disc segment that is detached from original with migration into the canal Disc degeneration: Irreversible structural and histiological changes in nucleus seen on MRI T2WI images (commonly associated with bulge)

29 Specificity / Sensitivity

30 G. Treatment Medications NSAIDS Membrane stabilizers Muscle relaxers:
TCA / Neurontin re-establish sleep pain reduce radicular dysesthesias Muscle relaxers: re-establish sleep patterns more useful in myofascial/muscular pain Narcotics: rarely indicated Steroids: more useful for radiculitis Non-narcotic analgesics: Ultram

31 Physical therapy Injections Modalities electrical stimulation/TENS
Postural education / body mechanics Massage / mobilization / myofascial release Stretching / body work Exercise / strengthening Traction Pre-conditioning / work-conditioning Injections Epidural blocks Facet blocks Trigger point SNRB SI joint

32 Surgery: Laminectomy Fusion Discectomy Percutaneous Lumbar Discectomy
Success rate variable % Low rate of complications: Infection Peripheral nerve injury Benefits: Outpatient procedure Minimal to no epidural scarring No general anesthesia Spine stability preservation Decreased cost

33 IDET: Intradiscal Electrotherapy or Spine CATH Alternative:
Chemonucleolysis IDET: Intradiscal Electrotherapy or Spine CATH Alternative: Chiropractic: Clinical studies show benefit only in first 3 weeks of symptoms Acupuncture Biofeedback

34 IV. Specific Disorder Considerations

35 A. Sacroiliitis: History: Biomechanics: Trauma is very common
Repetitive LS motion--lumbar rotation or axial loading No specific correlation with exacerbating activities Commonly have leg length discrepancy or condition contributing Biomechanics: Movement of the SIJ is involuntary, usually from muscle imbalances Can occur at multiple levels: lower extremities, hip, LS spine Motion is complex and not single-axis based

36 Differential Diagnosis:
a. Fracture Traumatic Insufficiency stress fractures: elderly patient with osteoporosis without history of trauma Fatigue stress fractures: usually athletes / soldiers b. Infection Hematogenous spread with predisposing history Usually unilateral symptoms present c. Degenerative joint disease d. Metabolic disease e. Referred pain

37 f. Seronegative spondyloarthropathies
RA--usually not until late in course of disease Ankylosing spondylitis Psoriatic arthritis g. Primary SI tumor Rare and usually synovial villoadenomas h. Iatrogenic instability Via pelvic tumor resection or bone graft site i. Osteitis condensans ilii Prevalence of 2.2 %, primarily in multiparous women Usually self-limiting and bilateral j. Reactive disease as sequellae of PID

38 Diagnostic Tools: Treatment:
X-rays: Up to 25 % of asymptomatic adults over 50 years can have abnormalities MRI / CT: Only if looking for tumor Bone scan: Good for fractures but less favorable for inflammation Treatment: Medications: NSAIDS Physical therapy Correct limb discrepancy Injection: Fluoroscopy-guided vs. local Surgical fusion: Few figures for efficacy

39 B. Cauda Equina Syndrome:
History: Sudden, partial or complete loss of voluntary bladder function due to massive disc impingement on spinal nerves Can include loss of sensation as well as sphincter tone Treatment: Urgent decompression is mandatory for prevention of irreparable / irreversible bladder damage 12 hours is the maximum time prior to irreversible changes

40 C. DDD and Spondylosis: Clinical:
Up to 75 % of involvement of the spine occurs at 2 levels: L5-S1 and L4-L5 Possible factors that contribute to development: Changes with maturation in: Nutrition Disc chemistry Hormones Occupational forces Progression of disc narrowing leads to degenerative changes of bony structures, especially posterior components, leading to spondylosis

41 Treatment: Medications Physical therapy Lifestyle changes: Injections:
Smoking cessation Weight loss Vocational changes Injections: Less helpful if pain is limited to central low back only Surgery: Laminectomy Fusion

42 D. Spinal Stenosis: Clinical:
Results from narrowing of spinal canal and / or neural foramina (CONGENITAL OR DEGENERATIVE) Most common complaint is leg pain limiting walking Neurogenic / Pseudoclaudication = pain in lower extremities with gait Relief can occur with: stopping activity sitting, stooping or bending forward Common are complaints of weakness and numbness of extremities Usually becomes symptomatic in 6th decade

43 Diagnosis: Treatment:
CT and MRI may yield false-positive results, therefore EMG / NCV can be helpful to confirm diagnosis Myelography also can be confirmatory and pre-surgical screening tool Treatment: Medications Physical therapy TENS Epidural injections Surgical decompression laminectomy

44 E. “HNP”: Clinical: Low back pain wit associated leg symptoms
Positions can induce radicular symptoms Posterolateral disc pathology most common: Area where anular fibers least protected by PLL Greatest shear forces occur with forward or lateral bend Central disc pathology: Usually with LBP only without radicular symptoms, unless a large defect is present

45 Treatment: Conservative treatment: Saul and Saul study 1989 Spine:
> 90 % success rate of symptom resolution with non-operative management Bozzao study 1992 Radiology: 69 patients with “HNP” studied longitudinally with MRI 63 % with >30 % reduction with 48 % > 70 % reduction over time Medications Physical therapy Injections Surgery

46 F. Pars Interarticularis Defects:
Spondylolysis: Anatomic defect in the bony pars interarticularis within the lamina May uni- or bilateral Can be congenital or induced Usually without clinical symptoms with incidental findings on radiographs

47 Spondylolisthesis Treatment:
Progression of spondylolysis with separation Grades assigned I-IV for level of translation Most common levels are L5-S1 (70 %) and L4-L5 (25 %) May be asymptomatic, but can result in Spondylosis DDD Radiculopathy Treatment: Medication Physical Therapy Injections Surgery

48 V. Chronic Pain Issues

49 A. Pain Reinforcing Factors:
Secondary gain: Support system allows passive / inactive role for patient via catering to needs and hence fostering dependency Environmental: Inadequate opportunity or skills to compete in the professional community Physician knowledge deficit: In areas of diagnosis and appropriate treatment, can prolong symptoms and validate pain behavior Worker’s compensation: Laws have become counterproductive-- financial compensation or open claim may discourage desire for return work and impede recovery Litigation: Anticipation of large financial settlement can reinforce pain behavior and develop into learned pain behavior

50 B. Risk Factors for Delayed Recovery:

51 C. Discouraging Chronic Pain:
Requiring employer to accommodate restrictions to allow continued working during treatment and recovery Rapid abjudication of disability and compensation claims Physician education re: appropriate treatments and limiting use of potentially addictive medications Ergonomic work environments Patient education re: disease process and treatment options

52 D. Considerations of PM & R Treatment:
Physical therapy is initially usually one of modalities with progression into more active exercise Pre-conditioning therapy is more functional with transition into Work Conditioning (Work Hardening) program Always consider return to work, whether modified duty with restrictions or limiting hours worked If patients poorly tolerate standard therapy, consider pool therapy intervention which allows elimination of gravity effects Functional Capacity Evaluations utilized if patients are not progressing through therapy or if have reached a plateau and abilities as well as restrictions need to be assessed Job site evaluations appropriate if concerns re: ergonomics

53 E. Final Thoughts: It is the patient, not the diagnostic test, that is treated 80 % of patients will recover from acute low back pain within 3 days to 3 weeks, with or without treatment, with up to 90 % resolved in 6-12 weeks

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