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