1. Low Back Pain

2. Goals and Objectives
Review evaluation and differential diagnosis of low back pain
Discuss when to obtain imaging
Discuss selected etiologies/radiography of back pain
Discuss treatment modalities
Have trivial Pennsylvania fun

3. Image Challenge Q: What is the diagnosis?
1. Atlanto-occipital dislocation
2. Atlanto-axial subluxation
3. Pillar fracture
4. Spinous process avulsion
5. Wedge fracture

4. Image Challenge Q: What is the diagnosis? Answer:
1. Atlanto-occipital dislocation
This computed tomogram of the cervical spine shows major atlanto-occipital dislocation in the lateral view that proved to be fatal.

5. Low Back Pain
Treatment for low back pain dated to Hippocrates ( BCE), who reported joint manipulation and use of traction
Second most common office visit
2/3 of all adults will suffer from
85% idiopathic “strain/sprain”
Most common pain syndrome
Risk factors: heavy lifting, twisting, bodily vibration, obesity, and poor conditioning
Deyo R and Weinstein J. N Engl J Med 2001;344:
Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008

6. Differential Diagnosis of Low Back Pain
Mechanical Low Back Pain 97%:
HNP: 4%
Spinal Stenosis 3%
Cancer: 0.7%
Infection: 0.1%
Inflammatory Arthritis: 0.3%
Strain and sprain have never been anatomically or histologically characterized, should be referred to as “idiopathic low back pain”
Table 1. Differential Diagnosis of Low Back Pain.
Deyo R and Weinstein J. N Engl J Med 2001;344:

7. Common Pathoanatomical Conditions of the Lumbar Spine
Figure 1. Common Pathoanatomical Conditions of the Lumbar Spine. A superior view of a lumbar vertebra with normal anatomy and canal configuration is shown in the upper right. In the superior view of a lumbar vertebra and intervertebral disk (center right), herniation of the nucleus pulposus into the spinal canal is evident. The nucleus pulposus has a soft consistency, at least from childhood to middle age, and may protrude through confluent fissures in the anulus fibrosus. This usually occurs in the lateral part of the spinal canal, as shown. The usual abnormalities that result in spinal stenosis (lower right) include hypertrophic degenerative changes of the facets and thickening of the ligamentum flavum. These processes may result in a severely narrowed canal, either centrally or in the lateral recesses of the canal. A lateral view of the lumbosacral spine, illustrating spondylolysis of the L5 vertebra with associated spondylolisthesis at L5-S1, is shown on the left. Spondylolysis refers to a defect in the pars interarticularis of the vertebra, which may be congenital or a result of stress fracture. Spondylolisthesis refers to the anterior displacement of a vertebra on the one beneath it. This may occur as a result of spondylolysis as shown (called isthmic spondylolisthesis) or as a result of degenerative disk disease, usually in the elderly. This process may contribute to narrowing of the spinal canal in spinal stenosis.
Deyo R and Weinstein J. N Engl J Med 2001;344:

8. Examination of the Low Back and SI Joints
Observed walk
Heel and toe walking
Skin exam…focused
-zoster
-café au lait spots
-hair tuft “faun’s beard”
-scoliosis
Fauns goat feet, satyrs human feet

9. Physical Exam
Palpate all of the spinous processes of the thoracolumbar spine
Neurologic, muscle strength and reflex testing
Straight leg testing
Bowstring sign
Distracted straight leg test, positive with Tripod sign or Flip sign
Femoral Stretch Test
Anal Wink

10. Straight Leg Testing
Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier 2006.

11. Bowstring Sign
With onset of pain posterior tibial nerve is stretched like a bowstring across the popliteal fossa
Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier 2006.

12. Femoral Stretch Test
Pain in the anterior thigh or L2/3 region indicates a positive test (tests for HNP compressing nerve roots L2/3/4)
Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier 2006.

13. Anal Wink

14. SI Joint Testing Gaenslen test Patrick test SI distraction
SI compression
Spondylitis measuring

15. Gaenslen Test http://www.hughston.com/hha/b.gaenslen.jpg
***Pain on the side of the hyperextended hip

16. Patrick Test (FABERE) Flexes, ABducts, Externally Rotates, and Extends

17. SI Distraction Testing

18. SI Compression

19. Spondylitis Measuring
Normal Finger to Floor: 0-5 cm
Normal Modified Schobers 15 increases to 20 cm
Distances:
Normal Modified Schobers 15 increases to 20 cm
Normal Occiput to Wall: 0-2 cm
Normal Finger to Fibula: 0-5 cm
Normal Finger to Floor: 0-5 cm
Normal Finger to Fibula: 0-5 cm
Normal Occiput to Wall: 0-2 cm
Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier 2006.

20. Is This Back Pain Serious?
Is there a serious underlying illness?
Does the back pain have a neurogenic claudication or sciatic-type syndrome?
Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008

21. When to Image? Limited to patients with systemic disease or trauma
Guidelines recommend plain radiography for patients:
-with fever
-unexplained weight loss
-history of cancer
-neurologic deficits
-alcohol or injection-drug abuse
-age of more than 50 years
-trauma
Bigos S, Bowyer O, Braen G, et al. Rockville, Md.: Agency for Health Care Policy and Research, December (AHCPR publication no )

22. When to Imag ACR Guidelines?
Recent significant trauma
Milder trauma age >50
Unexplained weight loss
Unexplained fever
Immunosuppression
History of cancer
Intravenous (IV) drug use
Osteoporosis
Prolonged use of corticosteroids
Age >70
Focal neurologic deficit progressive or disabling symptoms
Duration greater than 6 weeks
Low back pain. American College of Radiology. ACR Appropriateness Criteria. Copyright ©2005 American College of Radiology

23. Plain Films
There is no evidence that plain xrays in patients with nonspecific low back pain are associated with improvement in patient outcomes over selective imaging
RCT 421 patients with lumbago x 6 weeks
Exclusion criteria:
-if they had xrays of spine within 1 year
-unexplained weight loss or fever, were taking oral steroids, had a history of malignancy, tuberculosis, injecting drug use, or a positive result on a HIV test
-symptoms or signs of a cauda equina lesion
-were pregnant or planning a pregnancy
Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. BMJ. 2001;322:400-5.

24. Plain films: Results
Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. BMJ. 2001;322:400-5

25. MRI’s for Back Pain Researchers evaluated patients with baseline MRI
Repeated MRI when developed low back pain
Less than 5% developed new pathologic lesion

26. Representative Results of Magnetic Resonance Imaging Studies in Asymptomatic Adults
Table 2. Representative Results of Magnetic Resonance Imaging Studies in Asymptomatic Adults.
Deyo R and Weinstein J. N Engl J Med 2001;344:

27. Etiologies of Back Pain/Abnormal Radiography
Degenerative Disc Disease
Paget’s
DISH
Ochronosis
Renal Osteodystrophy
Sickle Cell
Scheuermann Kyphosis
Infectious, briefly
Idiopathic hemispherica sclerosis?

28. Degenerative Disc Disease
Signs of degeneration include loss of disk height, sclerosis of the endplates, or osteophytic ridging
Rajeev K Patel, MD. Lumbar Degenerative Disk Disease: Differential Diagnoses & Workup. emedicine.com, updated 03 Aug 2009

29. DDD Vaccuum Effect and Schmorl's Nodes
Intervertebral Osteochondrosis (dehydration and dessication of the nucleus pulposis) leads to the vaccuum phenomenom, nitrogen gas formation, bone sclerosis and disc space loss. This cavity then becomes surrounded by a rim of sclerosis (Schmorl’s node)

30. MR images of lumbar spine with degenerative changes at L1
Schellinger, D. et al. Am. J. Roentgenol. 2004;183:
Copyright © 2006 by the American Roentgen Ray Society

31. Paget’s Disease
Results from disturbance in bone modelling and remodelling due to increase in osteoblastic and osteoclastic activity
Spine is the second most common site of bone involvement (Pelvis #1)
Lumbar spine (L4 and L5 levels) are the most frequently involved sites (58%)
Thoracic (45%)
Cervical vertebrae (14%)
Why does Paget’s hurt?
-Periosteal stretching
-Vascular engorgement
-Microfractures
-Facet arthritis
-Intervertebral disc disease
-Overt fractures
-Spondylolysis/-listhesis
-Sarcoma—very rare
Langston A, Ralston SH .Rheumatology (Oxford) Aug;43(8): Epub 2004 Jun 8. C. Dell’Atti, V. N. et al Skeletal Radiol July; 36(7): 609–626.

32. CT Findings of Paget’s
Axial CT sections in different patients
showing the various mechanisms
and their effect on marrow size
(long white arrow) and cortical thickness
(short white arrow).
a Periosteal apposition, normal endosteum.
b Periosteal apposition, endosteal resorption.
c Periosteal and endosteal apposition.
d Pumice stone type (dashed arrow) of
focal periosteal apposition. Similar focal
periosteal apposition of the spinous process
is seen
C. Dell’Atti, V. N. et al Skeletal Radiol July; 36(7): 609–626.

33. Plain Film Findings of Paget’s
a Lateral and b antero-posterior radiographs demonstrate expansion of the vertebra with characteristic sclerotic lines parallel to the end-plates due to trabecular hypertrophy, an “early” sign of PD. c Lateral radiograph in a different patient demonstrates the “picture frame” vertebra due to thickening of the cortex and trabecular hypertrophy at the end-plates
C. Dell’Atti, V. N. et al Skeletal Radiol July; 36(7): 609–626.

34. Other Findings with Pagets
Differential diagnoses of “ivory vertebra” include, Paget’s, metastasis, osteosarcoma, carcinoid and Hodgkin’s lymphoma . This is a case of metastatic prostate CA
Graham T S Radiology 2005;235:
Langston A, Ralston SH .Rheumatology (Oxford) Aug;43(8): Epub 2004 Jun 8. C. Dell’Atti, V. N. et al Skeletal Radiol July; 36(7): 609–626.

35. DISH: Diffuse idiopathic skeletal hyperostosis
Most patients present with stiff back or non-specific back pain
Dysphagia, stridor, chronic pneumonia, and vascular compression are all complications from advanced disease
Khozaim Nakhoda Diffuse Idiopathic Skeletal Hyperostosis. emedicine .com

36. DISH Clinical Criteria:
- Flowing calcifications/ossifications along anterolateral aspect of 4 contiguous vertebral bodies, with or without osteophytes
-Preservation of disk height in involved areas and abscence of excessive disk disease
-Absence of bony ankylosis of facet joints and absence of sacroiliac erosion, sclerosis, or bony fusion (narrowing and sclerosis of facet joints ok)
Khozaim Nakhoda Diffuse Idiopathic Skeletal Hyperostosis. emedicine .com

37. DISH Paraspinal ligaments undergo attrition, degenerate then ossify
Three clinical variants of spinal enthesopathy
Forestier’s disease involves the anterior longitudinal ligament
DISH involves extra-axial sites
Ossification of the posterior longitudinal ligament
Khozaim Nakhoda Diffuse Idiopathic Skeletal Hyperostosis. emedicine .com

38. DISH Etiology is unknown however there are some associations:
-Hyperglcyemia and Diabetes
- Dyslipidemia
-Hyperuricemia
-Vitamin A derivatives used to treat acne
-Chronic fluoride intoxication
Vezyroglou G, Mitropoulos A, Antoniadis C. A . J Rheumatol. Apr 1996;23(4):672-6.
DiGiovanna JJ SO J Am Acad Dermatol 2001 Nov;45(5):S
Utsinger PD; Resnick D; Shapiro R . Arch Intern Med 1976 Jul;136(7):  

39. DISH, Unique Radiographic Findings
Ankylosing Spondylitis
DISH
Syndesmophytes arise from anterosuperior and anteroinferior margins of the vertebral body
Syndesmophytes may be best seen in the frontal projection
The presence of sacroiliac joint erosions and extensive intra- articular bony ankylosis of the sacroiliac and apophyseal joints in ankylosing spondylitis
The ossification in DISH attaches to the vertebral body several millimeters from these margins
Changes are most prominent on the lateral radiographic projection
None
Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008

40. DISH Radiography
Diffuse idiopathic skeletal hyperostosis. There is bone formation along the anterior aspects of more than four vertebral bodies. The disk spaces are maintained, and the sacroiliac joints were normal.
Most common in thoracic but also noted in cervical and lumbar spine
Calcification and ossification of the anterior longitudinal ligament of the spine
Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008

41. Ochronosis Absence of homogentisic acid oxidase
Consequent accumulation of homogentisic acid
Autosomal recessive inheritance discovered by Garod in 1902
Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008
Garrod, AE. The incidence of alkaptonuria: a study in chemical individuality. Lancet 1902; 2:1616.

42. Ochronosis
Dystrophic (hydroxyapatite crystal) calcification involving disks but calcification also seen in cartilage, tendons, and ligaments.
The most specific is in spine, which appears osteoporotic with dense disk calcification. Other joints involved show changes of mild degenerative joint disease, but this is a much less specific .
Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008

43. Renal Osteodystrophy
Sclerosis is noted adjacent to the endplates (rugger-jersey spine) in a patient with renal osteodystrophy -- of osteoid in these areas. DDX osteomalacia and hyperparathyroidism.
University of Washington Department of Radiology website. Musculoskeletal Radiology

44. Sickle Cell Disease
BONUS: What type of fish is pictured to the right of the screen?

45. Scheuermann Kyphosis
Scheuermann kyphosis is defined as anterior wedging of ≥5º in at least three adjacent vertebral bodies, as measured on lateral spine radiographs
Most common cause of structural kyphosis in adolescence.
The mode of inheritance is likely autosomal dominant
Etiology remains largely unknown
Indications for treatment remain controversial because the true natural history of the disease has not been clearly defined
Brace treatment appears to be very effective if the diagnosis is made early
Surgical treatment is rarely indicated for severe kyphosis (>75 degrees ) with curve progression, refractory pain, or neurologic deficit 
Lowe TG Orthop Clin North Am 1999 Jul;30(3):475-87, ix

46. Scheuermann Kyphosis
This lateral radiograph of the thoracic spine demonstrates moderate endplate irregularity, preserved vertebral disc spaces, and mild anterior wedging of the vertebral bodies, all of which are consistent with Scheuermann kyphosis. Courtesy of Jeanne Chow, MD, and Children's Hospital Boston.

47. Infectious Etiologies
Discitis
Epidural Abscess
Osteomyelitis

48. Discitis
To differentiate from vaccuum phenomenom look for gas, extension, osteophytes that occur in the upper outer annular attachmentgrowing horizontal then vertical (traction vs claw)

49. Idiopathic Hemispherica Sclerosis
Occurs in young women
Vertebral level L4
Appears as gas in an intervertebral body
Pneumocyst vs AVN

50. Treatment of Low Back Pain
NSAID’s
Tylenol
Narcotics
Tricyclic Antidepressants
Muscle Relaxants
Physical Therapy
Non-Surgical Intervention therapy
Surgery

51. Medication Therapy In a study of primary care patients
80% of patients prescribed at least 1 medication
Greater than 1/3 were prescribed 2 or more drugs
Cherkin DC, Wheeler KJ, Barlow W, Deyo RA. Spine. 1998;23:

52. Cochrane Review 5 acetaminophen trials 57 NSAID trials
10 trials of duloxetine and venlafaxine
8 trials of benzodiazepines
2 trials gabapentin
2 trials topiramate
36 trials of muscle relaxants
9 opiod trials
3 trials of tramadol
4 trials of systemic corticosteroids
...so what is the bottom line Dave?

53. Medications for Low Back Pain
Good evidence of short-term effectiveness for acute low back pain are:
- NSAIDs
-acetaminophen
-skeletal muscle relaxant
*tricyclic antidepressants for chronic low back pain
Evidence that opioids, tramadol, benzodiazepines, and gabapentin are effective for pain relief of radiculopathy.
Good evidence that systemic corticosteroids are ineffective.
Chou, Roger MD; Huffman, Laurie Hoyt MS Annals of Internal Medicine
Issue: Volume 147(7), 2 October 2007, pp

54. Treatment Regimen Tylenol first line NSAID’s for more severe pain
Opioids in select patients with more severe pain
My treatment regimen
-NSAID and muscle relaxant for mild to moderate pain followed by manipulation
-Narcotic plus benzodiazepine followed by manipulation for severe pain
Chou, Roger MD; Huffman, Laurie Hoyt MS Annals of Internal Medicine
Issue: Volume 147(7), 2 October 2007, pp

55. Osteopathic Manipulation
Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain,
-Spinal manipulation; for chronic or subacute low back pain
-Intensive interdisciplinary rehabilitation
-Exercise therapy
-Acupuncture
-Massage therapy
-Spinal manipulation
-Yoga
-Cognitive-behavioral therapy
-Progressive relaxation
***(weak recommendation, moderate-quality evidence).
Chou, roger et al. Diagnosis. Ann Intern Med October 2, 2007 vol. 147 no

56. Pilates and Low Back Pain
One RCT
39 patients
Results:
-The individuals in the specific-exercise-training group reported a significant decrease in LBP and disability
-Maintained over a 12-month follow-up period
-Treatment with a modified Pilates-based approach was more efficacious than usual care in a population with chronic, unresolved LBP
Rydeard R Leger A, Smith D
J Orthop Sports Phys Ther Jul;36(7):472-84

57. Non-Surgical Intervention Therapy???
For low back pain with radiculopathy, 10 of 17 trials found no difference in pain or function between epidural glucocorticoid and placebo injection
Similar findings for facet and nerve branch blocks
Discography or injection of the disc at the level of pain remains unproven
Other therapies out there:
-Chemonucleolysis
-Electrothermal
-Radiotherapy
-Botulinum toxin
Chou R; Atlas SJ; Stanos SP; Rosenquist RW Spine (Phila Pa 1976) May 1;34(10):
UptoDate.com

58. Indications for Surgical Referral among Patients with Low Back Pain
Table 3. Indications for Surgical Referral among Patients with Low Back Pain.
Deyo R and Weinstein J. N Engl J Med 2001;344:

59. ACP and APS Joint Guidelines
Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories:
-Nonspecific low back pain
-Back pain potentially associated with radiculopathy or spinal stenosis
-Back pain potentially associated with another specific spinal cause
The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).
  Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).
  Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).
  Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).
Chou, Roger MD et al. Annals of Internal Medicine
Issue: Volume 147(7), 2 October 2007, pp

60. ACP and APS Joint Guidelines
Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).
  Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self- care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first- line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
  Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
Chou, Roger MD et al. Annals of Internal Medicine
Issue: Volume 147(7), 2 October 2007, pp

61. Additional Tidbits Gibbus www.googleimages.com
Sir Percival Pott's description of paralysis in association with tuberculosis of the spine in the 18th century led to the eponym of Pott's paraplegia.

62. Key Review Articles
Chou, R et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society . Ann Intern Med October 2, 2007 vol. 147 no
Deyo R and Weinstein. Low Back Pain. J. N Engl J Med 2001;344: