EVALUATION AND TREATMENT OF ACUTE LOW BACK PAIN R. TYLER BOONE, MD ADVANCED ORTHOPEDICS OF OKLAHOMA

LOW BACK PAIN Affects of reports 5.6% of US adults each day Lifetime prevalence at least 60-70% Mostly self treated-only 25-30% seek medical care. 1st episode usually occurs between 20-40yrs of age Most cases self limited Recurrent LBP in 25-60% patients within 1-2 years. Family Physician/Primary Care treat more patients with LBP than any other specialist, about as many as orthpedists and neurosurgeons combined.

Etiology/Differential Diagnosis LBP refers to spinal and paraspinal symptoms in lumbosacral region. Pain occurs posteriorly in region between the lower rib margin and proximal thighs. Acute less than 2-4 weeks Subacute up to 12 weeks. Chronic more than 12 weeks. May radiate down one or both legs. Sciatica is pain that radiates down the posterior or lateral leg beyond the knee.

Etiology continued Most common etiology of acute LBP in primary care setting is “mechanical”. -Precise pathoanatomic cause hard to confirm. -Weak association among symptoms, exam findings, anatomic changes. Nonmechanical Causes -Cancer, infection, inflammatory arthritis can be diagnosed with greater certainty -Small fraction of acute LBP

Table 1

History and Physical Exam Goal is to identify patients who require immediate surgical evaluation and those whose symptoms suggest more serious underlying condition (malignancy or infection). Signs of cauda equina syndrome -progressive neurologic deficits -bowel or bladder dysfunction -saddle anesthesia -bilateral sciatica, leg weakness “Red Flag” findings -need inquiry -order appropriate imaging and lab studies

Table 2

Physical Exam continued -Strength, sensation and reflex testing -ROM of spine, hips, knees -SLR or reverse SLR -Peripheral pulses -Presence or absence of point tenderness -Skin changes

Table 3

Imaging and Lab Evaluation Immediate imaging rarely indicated In absence of Red Flags 4-6 weeks of conservative care before imaging Lab studies include CBC, Sed rate, C-reactive protein.

Treatment of Acute LBP Recommended -Medications 1)NSAIDS 2)Acetaminophen 3)Non-benzodiazepine muscle relaxers 4)Caution with Soma and Valium 5)Opioids-little evidence of benefit in pain relief or time to return to work 6)Oral corticosteriods -Epidural steroid injections -May be helpful for radicular pain that does not respond to 2-6 weeks of non invasive care.

Recommended Treatment Cont. Patient Education -Discussion of usual benign nature of acute LBP -Reassurance -Stay as active as possible -Avoid repetitive bending, stooping, twisting

Acceptable Treatment Physical Therapy -Physical therapy/home exercises *McKenzie and spine stabilization *Best to start after acute pain lessens *Decreases pain, disability and risk of recurrence *Cost effective -Application of Ice or Heat *More effective in first 5 days

Treatment cont. Unsupported -Acupuncture -Lumbar support -Massage -Spinal manipulation *may be more effective than sham treatments *little evidence of cost-effectiveness for acute LBP -Traction Inadvisable -Bedrest *should not be recommended for non specific acute LBP

Conclusion Acute LBP is common and usually benign and self limited Conservative care appropriate for non specific LBP -refer if no improvement after 4-6 weeks -refer if pain accelerates -refer if progressive neurologic deficit -refer if radicular pain not improving In absence of “Red Flags” findings or signs of “cauda equina” syndrome 4-6 weeks of conservative care is appropriate for most patients with acute LBP.

Conclusion cont. Red Flags -age over 50 -history of cancer -fever, chills, recent UTI or skin infection -significant trauma -unrelenting night pain or rest pain -progressive motor of sensory deficit -saddle anesthesia, bilateral sciatica or leg weakness, difficulty urinating, fecal incontinence. -unexplained weight loss -Immunosuppression -Osteoporosis

Red Flags cont. -Chronic steriod use -IV drug use -substance abuse -failure to improve after 6 weeks of conservative care.

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