The evaluation and management of low back pain  Asgar Ali Kalla  Professor and Head  Division of Rheumatology  University of Cape Town

Some helpful statistics  Backpain affects two thirds of adults  Second to URTI in frequency  Affects men and woman equally  Most common between 30 and 50 years  Expensive cause of work related disability  Uncertainty about optimal approach

90% of low back pain is mechanical  Musculoligamentous injuries  Age-related degeneration in the intervertebral discs and facet joints  Spinal stenosis  Disc herniation  Osteoporotic compression fractures  Spondylolysis and spondylolisthesis

Natural history  Spontaneous improvement is the rule  50% better at 1 week  > 90% better at 8 weeks  7-10% persist beyond 6 months

Medical causes  Uncommon but important not to miss them  Spondylarthropathy  Spinal infection  Osteoporosis  Malignancy  Referred visceral pain pelvis, renal, aortic aneurysm, pancreatitis pelvis, renal, aortic aneurysm, pancreatitis

Clinical evaluation  Precise anatomical diagnosis often elusive  Is a systemic disease causing the pain?  Is there neurological compromise that may require surgical evaluation?  Is there social or psychological distress that may amplify or prolong pain?

BACK PAIN serious neurology serious neurology serious medical serious medical systemic symptoms systemic symptoms conservative management conservative management

Management: Watchful waiting  Patient education  Spontaneous recovery is the rule  Those who remain active despite pain have less future chronic pain  Exercise has prevention power  Rest: 2 days or less  Analgesics to permit activity  Reassess if pain worsens or neurological symptoms develop

Why not get imaging studies?  Imaging can be misleading: many abnormalities as common in pain-free individuals as in those with back pain  If under age 60  low yield: unexpected Xray findings 1: 2500  bulging disc in 1 of 3  herniated disc in 1 of 5

 Over age 60 and pain-free  herniated disc in 1 of 3  bulging disc in 80%  all have age-related disc and apophyseal joint degeneration  spinal stenosis in 1 of 5 cases

BACK PAIN conservative management PERSISTENT PAIN DEVELOPING NEUROLOGY PERSISTENT PAIN DEVELOPING NEUROLOGY red flags imaging lab tests

Red flags for serious back pain  Fever, weight loss  Pain with recumbency, nocturnal pain  Morning stiffness  Persistent pain lasting > 6 weeks  Age over 50 with new onset pain  Abnormal neurology  Point tenderness

Further evaluation  Goal is to discriminate between “ benign” cases and disorders that require further diagnostic studies  Radiological imaging: Xray/ CT Scan/ MRI  Useful lab tests:  FBC, ESR  Calcium, ALP  protein electrophoresis

What should I be worried about?  Herniated disc  Spinal stenosis  Cauda equina syndrome  Inflammatory spondylarthropathy  Spinal infection  Vertebral fracture  Cancer  Referred visceral pain

 CT scan shows spinal stenosis due to hypertrophic changes in the facet joints  CT myelogram reveals canal occlusion with flexion due to spondylolisthesis Imaging Studies: Spinal Stenosis

 MRI image shows a protruding disk (arrow) that compresses the thecal sac (short arrow) Disk Herniation

Ankylosing Spondylitis: X-Ray Changes

Spinal infection — X-Rays

Multiple compression fractures Osteoporosis- X-Ray

RRed flags for spinal malignancy PPain worse at night OOften associated local tenderness CFBC, ESR, protein electrophoresis if ESR elevated Multiple Myeloma

When is surgical referral indicated?  Sciatica and probable herniated discs  Cauda equina syndrome  Progressive or severe neurological deficit  Persistent neuromotor deficit after 4-6 weeks conservative treatment  Persistent sciatica with consistent neurologic and clinical findings

When is surgical referral indicated?  Spinal Stenosis  Progressive or severe neurological deficit  Persistent back and leg pain improving with flexion and associated with spinal stenosis on imaging  Spondylolisthesis  Progressive or severe neurological deficit  Severe back pain/ sciatica with functional impairment that persists > 1 year

Key Points about low back pain  90% are due to mechanical causes and will resolve spontaneously within 6 weeks to 6 mths  Pursue diagnostic workup if any red flags found during initial evaluation  If ESR elevated, evaluate for malignancy or infection  In older patients initial Xray useful to diagnose compression fracture or tumuor

Key Points about low back pain  Bed rest is not recommended for low back pain or sciatica, with a rapid return to normal activities usually the best course  Back exercises are not useful for the acute phase but help to prevent recurrences and treat chronic pain  Surgery is appropriate for a small portion of patients with low back pain

Further reading  Deyo RA, Weinstein JN. Low back pain. NEJM 2001;344:  Malmivaara A, Hakkinen U, et al. The treatment of acute low back pain. NEJM 1995;332:  Borenstein DG. Low back pain. In:Klippel J, Dieppe P, editors. Rheumatology. London : Mosby; p