1. Amy Gutman MD Chief of Emergency Medicine
An Illness In Search of a Disease Assessment & Management of Low Back Pain
Amy Gutman MD Chief of Emergency Medicine /

2. Objectives Epidemiology Anatomy & “Patho-Anatomy”
Differential diagnosis
Physical exam
Red & yellow flag recognition
Multidisciplinary management

3. Bias Warning ~ I Hate This Subject
Painful for patient or painful for me (or both)!
Good exercise in spending more time learning about things your dislike

4. Epidemiology Lifetime incidence 60-90%, annual incidence 5%
90% resolve in 6-12 weeks
7% become chronic
>50% without specific diagnosis
1.5% diagnosed with sciatica
98% significant disc herniations at L4-5 (L5 root) or L5-S1 (S1 root)
#1 cause of disability in US <45 years
3rd leading cause of medical office visits
2nd MCC missed work days
Healthcare expenditures >50 billion
M = F affected

5. Misconceptions “I hurt my back lifting something heavy at work”
“My slipped disk is causing my back pain”
“Because I have back pain, I should not work at all”
“I need an MRI because my back pain won’t go away”
“I should be on bed rest until my back pain goes away”
“I need narcotics for my back injury from 1972”
“My back pain means I have significant anatomical damage”
“Back pain is usually fixed with pain medication”

6. Anatomy

7. Anatomy

9. Sagittal Anatomy Intervertebral disc 2. Vertebral body 3. Dura mater
4. Extradural or epidural space
5. Spinal cord
6. Subarachnoid space

10. Dermatomes & Myotomes

11. Lumbosacral Dermatomes

12. Referred Pain

13. History & Exam For “Red Flags”
Focused medical history, work history & physical exam
Does history make sense with presentation?
Does time course make sense with presentation?
Evaluation of underlying conditions, including referred symptoms
Systemic disease?
Neurologic change or compromise?
Suspicion for serious underlying disorders?
Frequency, intensity & duration of complaints
Aggravating & relieving factors
Psychosocial stressors prolonging or amplifying symptoms?

14. Red Flags Age >50 Unexplained weight loss
History of cancer / inflammatory arthritis
Persistent fever / recent bacteremia
IVDA
Immunocompromised
Incontinence / retention
Trauma
Neurologic deficit, weakness
Pain quality / duration
Response to previous therapy

15. Cancers Metastatic to Bone~ Lead Kettle: PB KTL
Prostate Blastic, sclerotic
Breast Mixed
Kidney Lytic
Thyroid Lytic
Lung Lytic
Distribution:
Women: 80% from lung, breast
Men: 80% from lung, prostate
Both: 20% from kidney, thyroid, GI, other

16. Differential Diagnosis

17. Differential Diagnosis of Low Back Pain

18. Physical Exam

19. Physical Examination Goals: Vertebral tenderness / step-off
Determine presence of focal neurological deficits
Determine functional assessment
Vertebral tenderness / step-off
Mobility & gait
Motor / sensory exam

20. Determine presence of neurological deficits

22. Straight Leg Raise Lasègue Test or Lazarević's Sign
Positive if pain in sciatic distribution reproduced between 30° - 70° passive flexion of the straight leg
Foot dorsiflexion worsens pain
Ipsilateral test sensitive, not specific
Crossed leg test not sensitive but highly specific

23. Nerve Root Pain / Radiculopathy ~ Sciatica
Diagnostic keys:
No focal neurological findings
Pain is more in leg than in back
Herniated disk
Foraminal or spinal stenosis
Ligamentous hypertrophy
Space filling lesions
Cysts, tumor, abscess
Inflammation
Can occur w/ peripheral nerve involvement

24. Piriformis Syndrome Not all pain radiating down leg is sciatica
Piriformis muscle disease pain from irritation of sciatic nerve passing deep or through it
Patrick’s Test
Pain on resisted abduction / external rotation of leg
FABER: Flexion, Abduction and External Rotation

25. Herniated Nucleus Pulposus
Significant motor weakness
Foot drop
Focal sensory changes

26. Spinal Stenosis Subtle BL radicular signs
Radiates to buttocks, thighs, lower legs
“Shopping cart sign”
Pain increases with extension (standing, walking)
Pain decreases with flexion (sitting, stooping forward
Neurogenic claudication / pseudo- claudication

27. Ankylosing Spondylitis
Difficult to diagnose in early stages
Morning stiffness for > 30 mins
Pain alternates side to side of lumbar spine
Sternocostal pain with reduced chest expansion
Schobers test

28. Imaging Studies

29. Imaging Studies Who gets imaging? Plain Radiography CT & / or MRI
Present / progressive neurologic Deficits
Failure to Improve / worsens
Trauma
Red Flags
Plain Radiography
Screening
CT & / or MRI
Suspected malignancy
Infection
Persistent neurologic deficit

30. AP Abdomen 1. 1st Lumbar vertebra 2. 2nd Lumbar vertebra
3. 3rd Lumbar vertebra
4. 4th Lumbar vertebra
5. 5th Lumbar vertebra
6. T12
7. 12th rib
8. Sacroiliac joint
9. Sacrum
10. Sacral foramen
11. Ilium
12. Pelvic brim
13. Superior ramus pubic bone
14. Pubic symphysis

31. Plain Spinal X-Rays

32. Prolonged use of corticosteroids Osteoporosis / osteoarthritis
Vertebral Fracture
Prolonged use of corticosteroids
Age >70 years
Osteoporosis / osteoarthritis
Any trauma >50 years

33. MRI Imaging Excellent view of bones & soft tissues
Poor screening tool due to false (+)
NEJM
98 asymptomatic patients yo
52% disk bulging >1 level
27% disk protrusion >1 level
1% disk extrusion >1 level
Not done emergently except:
Suspected cauda equina
Acute focal neurological findings

34. MRI 34

35. Cauda Equina Syndrome
Damage to cauda equina causes loss of function of lumbar plexus / nerve roots of below conus medullaris cord termination
Back pain plus progressive lower extremity neurological deficits
S3-S5 saddle anesthesia (perineum, external genitalia, anus)
Bladder & bowel dysfunction from decreased urinary & anal sphincter tone & detrusor weakness
Unilateral / bilateral sciatica pain
BL LE weakness with absent Achilles reflex
Impotence (absent bulbocavernosus reflex)
deficit in the lower limb (motor/sensory loss, reflex change).
Recommended. After ruling out “red flags, there is considerable value in first determining whether or not there are radicular signs. This will allow branching based on generalized low back pain including spains and strains, versus potential disc problems. Determine radiculopathy via sensation (pain radiating below the knee) not just referred pain (pain radiating to buttocks or thighs), & dermatological sensory loss, plus straight leg raising test (sitting & supine), motor strength (deep tendon reflexes), flexibility (fingertip test), muscle atrophy (calf measurement), and local areas of tenderness. (Bigos, 1999) Among the "red flags" for serious abnormalities are inflammatory disease, fracture, referred pain (eg, from rupturing aortic aneurysm), infection, or cancer. In this study only 11 of 1172 (0.9%) patients were confirmed as having a serious spinal condition, including spinal fracture (n = 8), cauda equina syndrome (n = 1), or inflammatory disorder (n = 2). No patients were identified with cancer or infection as the cause of their pain. For spinal fractures, the diagnostic accuracy of the following red-flag questions was determined: (1) age > 70 years; (2) significant trauma; (3) prolonged corticosteroid use; & (4) altered sensory level (from the trunk down). The authors concluded that serious spinal abnormalities are rare in primary care settings, and the questions on the possibility of fracture may be useful. (Henschke, 2009)

36. Cauda Equina Syndrome Confirmed by MRI or contrast CT
Management involves surgical decompression
Sudden symptom onset is a surgical emergency  

37. Epidural Abscess Infection between dura & vertebrae Classic triad:
Loose association between dura & vertebrae allows abscess extension to numerous levels
Classic triad:
Fever, spinal pain, & neurological deficits
Symptom progression:
Back pain
Radicular irritation;
Motor weakness
Sphincter dysfunction
Sensory changes
Paralysis

38. Epidural Abcess
Enlargement of abscess & surrounding inflammation leads to tissue compression & spinal cord ischemia
Often requires multiple laminectomies / debridements
Patient's neurological status at the time of diagnosis is most accurate predictor of outcome & prognosis

39. Abdominal Aortic Aneurysm
Syncope + back pain
Abdominal pulsating mass
Atherosclerotic vascular disease
Hypertensive heart disease
Pain at rest or nocturnal pain
Age >60 years

40. CT Scan Shows bone well but not soft tissues Good for acute pain
Myelogram adds CSF contrast to better show spinal cord & nerve contours 40

41. Disc Herniation
With age & repetitive stress, lumbar discs lose height & water content
Abnormal motion between bones causes pain
Conditions
Tears in annulus
Herniation of nucleus pulposus
Compression of foraminal nerve root 41

42. Disk Disease Conservative Treatment
Moderate bed rest
Spinal manipulation
Physical therapy
Medication
NSAIDs
Muscle relaxants
Rarely narcotics 42

43. Indications for Surgical Intervention
Low back pain >2 years
Incapacitating
Resistant to physical therapy & medication
Degenerative findings on MRI 43

44. (Micro) Discectomy / Laminectomy
Often same-day surgery
80-90% “good” outcome
Residual pain up to 6 months postop
Results worse if pain present >8 months pre-surgery 44

45. Yellow Flags ~ Risks For Delayed Functional Recovery
Multiple prior injuries with multiple claims
Prolonged / multiple absences
Victim of abuse
Substance abuse
Mental illness
Job dissatisfaction
Delayed presentation
Chronic pain symptoms with multiple diagnoses
Subjective > objective findings
ACOEM Guidelines

46. Non-Organic Pain Superficial non-anatomic tenderness
Pain from maneuvers that should not elicit pain
Distraction maneuvers that should elicit pain but don’t
Disturbances not consistent with known patterns of pain
Pain out of proportion during exam
Not definitive to rule out organic disease
Multiple visits to multiple physicians / sites / offices / specialities

47. Non-Organic Pain Management
Multidisciplinary biopsychosocial model
Cognitive behavioral therapy
Avoid disability by exploring work barriers
Physical / Occupational Therapy
Case management
Early follow up, limit further work up unless change in condition

48. Medication Management
1st line APAP & NSAIDS
Muscle relaxants
Transdermal medications
Glucocorticoids
Short-term opioids (3 days)
Opioids
Not recommended except for short use for severe cases, not

49. Non-Medication Therapy ~ Non-Specific LBP
Physical therapy / occupational therapy
Delay referral until pain persists >3 weeks
50% will improve prior to 3 weeks
Rapid return to normal activities
Reinforce good body mechanics
Consider alternatives
Massage
Osteopathic manipulation
Chiropractic
Acupuncture

50. Management Review
If no cauda equina or progressive neurologic deficit:
Treat non-surgically minimum one month
Treat similar to non-specific LBP
Limited narcotics
Epidural steroids (helps in some)
If severe pain or persistent neurological deficit
CT/ MRI / consider for surgery
Diskectomy
Improved relief vs. non-surgery at 4 years

51. References
Hardy S. Acute Back Pain ~ Evidence Based Approach. UCI Occupational Medicine, December, 2015
Dunbar LM. Low Back Pain: Approach to the patient in the ED. LSU HSC
/ MMWR. “Low Back Pain”. Queried May 2017
Jensen MC, et. Al, MRI of the Lumbar Spine in People without Back Pain, NEJM, 1994, Jul 14, 331(2): 69-73
Virtualmedicalstudent.com. “Spinal radiology”. Queried May 2017
Life In The Fast Lane. “Acute Back Pain”
“Low back pain”, “Back Pain”, “Red Flags”, “Diagnostic Imaging for Back Pain”. Queried May 2017
Dixon J. Examination, assessment, red flags, Good Back Guide. Queried May 2017
The Anatomy Project. Medical Images. Queried May 2017
St. Sauver, JL. Mayo Clinic Proceedings Vol 88:1, 56-7.
Wikimedicine, Medical images. Queried May 2017

52. Conclusions prehospitalmd@gmail.com
Diagnosis primarily from history & exam, with further diagnostic testing limited to patients with Red Flags
Providers have a positive impact on improving outcomes, reducing symptoms, & improving functional recovery by utilizing multimodal management
Excessive / long-term over- medicating & disability not supported by evidence