1. Low Back Pain: Case Based Evaluation and Management
Patrick Kortebein, M.D.
Departments of PM&R and Geriatrics
University of Arkansas for Medical Sciences
5/31/09
Slides:

2. Objectives
Understand the evaluation and management of common sources of low back and related pain
Understand the significance of abnormal findings on lumbar spine MRI in individuals with low back and related pain.
Understand the evaluation and management of chronic low back pain.

3. Low Back Pain Common; 2nd primary care visits Acute episodes
5-15% per year
60-80% lifetime
Acute episodes
75-90% recover w/in 3 months
25-75% will have recurrence w/in 6 months

4. LBP: Anatomy Bone / Vertebrae Disc Muscles / Ligaments
Annulus
Nucleus Pulposus
Muscles / Ligaments
Spinal Nerve Roots

5. LBP
Facet joint
Zygopophyseal joint
Synovial

6. LBP
Sacroiliac Joint
Tight, Synovial
Ligaments
“SI Dysfunction”

7. Case #1 28 yo M presents with CC: LBP
Started 4 days ago while bending over to pick up his 14 mo old child
PMHX: L knee arthroscopy
Meds: Acetaminophen
NKDA
Social Hx: Married, insurance salesman
What other information is important?

8. Acute LBP: History Location Onset: Traumatic, Insidious Duration:
Axial or Radiating (Sciatica) ?
Onset: Traumatic, Insidious
Duration:
Acute: < 12 weeks
Chronic: > 12 weeks
Character/Quality: Ache, Burning, etc
Exacerbating / Alleviating Factors

9. Acute LBP: History “Red Flags” (AHCPR 1994) Fracture: Cauda Equina
Major/minor trauma
Age > 70 yrs (~50 yrs)
Chronic corticosteroids
Cauda Equina
B/B dysfunction
Saddle Anesthesia
LE weakness

10. Acute LBP: History “Red Flags” (AHCPR 1994) Infection Cancer Fever
Steroids / Immunosuppression / IV Drug Use
UTI / Systemic Infection
Cancer
Hx of Cancer
Unintentional Weight Loss
Supine/Night Pain
Age > 50

11. “Red Flag” Evaluation

12. Acute LBP: Physical Exam
Lumbar Spine:
Inspection
Palpation
ROM: Flexion / Extension
+/- LE Neurologic Exam

13. Acute LBP: Imaging
When?
What imaging?

14. Acute LBP: Imaging When? What? Minimum 6 weeks + “Red Flags” X-ray
3-view:
AP / Lat / L5 Spot
Obliques:
Limited information
Radiation exposure

15. Acute LBP: Imaging
Lumbar MRI

16. Acute LBP: Imaging Abnormal findings “Degenerative disc disease”
“Bulging disc”
“Herniated disc”

17. LBP: Imaging MRI Abnormalities in Normals / No LBP
Boden et al (N=67) JBJS 1990
HNP: 21-36%
Bulging Disc: 50-80%
Degenerative Disc Changes: 34-93%
Jensen et al (N= 98) NEJM 1994
Bulging Disc: 52% (28-100%)
Disc Protrusion: 27% (21-30%)

18. Case #1 History Onset: 4 days ago, constant
Location: R lumbosacral junction
No radiation / neurological symptoms
No clear exacerbating / alleviating factors
Physical Exam
Mild tenderness R low lumbar region
Increased pain with flexion
Normal LExt neuro exam

19. Case # 1
Diagnosis ?
Management ?

20. LBP: Differential Diagnosis
Deyo NEJM 2001

21. Case # 1 Diagnosis: “Mechanical” LBP
Education / Activity Modification
Bedrest: ~ 2 days (Deyo NEJM 1986)
Analgesics:
Acetaminophen
NSAID’s
Tramadol
Muscle Relaxants
Cyclobenzaprine

22. “Mechanical” LBP Physical Therapy Chiropractic Acupuncture Exercise
Modalities
Lumbar Support
Chiropractic
Acupuncture
Back Heat

23. LBP: Zygapophyseal (Facet) joint
History/Examination
Axial LBP +/- post thigh
No neuro sxs
Worse w/ static posture
Lumbar Extension
Stand / Walk
Neuro exam normal

24. LBP: Zygapophyseal (Facet) joint
Management
Analgesics
Tylenol, NSAID
Physical Therapy
Injections
Diagnostic
Therapeutic

25. LBP: Sacroiliac (SI) Joint
History
Atraumatic > Traumatic
Axial; Lumbosacral
Uni- > Bilateral
No radiation / neuro sxs
Physical Exam
~ Normal
Tender SI region

26. LBP- SI Joint
Diagnosis / Treatment
Physical Therapy
Injection

27. LBP: Discogenic History / Exam Axial LBP No radiation / neuro sxs
Aggravating:
Static posture- Sitting or Sit to stand
Normal neurological exam

28. LBP: Discogenic Management Physical Therapy Surgery: Core Strength
Fusion
Artificial Disc
Not yet

29. Case # 2
38 yo with left LE radicular pain > LBP for ~6 weeks. Also left foot tingling and weakness.
PMHx: HTN, Hyperlipidemia
Meds: HCTZ, Atorvastatin
Allergies: Sulfa
Social Hx: Divorced, Landscaper

30. Case # 2 Physical Exam L-spine: Non-tender
Left LExt: + SLR / Crossed SLR
Neuro
Motor: 5/5 except Plantar Flexion
Reflex: KJ +2/+2, AJ +2 / 0
Sensory: Dec to LT lateral heel

31. Case # 2
Diagnosis ?

32. LBP: Radiculopathy Diagnosis Physical Exam MRI EMG CT Myelogram
* Correlate anatomy w/ sxs and exam

33. LBP: Radiculopathy Neurological Exam: Motor Reflex Sensory
L2/3: Hip Flex/Add Knee Med Thigh /Knee
L4: Knee Ext/DFlex Knee Med Ankle
L5: Great toe/EHL Int. HS Dorsum Foot
S1: Plantarflex Ankle Lat Heel
Functional: Squat, Heel / Toe Walk, Heel Raise

34. LBP: Evaluation
SLR / Dural Tension

35. Case # 2 MRI: Left L5-S1 disc herniation impinging on S1 nerve root
Management?

36. LBP: Radiculopathy Management Medications Steroids; NSAID’s
Acetaminophen
Tramadol
Neuropathic
Steroids;
Oral (? dose) vs epidural

37. LBP: Radiculopathy Management Physical Therapy McKenzie
Extension therapy
TENS
~ No benefit

38. LBP: Radiculopathy
Injections
Epidural Selective

39. LBP: Radiculopathy Surgery Indications SPORT trial Cauda equina
Progressive neuro deficits
No relief w/ conservative treatment
SPORT trial
JAMA 2006

40. LBP: Spinal Stenosis History (Neurogenic claudication) Physical Exam
Prox LE Pain +/- Neuro sxs
Walk / Stand
Uphill > Downhill
Grocery Cart
Physical Exam
~ Normal
Stand / Walk

41. LBP: Spinal Stenosis Diagnosis Management MRI EMG Medications PT
Neuropathic PT
Epidural Injection
Surgery: (SPORT trial)

42. Case # 3
51 yo M truck driver injured at work 2 years ago lifting a 30# box, and applying for disability
Continued axial LBP and “numb” R LE
No “Red Flags”
Treatments to date:
Medications: NSAIDs, Tramadol, Hydrocodone
Physical Therapy: 24 sessions
Work restrictions; not working
Injections: Epidural / Facet / Sacroiliac

43. Case # 3 Physical Examination Lower Extremity Neurologic
Lumbar: Diffuse tenderness to light palpation
Exaggerated pain behavior w/ trunk rotation
Lower Extremity Neurologic
50% decreased sensation entire LExt
Normal strength / reflexes
Supine SLR: LBP; Seated SLR: No pain

44. Case # 3 Lumbar MRI: Diagnosis? Treatment?
Mild DD changes with diffuse disc bulge at L4-5 and L5-S1
Diagnosis?
Treatment?

45. Chronic LBP Duration Poor Correlation > 12 weeks Symptoms
Objectives Finding

46. Chronic LBP Strong Association Depression Anxiety Poor Coping Skills
“My back hurts, but I’m here because I can’t cope with this episode, as well as the turmoil at home (or work)”- N Hadler “Last Well Person”

47. Chronic LBP

48. Chronic LBP **Goal** Improve Function Minimize focus
on treating pain itself
Biopsychosocial Model of Pain
Maladaptive Behavior
Neuroplasticity

49. Chronic LBP

50. Case # 3 Multidisciplinary Pain Management Education Medications PT
Chronic Opioids ? PT
Functional Restoration
Psychology
Pain Management

51. Recommended Reading
Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician 2007; 75:1181-8,
Deyo et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22:62-8.
LBP Handbook 2003
Cole & Herring

52. LBP

53. Questions ?

54. Other

55. LBP: Evaluation Waddell’s Signs (Non-organic PE) Tenderness
Overreaction
Regional
Distraction
Simulation
> 3/5
* Behavioral Component of Pain
Spine 1980