1. Low Back Pain

2. What is low back pain? Pain in the low back

4. Epidemiology  80% of the population will have at least one episode of LBP in their lifetime  Annually $20 million in direct cost and $50 million when indirect cost is added  3% of workers’ comp case but account 30% of the cost and receive 75% of the payment

5. Common causes of LBP?  Nonspecific – ligamentous or articular structures, strain, myofascial disorders, psychosocial factors  Arthritis  Spondylolisthesis  Disc herniation - >95% L4-5, L5-S1  Spinal stenosis  Fracture  Tumor

6. History?  Characterize the pain Diffuse, tight, gradual onset, worse after sitting or with cold, relieved with warmth, associated stiffness – myofascial disorder Brief, shooting, worse with coughing, standing or sitting, relieved when lying down, radiating down the leg – nerve root, sciatica Persistent, burning, tingling, worse when lying down at night – peripheral nerve or lumbosacral plexus Radiating to buttock, thighs, legs, worse with back extension, relieved with sitting – spinal stenosis Associated with horse saddle – cauda equina syndrome

7. History – rule out “red flags” symptoms?  Trauma  Fever  Weight loss  Neurologic deficits – numbness, bowel/bladder incontinence  History of IVDA, cancer, steroid use  Last longer than one month  Associated with abdominal pain

8. Physical exam?  Gait Muscle weakness – atrophy, pelvic tilt Knee flexion – guard against root traction  ROM  Palpation – tenderness, step off

9. Physical exam  Motor strength Heel – L5 Tiptoe – S1  Sensation – dermatomes L4 – big toe L5 – middorsum of foot S1 – lateral foot

10. Physical exam  Reflex Knee – L3, L4 Ankle – S1  Straight leg raise  Crossed straight leg raise - > specificity than straight leg raise  Rectal exam

11. Inconsistent examinations  Axial loading  Whole body rotation at the hip  Straight leg raise in sitting position

12. Tests for patients without “red flags” symptoms?  None  90% resolve spontaneously in 4 weeks

14. Tests with “red flags” symptoms?  CBC and ESR  X-ray  CT scan – fracture, fact joint

15. Tests with “red flags” symptoms?  MRI Infection, cancer, disc herniation Age >50, asymptomatic, disc bulging 75- 80% and 30% disc protrusion  Bone scan – cancer  EMG Nerve root involvement after multiple back surgeries Fastitious weakness

16. Treatments – acute LBP?  Activity versus bed rest Without radiculopathy, activity as tolerated With radiculopathy, may consider bed rest < 3 days

17. Treatments – acute LBP?  Medications Acute – around the clock rather than prn Analgesics: acetaminophen, NSAID, cox- 2 inhibitor, narcotics Muscle relaxants – short term Subacute/chronic: TCA, SSRI, phenytoin, tramadol, gabapentin

18. Treatments – acute LBP  Soft tissue injection – controversial  Back exercise Limited benefit Not during acute attack

19. Treatments – acute LBP  Disc herniation Multiple conservative modalities - >90% resolved Discectomy  Sciatica Conservative treatment initially for 1-3 months - 80% resolved spontaneously 73% recurred at least once

20. Treatment – chronic LBP?  Back exercise  Antidepressants – mixed result, confounding depression  Steroid injection in Epidural space – may help in some patients, conflicting reports Facets – limited data, one small study showed relief at 6 months but not month 1-3  Spinal stenosis – laminectomy  Minimally invasive procedures  Spinal fusion – multiple laminectomy, unstable

21. Treatment – chronic LBP  Lumbar disc replacement  Behavior therapy  Spinal manipulation – mildly effective in some patients but no better than other routine modalities  TENS – no benefits