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Lower Back Pain . MS3 Sports Medicine Workshop. Objectives . Review the functional anatomy of lumbo-sacral spine List essential components of a LBP history, including RED FLAGS Describe common causes of LBP Review proper indications for imaging and referral

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lower back pain

Lower Back Pain

MS3 Sports Medicine Workshop

objectives
Objectives
  • Review the functional anatomy of lumbo-sacral spine
  • List essential components of a LBP history, including RED FLAGS
  • Describe common causes of LBP
  • Review proper indications for imaging and referral
  • Review Physical Examination of LS spine
  • Correlate pathology with pertinent physical findings
red flags in back pain
“Red Flags” in back pain
  • Age < 15 or > 50
  • Fever, chills, UTI
  • Significant trauma
  • Unrelenting night pain; pain at rest
  • Progressive sensory deficit
  • Neurologic deficits
    • Saddle-area anesthesia
    • Urinary and/or fecal incontinence
    • Major motor weakness
  • Unexplained weight loss
  • Hx or suspicion of Cancer
  • Hx of Osteoporosis
  • Hx of IV drug use, steroid use, immunosuppression
  • Failure to improve after 6 weeks conservative tx
epidemiology of back pain
Epidemiology of back pain
  • Fifth most common reason for all physician visits in US
  • Second only to common cold as cause of lost work time
  • 25% of US adults have LBP x1d in last 3 mos
  • The most common cause of disability in persons under the age of 45
slide5

Your patient with LBP has paresthesias in the lateral foot, decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

  • L4
  • L5
  • S1
  • S2
slide10
Vertebra
    • Body, anteriorly
      • Functions to support weight
    • Vertebral arch, posteriorly
      • Formed by two pedicles and two laminae
      • Functions to protect neural structures
ligaments
Ligaments
  • Anterior longitudinal ligament
  • Posterior longitudinal ligament
  • Ligamentum flavum
  • Interspinous ligament
  • Supraspinous ligament
slide13

Ligamentous

Anterior longitudinal ligament

muscles
Muscles
  • Spinalis
  • Longissimus
  • Iliocostalis
  • Quadratus lumborum
    • Ilium to lumbar TPs
  • Intertransversalis
  • Interspinals
  • Multifidus
  • Erector spinae
sciatica is defined as
Sciatica is defined as…
  • Pain radiating up the back
  • Pain radiating to the thigh
  • Pain radiating below the knee
  • Pain in the butt
slide19

L4

  • L5
  • S1
patient history opqrstu
PATIENT HISTORY “OPQRSTU”
  • Onset
  • Palliative/Provocative factors
  • Quality
  • Radiation
  • Severity/Setting in which it occurs
  • Timing of pain during day
  • Understanding - how it affects the patient
which one is not considered a red flag of lbp
Which one is NOT considered a “red flag” of LBP?
  • History/suspicion of cancer
  • Age over 50
  • Fever or chills
  • Sciatica
red flags in back pain22
“Red Flags” in back pain
  • Age < 15 or > 50
  • Fever, chills, UTI
  • Significant trauma
  • Unrelenting night pain; pain at rest
  • Progressive sensory deficit
  • Neurologic deficits
    • Saddle-area anesthesia
    • Urinary and/or fecal incontinence
    • Major motor weakness
  • Unexplained weight loss
  • Hx or suspicion of Cancer
  • Hx of Osteoporosis
  • Hx of IV drug use, steroid use, immunosuppression
  • Failure to improve after 6 weeks conservative tx
onset
Onset
  • Acute - Lift/twist, fall, MVA
  • Subacute - inactivity, occupational (sitting, driving, flying)
  • ?Pending litigation
  • Pain effect on:
    • work/occupation
    • sport/activity (during or after)
    • ADL’s
other history
Other History
  • Prior h/o back pain
  • Prior treatments and response
  • Exercise habits
  • Occupation/recreational activities
  • Cough/valsalva exacerbation
diagnoses red flags
Cancer

Age > 50

History of Cancer

Weight loss

Unrelenting night pain

Failure to improve

Infection

IVDU

Steroid use

Fever

Unrelenting night pain

Failure to improve

Fracture

Age >50

Trauma

Steroid use

Osteoporosis

Cauda Equina Syndrome

Saddle anesthesia

Bowel/bladder dysfunction

Loss of sphincter control

Major motor weakness

Diagnoses & Red Flags
physical examination msk big 6
Physical ExaminationMsk Big-6
  • Inspection
  • Palpation
  • Range of motion
  • Strength testing
  • Neurologic examination
  • Special tests
approach to lbp
Approach to LBP
  • History & physical exam
  • Classify into 1 of 4:
    • BAD: LBP from other serious causes
      • Cancer, infection, caudaequina, fracture
    • LBP from radiculopathy or spinal stenosis
    • Non-specific LBP
    • Non-back LBP
  • Workup or treatment
what to do about possible bad low back pain
What to do aboutPossible BAD Low Back Pain
  • Cauda Equina:
    • MRI STAT Neurosurgery consult
  • Fracture: x-rays
    • MRI/CT if still suspect
  • Cancer: x-rays + CRP, ESR, CBC (+/- PSA)
    • MRI if still suspect
  • Infection: x-rays; CRP, ESR, CBC, +/- UA
radiculopathy spinal stenosis
Radiculopathy, Spinal Stenosis
  • Sciatica (pain below knee)
  • May have abnl neuro exam
  • Radiates to leg
  • Pain worse walking, better sitting (pseudo-claudication)
what to do about suspected radiculopathy or spinal stenosis
What to do aboutSuspected Radiculopathy or Spinal Stenosis
  • Refer to Physical Therapy
  • Follow in 2-4 weeks for progress
  • If no improvement by 6-12 weeks
    • Plain films, MRI, +/- EMG/NCV
    • Refer for interventions
      • Epidural steroid injections for radiculopathy
causes of non specific lbp
Spondylosis (Osteoarthritis of facet/disk)

Spondylolysis/-listhesis

Kyphosis/scoliosis

Acute lumbar strain

Facet pain

Discogenic pain

Ligamentous pain

Causes of “Non-specific LBP”
management of an acute low back muscle strain should consist of all the following except
Management of an acute low back muscle strain should consist of all the following EXCEPT:
  • X-rays to rule out a fracture
  • Educate the patient on generally good prognosis
  • Non-opiate analgesics
  • Remain active
what to do about non specific low back pain
What to do aboutNon-specific Low Back Pain
  • Educate patient about expected good prognosis
  • Advise to remain active as tolerated
  • Provide analgesics and self-care directions
  • FU in 2-4 weeks; adjust tx as needed
  • Don’t do x-rays unless it becomes chronic
  • WU if no improvement
think outside the back
Renal dz (pyelo, stones, abscess)

Pelvic dz (PID, endometriosis, prostate)

Gastrointestinal dz (cholecystitis, ulcer, cancer)

Retroperitoneal dz

Aortic aneurysm

Zoster

Diabetic radiculopathy

Rheumatologic disorders

Reiters

Ankylosing Spondylitis

Inflammatory bowel dz

Psoriatic spondylitis

Neoplasia (multiple myeloma, metastatic CA, lymphoma, leukemia, spinal cord tumors, vertebral tumors)

“Think Outside the Back”
what to do about non back lbp
What to do aboutNon-back LBP
  • WU and tx as appropriate for suspected diagnoses
diagnostic studies
Diagnostic Studies

Radiographs

Early if RED FLAGS

Symptoms present > 6 weeks despite tx

diagnostic studies38
Diagnostic Studies

MRI indications

Possible cancer, infection, cauda equina synd

>6-12 weeks of pain

Pre-surgery or invasive therapy

Disadvantages

False-positives; may not be causing pain

More costly, increased time to scan, problem with claustrophobic patients

diagnostic studies39
Diagnostic Studies

Bone Scan indications

Adolescent LBP (r/o spondy)

SPECT scan

Cost ~$300

diagnostic studies40
Diagnostic Studies

EMG/NCV

r/o peripheral neuropathy

localize nerve injury

correlate with radiographic changes

order after 6-12 weeks of symptoms

Pre-surgical or invasive therapy

lab studies
Lab Studies

Indications

Chronic LBP

Suspected systemic disease

CBC, CRP, ESR, +/- UA, SPEP, UPEP

Avoid RF, ANA or others unless indicated

issues specific to chronic lbp 6 weeks and or non responsive
Issues specific to CHRONIC LBP(>6 weeks and/or non-responsive)
  • Evaluation
    • X-rays, labs
    • Evaluate for “YELLOW FLAGS”
  • Management
    • Medication selection
    • Interventions
yellow flags in chronic lbp
YELLOW FLAGS in Chronic LBP
  • Affect: anxiety, depression; feeling useless; irritability
  • Behavior: adverse coping, impaired sleep, treatment passivity, activity withdrawal
  • Social: h/o abuse, lack of support, older age
  • Work: believe pain will be worse at work; pending litigation; workers comp problems; poor job satisfaction; unsupportive work env’t
medications in chronic lbp
Medications in Chronic LBP
  • FIRST: Acetaminophen
  • Second: NSAIDs
    • If one fails, change classes
      • Meloxicam  naproxen  COX2’s
  • Third: tramadol
  • Fourth: tri-cyclic antidepressants
    • Radiculopathy: gabapentin
  • LOATHE: narcotics
non pharmacologic treatments
Non-pharmacologic treatments

EFFECTIVE

NOT EFFECTIVE/

CONFLICTING EVIDENCE

BACK SCHOOLS

LOW-LEVEL LASER

LUMBAR SUPPORTS

PROLOTHERAPY

SHORT WAVE DIATHERMY

TRACTION

ULTRASOUND

  • Acupuncture
  • Exercise therapy
  • Behavior therapy
  • Massage
  • TENS
  • Spinal manipulation
  • Multidisciplinary rehab program
epidural steroid injections
Epidural Steroid Injections
  • Indicated for radiculopathy not responding to conservative mgmt
    • Conflicting evidence
    • Small improvement up to 3 months
    • Less effective in spinal stenosis
surgery for chronic lbp
Surgery for Chronic LBP
  • Most do NOT benefit from surgery
  • Should have ANATOMIC LESION C/W PAIN DISTRIBUTION
  • Significant functional disability, unrelenting pain
    • Several months despite conservative tx
  • Procedures: spinal fusion, spinal decompression, nerve root decompression, disc arthroplasty, intradiscal electrothermal therapy
inspection
Inspection
  • Observe for areas of erythema
    • Infection
    • Long-term use of heating element
  • Unusual skin markings
    • Café-au-lait spots
      • Neurofibromatosis
    • Hairy patches, lipomata
      • Tethered cord
    • Dimples, nevi (spina bifida)
inspection cont
Inspection (cont.)
  • Posture
    • Shoulders and pelvis should be level
    • Bony and soft-tissue structures should appear symmetrical
  • Normal lumbar lordosis
    • Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall
slide52

Posture

    • Shoulders and pelvis should be level
    • Bony and soft-tissue structures should appear symmetrical
  • Normal lumbar lordosis
    • Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall
bone palpation
Bone Palpation
  • Palpate L4/L5 junction (level of iliac crests)
  • Palpate spinous processes superiorly and inferiorly
    • S2 spinous process at level of posterior superior iliac spine
  • Absence of any sacral and/or lumbar processes suggests spina bifida
  • Visible or palpable step-off indicative of spondylolisthesis
soft tissue palpation
Soft Tissue Palpation
  • 4 clinical zones
    • Midline raphe
    • Paraspinal muscles
    • Gluteal muscles
    • Sciatic area
    • Anterior abdominal wall and inguinal area
slide63

Flexion - 80º

Extension - 35º

Side bending - 40º each side

Twisting - 3-18º

Range of Motion

neurologic examinaion
Neurologic Examinaion
  • Includes an exam of entire lower extremity, as lumbar spine pathology is frequently manifested in extremity as altered reflexes, sensation and muscle strength
  • Describes the clinical relationship between various muscles, reflexes, and sensory areas in the lower extremity and their particular cord levels
neurologic examination t12 l1 l2 l3 level
Neurologic Examination(T12, L1, L2, L3 level)
  • Motor
    • Iliopsoas - main flexor of hip
    • With pt in sitting position, raise thigh against resistance
  • Reflexes - none
  • Sensory
    • Anterior thigh
neurologic examination l2 l3 l4 level
Neurologic Examination(L2, L3, L4 level)
  • Motor
    • Quadriceps - L2, L3, L4, Femoral Nerve
    • Hip adductor group - L2, L3, L4, Obturator N.
  • Reflexes
    • Patellar - supplied by L2, L3, and L4, although essentially an L4 reflex and is tested as such
neurologic examination l4 level
Neurologic Examination(L4 level)
  • Motor
    • Tibialis Anterior
      • Resisted inversion of ankle
  • Reflexes
    • Patellar Reflex (L2, L3,L4)
  • Sensory
    • Medial side of leg
neurologic examination l5 level
Neurologic Examination(L5 level)
  • Motor
    • Extensor Hallicus Longus
    • Resisted dorsiflexion of great toe
  • Reflexes - none
  • Sensory
    • Dorsum of foot in midline
neurologic examination s1 level
Neurologic Examination(S1 level)
  • Motor
    • Peroneus Longus and Brevis
    • Resisted eversion of foot
  • Reflexes
    • Achilles
  • Sensory
    • Lateral side of foot
special tests
Special Tests
  • Tests to stretch spinal cord or sciatic nerve
  • Tests to increase intrathecal pressure
  • Tests to stress the sacroiliac joint
tests to stretch the spinal cord or sciatic nerve
Tests to Stretch the Spinal Cord or Sciatic Nerve
  • Straight Leg Raise
  • Cross Leg SLR
  • Kernig Test
test to increase intrathecal pressure
Test to increase intrathecal pressure
  • Valsalva Maneuver
    • Reproduction of pain suggestive of lesion pressing on thecal sac
kernig sign
Kernig Sign

Pain relieved

Pain present

slide80

FABER test:

Flexion

A-

Bduction

External

Rotation

non organic physical signs waddell s signs
Non-organic Physical Signs(“Waddell’s signs”)
  • Non-anatomic superficial tenderness
  • Non-anatomic weakness or sensory loss
  • Simulation tests with axial loading and en bloc rotation producing pain
  • Distraction test or flip test in which pt has no pain with full extension of knee while seated, but the supine SLR is markedly positive
  • Over-reaction verbally or exaggerated body language

Waddell, et al. Spine 5(2):117-125, 1980.

hoover test
Hoover Test
  • Helps to determine whether pt is malingering
  • Should be performed in conjunction with SLR
  • When pt is genuinely attempting to raise leg, he exerts pressure on opposite calcaneus to gain leverage
other
Other
  • Rectal tone
  • Anal wink
  • Cremasteric reflex
ad