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Treating Low Back Pain

Treating Low Back Pain. Carmen P. Pichard-Encina, MD Assistant Professor Johns Hopkins Orthopaedic Surgery at Good Samaritan Hospital September 12, 2012. Disclosures. Nothing to disclose at this time. Outline. Anatomy of the lumbar spine Sources of low back pain

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Treating Low Back Pain

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  1. Treating Low Back Pain • Carmen P. Pichard-Encina, MD • Assistant Professor • Johns Hopkins Orthopaedic Surgery at • Good Samaritan Hospital • September 12, 2012

  2. Disclosures • Nothing to disclose at this time.

  3. Outline • Anatomy of the lumbar spine • Sources of low back pain • Evaluation of the lower back • Treatment Options

  4. Anatomy • The lumbar region or lower back, consists of five vertebrae labeled L1 to L5. • This is the main weight-bearing section of the spinal column.

  5. Anatomy • Vertebral bodies • Provide structural support. • Separated by intervertebral discs.

  6. Anatomy • Pedicles • On either side of the vertebral canal, they connect the vertebral body to the lamina.

  7. Anatomy • Lamina • The lamina creates an outer wall, which protects the spinal cord posteriorly. • The lamina ends at the transverse process. Transverse processes are the sites of attachment for ligaments and muscles.

  8. Anatomy • Facet joints • The articular facets form the joints connecting each vertebrae with the vertebrae above and below (so that each vertebrae has four facets, two superior and two inferior). • The facet joints, like other mobile joints in the body, are covered with cartilage.

  9. Anatomy • Spinal Cord • The spinal cord is the main bundle of nerve fibers connecting the brain to the rest of the body. • The spinal cord ends near the L1 and L2 vertebrae, where it divides into bundles of nerve roots called the cauda equina.

  10. Anatomy • Nerve roots • Exiting from the spinal cord are nerve roots. • Nerve roots transmit signals between the spinal cord and the other parts of the body.

  11. Anatomy • Each nerve root has a specific distribution • motor • sensory • reflex (patellar- L4, Achilles-S1)

  12. Anatomy • Intervertebral disc • They provide a tough but flexible cushion for the vertebrae. • They allow movement. • They have a soft interior called the nucleus pulposus and an outer wall called the annulus fibrosus.

  13. Sources of low back pain (LBP) • Degenerative Changes • Sprains and strain of muscles • Fractures • Infection • Tumor

  14. Sources of LBP • Sprain or strain • Usually poor lifting technique, specific trigger event • Acute episode (less than 6 weeks) • 50% resolve by 2 weeks (NASS) • 80% resolve by 8 weeks.

  15. Sources of LBP • Fractures • Osteoporosis • Chronic steroid use • Low energy trauma in elderly • Car accidents • Falls from heights

  16. Compression fracture risk • 2 or more previous osteoporotic compression fractures (future fracture risk increased by 12 fold) • 2 SD decrease in BMD (4-6 fold) • Positive family history (2.7 fold) • Premature menopause (1.6 fold) • Smoking (1.2 fold)

  17. Sources of LBP • Infection • Drug abuse • Diabetes • Recent spine surgery • Pain + constitutional symptoms. Bacteria has hyaluronase enzyme

  18. Sources of LBP • Infection • Osteodiscitis (Usually nonop) • Only 50% have a fever. • ESR/CRP elevated in more than 90% but not specific • WBC only elevated in 42% • Blood cultures positive in 24% • XR lag behind up to 2-8 weeks. • MRI with gadolinium gold standard

  19. Sources of LBP • Infection • Epidural abscess • Hematogenous or direct inoculation • Patients usually more systemically ill than osteodiscitis • Usually posterior • Surgical management usually necessary

  20. Sources of LBP • Tumor • History of cancer • Weight loss • Night pain

  21. Sources of LBP • Degenerative changes • 95% of the population will have degenerative changes of the spine by age 50.

  22. By age 50ext

  23. To image or not to image? • LBP does NOT correlate with radiographic evidence of low back DDD. • With no red flags can usually be deferred 6 weeks.

  24. To image or not to image? • False positive rate of MRI is very high: • 35% of patients less than 40yo. • 93% of patients more than 60yo. MRI is effective when used as a confirmatory study only

  25. Risk factors for LBP • 30-50 years old • Male • Job occupation • Lower income • Cigarette smoking (vasoconstriction, pain receptors) • Prolonged exposure to vibrations (truck drivers) • Weight

  26. Natural history of LBP • 90% resolve spontaneously. • Lifetime incidence is 60-90%.

  27. Degenerative changes in the lumbar spine • Glycosaminoglycan (GAG) levels in the nucleus gradually decline. • Water content decreases in the 6th decade and beyond. • Noncollagen glycoproteins replace GAG.

  28. Degenerative changes of the lumbar spine • Phase 1: Dysfunctional phase (Kirkaldy-Willis) • Biochemical changes in aggregating proteoglycans. • Circumferential annular tears and fissures (scar weaker) Pain: Outer ring of annulus has pain sensors, and inflammation

  29. Degenerative changes of the lumbar spine • Phase 2: Unstable phase • Loss of mechanical integrity (progressive) • Propagation of tears (herniations) Posterolateral herniated nucleus pulposus most common (weakest PLL site). Most common at L4-5.

  30. Degenerative changes of the lumbar spine • Phase 2: Unstable phase • Loss of disc-space height • Facet joint/capsular laxity, subluxation

  31. Degenerative changes of the lumbar spine • Phase 3: Final Stabilization Phase • Further disc degeneration • Endplate destruction. • Osteophyte formation • Less pain.

  32. History • Timing of pain • Correlate with intradiscal pressure (highest sitting leaning forward with weight in hands)

  33. History • Radicular pain • Usually radiates below the knee and has a dermatomal pattern. • Referred pain usually is deep and dull aching, usually to buttocks or hamstrings. Also rule out GT bursitis.

  34. History • Cauda Equina Syndrome • Bowel and bladder difficulties • Perianal/saddle anesthesia • Diminished rectal tone • +/- motor deficits

  35. History • Spinal stenosis (central) • More common in men because their spinal canal is smaller at the L3-5 level than women • Insidious pain • Few neurologic findings on exam. • Typically will have pain with extension. • 50% have neurogenic claudication

  36. History • Spinal stenosis • Neurogenic claudication • Radiates from proximal to distal • Alleviated by flexing forward (sitting, grocery cart) • Heaviness and cramping of calves • Vascular claudication • Radiates retrograde • Alleviated by stopping/standing still.

  37. Physical • Full neuro and motor exam • Tension signs for lumbar disc herniation • SLR (L4-5, L5-S1)- pain below the knee • Femoral nerve stretch (L2-3, L3-4) • Contralateral SLR (axillary HNP)

  38. Physical • Waddell’s signs: • Tenderness to light touch. • Simulation (axial loading, pelvic rotation) • Distraction (SLR sitting versus supine) • Regional rather than anatomic distribution of pain. • Overreaction

  39. Physical • Waddell’s Signs • Evaluates psychological component. • More than 2 suggest malingering, secondary gain or psych component.

  40. Treatment of LBP • Initial treatment always conservative management: • Rest • 1-2 days • resume ADL • No lifting • Walking

  41. Treatment of LBP • Initial treatment: • NSAIDs • Pain reliever initially • 5-10 days has antiinflammatory effect • Gastritis/stomach ulcers • +/- opioids and non-opioid pain medication.

  42. Treatment of LBP • Initial treatment: • +/- opioids and non-opioid pain medication. • Muscle relaxers (CNS not skeletal muscle)

  43. Treatment of LBP • Physical therapy • Core strenghtening • Hamstring stretching • Lifting techniques/back school. • Supervised

  44. Treatment of LBP • Pain management for possible injections. • Epidural injections • Facet injections

  45. Treatment of LBP • Epidural injections • Do not change underlying condition. • Anti-inflammatory action breaks the cycle of pain inflammation and pain. • Effects longer than the actual steroid.

  46. Treatment of LBP • Epidural injections • Three different methods: • 1. Interlaminar • back of epidural space • wider space

  47. Treatment of LBP • Epidural injections • 2. Caudal • Sacral hiatus • Several segments

  48. Treatment of LBP • Epidural injections • 3. Transforaminal • “nerve block” • along side the nerve • One side/one segment

  49. Treatment of LBP • Facet injections • Intraarticular or medial branch block

  50. Treatment of LBP • Surgical • Usually after failed conservative management • Neurological deficits

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