Low back pain case based evaluation and management
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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: www.uams.edu/pmr. Objectives. Understand the evaluation and management of common sources of low back and related pain

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Low Back Pain: Case Based Evaluation and Management

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Low back pain case based evaluation and management

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: www.uams.edu/pmr


Objectives

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.


Low back pain

Low Back Pain

  • Common; 2nd primary care visits

    • 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


Lbp anatomy

LBP: Anatomy

  • Bone / Vertebrae

  • Disc

    • Annulus

    • Nucleus Pulposus

  • Muscles / Ligaments

  • Spinal Nerve Roots


Low back pain case based evaluation and management

LBP

  • Facet joint

    • Zygopophyseal joint

    • Synovial


Low back pain case based evaluation and management

LBP

  • Sacroiliac Joint

    • Tight, Synovial

    • Ligaments

    • “SI Dysfunction”


Case 1

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?


Acute lbp history

Acute LBP: History

  • Location

    • Axial or Radiating (Sciatica) ?

  • Onset: Traumatic, Insidious

  • Duration:

    • Acute: < 12 weeks

    • Chronic: > 12 weeks

  • Character/Quality: Ache, Burning, etc

  • Exacerbating / Alleviating Factors


Acute lbp history1

Acute LBP: History

“Red Flags” (AHCPR 1994)

  • Fracture:

    • Major/minor trauma

    • Age > 70 yrs (~50 yrs)

    • Chronic corticosteroids

  • Cauda Equina

    • B/B dysfunction

    • Saddle Anesthesia

    • LE weakness


Acute lbp history2

Acute LBP: History

“Red Flags” (AHCPR 1994)

  • Infection

    • Fever

    • Steroids / Immunosuppression / IV Drug Use

    • UTI / Systemic Infection

  • Cancer

    • Hx of Cancer

    • Unintentional Weight Loss

    • Supine/Night Pain

    • Age > 50


Red flag evaluation

“Red Flag” Evaluation


Acute lbp physical exam

Acute LBP: Physical Exam

  • Lumbar Spine:

    • Inspection

    • Palpation

    • ROM: Flexion / Extension

  • +/- LE Neurologic Exam


Acute lbp imaging

Acute LBP: Imaging

  • When?

  • What imaging?


Acute lbp imaging1

Acute LBP: Imaging

When?

  • Minimum 6 weeks

  • + “Red Flags”

    What?

  • X-ray

    3-view:

    • AP / Lat / L5 Spot

      Obliques:

    • Limited information

    • Radiation exposure


Acute lbp imaging2

Acute LBP: Imaging

  • Lumbar MRI


Acute lbp imaging3

Acute LBP: Imaging

Abnormal findings

  • “Degenerative disc disease”

  • “Bulging disc”

  • “Herniated disc”


Lbp imaging

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%)


Case 11

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


Case 12

Case # 1

  • Diagnosis ?

  • Management ?


Lbp differential diagnosis

LBP: Differential Diagnosis

Deyo NEJM 2001


Case 1 diagnosis mechanical lbp

Case # 1Diagnosis: “Mechanical” LBP

  • Education / Activity Modification

    • Bedrest: ~ 2 days (Deyo NEJM 1986)

  • Analgesics:

    • Acetaminophen

    • NSAID’s

    • Tramadol

  • Muscle Relaxants

    • Cyclobenzaprine


Mechanical lbp

“Mechanical” LBP

  • Physical Therapy

    • Exercise

    • Modalities

    • Lumbar Support

  • Chiropractic

  • Acupuncture

Back Heat


Lbp zygapophyseal facet joint

LBP: Zygapophyseal (Facet) joint

  • History/Examination

    • Axial LBP +/- post thigh

    • No neuro sxs

    • Worse w/ static posture

      • Lumbar Extension

      • Stand / Walk

    • Neuro exam normal


Lbp zygapophyseal facet joint1

LBP: Zygapophyseal (Facet) joint

Management

  • Analgesics

    • Tylenol, NSAID

  • Physical Therapy

  • Injections

    • Diagnostic

    • Therapeutic


Lbp sacroiliac si joint

LBP: Sacroiliac (SI) Joint

  • History

    • Atraumatic > Traumatic

    • Axial; Lumbosacral

    • Uni- > Bilateral

    • No radiation / neuro sxs

  • Physical Exam

    • ~ Normal

    • Tender SI region


Lbp si joint

LBP- SI Joint

  • Diagnosis / Treatment

    • Physical Therapy

    • Injection


Lbp discogenic

LBP: Discogenic

History / Exam

  • Axial LBP

  • No radiation / neuro sxs

  • Aggravating:

    • Static posture- Sitting or Sit to stand

  • Normal neurological exam


Lbp discogenic1

LBP: Discogenic

Management

  • Physical Therapy

    • Core Strength

  • Surgery:

    • Fusion

    • Artificial Disc

      • Not yet


Case 2

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


Case 21

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


Case 22

Case # 2

  • Diagnosis ?


Lbp radiculopathy

LBP: Radiculopathy

Diagnosis

  • Physical Exam

  • MRI

  • EMG

  • CT Myelogram

    * Correlate anatomy w/ sxs and exam


Lbp radiculopathy1

LBP: Radiculopathy

Neurological Exam:

MotorReflexSensory

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


Lbp evaluation

LBP: Evaluation

  • SLR / Dural Tension


Case 23

Case # 2

  • MRI: Left L5-S1 disc herniation impinging on S1 nerve root

    Management?


Lbp radiculopathy2

LBP: Radiculopathy

Management

  • Medications

    • NSAID’s

    • Acetaminophen

    • Tramadol

    • Neuropathic

  • Steroids;

    • Oral (? dose) vs epidural


Lbp radiculopathy3

LBP: Radiculopathy

Management

  • Physical Therapy

    • McKenzie

      Extension therapy

    • TENS

      ~ No benefit


Lbp radiculopathy4

LBP: Radiculopathy

  • Injections

    EpiduralSelective


Lbp radiculopathy5

LBP: Radiculopathy

Surgery

  • Indications

    • Cauda equina

    • Progressive neuro deficits

    • No relief w/ conservative treatment

  • SPORT trial

    • JAMA 2006


Lbp spinal stenosis

LBP: Spinal Stenosis

  • History (Neurogenic claudication)

    • Prox LE Pain +/- Neuro sxs

    • Walk / Stand

    • Uphill > Downhill

    • Grocery Cart

  • Physical Exam

    • ~ Normal

    • Stand / Walk


Lbp spinal stenosis1

LBP: Spinal Stenosis

  • Diagnosis

    • MRI

    • EMG

  • Management

    • Medications

      • Neuropathic

    • PT

    • Epidural Injection

    • Surgery: (SPORT trial)


Case 3

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


Case 31

Case # 3

Physical Examination

  • 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


  • Case 32

    Case # 3

    • Lumbar MRI:

      • Mild DD changes with diffuse disc bulge at L4-5 and L5-S1

    • Diagnosis?

    • Treatment?


    Chronic lbp

    Chronic LBP

    • Duration

      • > 12 weeks

    • Poor Correlation

      • Symptoms

      • Objectives Finding


    Chronic lbp1

    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”


    Chronic lbp2

    Chronic LBP


    Chronic lbp3

    Chronic LBP

    **Goal**

    • Improve Function

    • Minimize focus

      on treating pain itself

    • Biopsychosocial Model of Pain

      • Maladaptive Behavior

      • Neuroplasticity


    Chronic lbp4

    Chronic LBP


    Case 33

    Case # 3

    Multidisciplinary Pain Management

    • Education

    • Medications

      • Chronic Opioids ?

    • PT

      • Functional Restoration

    • Psychology

      • Pain Management


    Recommended reading

    Recommended Reading

    • Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician 2007; 75:1181-8, 1190-2.

    • 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


    Low back pain case based evaluation and management

    LBP


    Questions

    Questions ?


    Other

    Other


    Lbp evaluation1

    LBP: Evaluation

    • Waddell’s Signs (Non-organic PE)

      • Tenderness

      • Overreaction

      • Regional

      • Distraction

      • Simulation

      • > 3/5

        * Behavioral Component of Pain

    Spine 1980


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