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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

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
slide5
LBP
  • Facet joint
    • Zygopophyseal joint
    • Synovial
slide6
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
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 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 ?
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

Epidural Selective

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 lbp3
Chronic LBP

**Goal**

  • Improve Function
  • Minimize focus

on treating pain itself

  • Biopsychosocial Model of Pain
    • Maladaptive Behavior
    • Neuroplasticity
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
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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