
Definitions History with red flags Physical Examination with red flags Diagnostic testing Treatment Sciatica and Back Pain Epidural Compression Syndrome Vertebral Osteomyelitis Back Pain in the Cancer Patient Introduction
Definitions • Low back pain: pain located between the lower rib cage and the gluteal folds • Extending or radiating into the thighs • Acute: lasting less than six weeks • Subacute: lasting between 6 and 12 weeks • Chronic: lasting longer than 12 weeks
Red Flags • Less than 18 yrs of age • More than 50 yrs of age • Trauma (even minor if patient is elderly or taking steroids chronically) • Cancer • Fever, chills, night sweats • Weight loss
Red Flags • Injection drug use • Compromised immunity • Recent GI or GU procedure • Pain at night • Pain radiating below knee • Pain with prolonged sitting, coughing, or Valsalva manouver
Red Flags • Severe and unremitting pain • Incontinence, saddle anesthesia • Severe or rapidly progressing neurologic deficit
Age • More than 50 years old or younger than 18 • Older than 50 • Tumor • Abdominal aortic aneurysm • Infection
Age • Older than 65 • Hypertrophic degenerative spinal stenosis • Under 18 • Congenital defect • Tumor • Infection • Spondylolysis • Spondylolisthesis
Duration of Pain • Approximately 80% of patients with acute low back pain will be symptom-free within six weeks • Pain lasting longer: tumor, infection, or a rheumatologic etiology
Location and Radiation of the Pain • Muscular or ligamentous strain or disk disease without nerve involvement • Primarily in the back with radiation into the buttocks or thighs • Radiating below the knee, especially calf and foot • Nerve root inflammation below L3 level • Approximately 95% of all herniated disks occur at the level of either L4-L5 or L5-S1
History of Trauma • Major or minor trauma • Elderly or chronic steroid user: Fracture! • More likely to have osteoporosis • Fall from a standing or a seated position
Systemic Complaints • Constitutional symptoms • Fever, night sweats, malaise, or unintended weight loss • Infection or malignancy • More worrisome for infection if additional risk factors • Recent bacterial infection • Immunocompromised status
Systemic Complaints • Injection drug user: assumed to be osteomyelitis or epidural abscess until these conditions are ruled out by diagnostic studies • Recent invasive procedures, such as colonoscopy
Atypical Pain • Typical pain: dull, achy pain that is exacerbated with movement and improves with rest • Tumor and infection • Worse at night • Often awakens patient from sleep • Not relieved with rest • Unrelenting despite appropriate analgesic treatment
Atypical Pain • Worsened with prolonged sitting, coughing, and the Valsalva maneuver: Disk Herniation
Associated Neurological Symptoms • Epidural compression syndrome (spinal cord compression, cauda equina syndrome, or conus medullaris syndrome) • Saddle anesthesia • Bowel or bladder incontinence • Erectile dysfunction • Severe and progressive neurologic deficit
Associated Neurological Symptoms • Residual bladder volumes • Assist in the evaluation of bladder incontinence • Large post-void residual volumes: significant neurologic compromise. Evaluate for epidural compression syndrome
Associated Neurological Symptoms • Complaints of worsening paresthesias, weakness, gait disturbances • Single nerve root pathology: compression by a herniated disk • Multiple or bilateral nerve root complaints: compression from a mass
History of Cancer • Risk of metastatic spread to the spine • Most likely to metastasize to the spine: • Breast, lung, thyroid, kidney, prostate cancer • Primary tumors originating in the spine: • osteosarcoma, lymphoma, multiple myeloma, neurofibromas
Physical Examination • Vital signs • Fever: red flag for infection • 27% of patients with tuberculous osteomyelitis • 50% of patients with pyogenic osteomyelitis • 87% of patients with spinal epidural abscess • Absence of fever does not rule out spinal infection
Physical Examination • General appearance • Benign low back pain: patients prefer to remain still • Writhing in pain or in extreme pain • Spinal infection • Abdominal aortic aneurysm • Nephrolithiasis
Physical Examination • Expose back and palpate • History of trauma: focus on midline spinous processes for tenderness • Muscular spasm or edema
Physical Examination • Lower extremity strength and sensation • Focus on muscle groups and dermatomes innervated by specific spinal nerve roots • Patellar and Achilles reflexes: symmetry • Babinski's test: upper motor nerve syndrome • All deficits or abnormalities should be compared with the nerve root involved
Straight Leg Raising • Evaluate for disk herniation • Patient placed in the supine position. Leg elevated by clinician up to 70 degrees • Positive test: radicular pain below the knee along the path of a nerve root in the 30- to 70- degree range of elevation • Further verified by lowering the leg 10 degrees from the point of radicular pain and dorsiflexing the foot
Straight Leg Raising • Reproduction of back pain or pain in the hamstring is not a positive test! • 80% sensitive for disk herniation • Positive crossed straight leg raise: radicular pain down the affected leg when the asymptomatic leg is raised • Highly specific but not sensitive
Rectal Examination • Integral part of examination of patients with back pain • Perianal sensation, rectal tone, and rectal and prostatic masses • Abnormal tone or sensation: bulbocavernous reflex testing and anal wink • Poor rectal tone in association with back pain and saddle anesthesia: epidural compression syndrome
Laboratory Tests • Infection or tumor: • CBC: elevated WBC count consistent with infection • ESR: elevated in infection and rheumatologic disease. Also marker of an undiscovered malignancy • CRP: same as the ESR • UA: UTI in patients who have evidence of spinal infection. Urinary system common primary source for such infections
Radiography • Plain radiographs: simply not necessary in the absence of red flags • Concern for fracture, infection, rheumatologic disease, or metastatic disease • Anteroposterior and lateral films • Magnetic resonance imagery (MRI) or computed tomography (CT) if films negative and concern remains
Radiography • MRI • Gold standard for compressive lesion of the spinal cord or cauda equina, spinal infection, or disk herniation. • May be delayed for four to six weeks if disk herniation is the only concern
Radiography • CT • Study of choice for bony structure • Spinal trauma: spinal column stability and integrity of spinal canal • Vertebral osteomyelitis • CT-myelogram in absence of MRI: epidural compressive lesions
Activity • No benefit of prolonged bed rest 1 • Recently shown that patients who resumed their normal activities to whatever extent they could tolerate recovered faster than those who stayed in bed for two days • Active exercise: not beneficial during acute stage • After recovery, exercise helps prevent future episodes 1. How many days of bed rest for acute low back pain?A randomized clinical trial. N Engl J Med 1986; 315:1064-70
Analgesia • Mainstays of pharmacologic therapy: acetaminophen, NSAIDs, and opiate analgesics • Acetaminophen: analgesic with proven efficacy comparable to NSAIDs • Inexpensive • Innocuous side-effect profile
Analgesia • NSAIDs: equally efficacious in the management of acute pain • Best to choose lowest effective dose based on side effects and cost • Opiate analgesics: moderate to severe pain • Combinations of acetaminophen and codeine phosphate, hydrocodone, or oxycodone • Other medications • muscle relaxants, such as diazepam, methocarbamol, and cyclobenzaprine
Sciatica • Sciatica: pain radiating along a nerve root path to the foot • Afflicts 2% to 3% of patients with low back pain • Compression of a nerve root by a herniated nucleus pulposus • Associated weakness, paresthesias, and numbness along a nerve root
Sciatica • More than 95% of disk herniations occur at the L4-L5 or L5-S1 levels, corresponding to L5 or S1 radiculopathies • Other causes of nerve root irritation: • Space-occupying lesions (including central canal or foraminal stenosis, usually found in patients over age 50) • Tumor • Hematoma • Infection
Sciatica • Outcome generally positive: • 50% recovering in six weeks • 5% to 10% ultimately require surgery • Management similar to uncomplicated low back pain • Limited bed rest • Activity as tolerated • Analgesics • Steroids: epidural steroid injection produces mild to moderate reduction in pain
Sciatica • Radiographs not required • Only to rule out bony pathology • MRI: needed emergently only if patient has a progressing neurologic deficit
Epidural Compression Syndrome • Encompasses: • Spinal cord compression • Cauda equina syndrome • Conus medullaris syndrome • Grouped together because: • Similar presentation except for the level of the neurologic deficit • Similar evaluation and management until actual diagnosis is known
Epidural Compression Syndrome • Medical Emergency! • Difficult to evaluate patients with early signs and symptoms • Broad initial differential diagnosis • Determine whether symptoms are bilateral • Evaluate combination of motor, sensory, and autonomic dysfunction
Epidural Compression Syndrome • Signs and symptoms: • Minimal low back complaints • Constipation or incontinence of the bowel • Urinary retention or incontinence • Saddle anesthesia • Decreased rectal tone