Low Back Pain

1. Low Back Pain Dabbas W, M.D. Neurosurgeon Dept. of Neurosciences, School of Medicine, Al Balqa University

2. 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

3. Epidemiology • Incidence of LBP: • 60-90 % lifetime incidence • 5 % annual incidence • 90 % of cases of LBP resolve without treatment within 6-12 weeks • 40-50 % LBP cases resolve without treatment in 1 week • 75 % of cases with nerve root involvement can resolve in 6 months • LBP and lumbar surgery are: • 2nd and 3rd highest reasons for physician visits • 5th leading cause for hospitalization • 3rd leading cause for surgery

4. Disability • Age and LBP: • Leading cause of disability of adults < 45 years old • Third cause of disability in those > 45 years old • Prevalence rate: • Increased 140 % from 1991 to 2000 with only 125 % population growth • Nearly 5 million people in the U.S. are on disability for LBP

5. Lifetime Return to Work • Success of < 50 % if off work > 6 months • 25 % success rate if off work > 1 year • Nearly 0 % success if return to work has not occurred in 2 years

6. Differential Diagnoses • Lumbar Strain • Disc Bulge / Protrusion / Extrusionproducing Radiculopathy • Degenerative Disc Disease (DDD) • Spinal Stenosis • Spondyloarthropathy • Spondylosis • Spondylolisthesis • Sacro-iliac Dysfunction

7. Frequency of Back Pain Types 97% “mechanical”

8. Better anatomy knowledge=Better diagnoses and treatments

11. Vertebra • Body, anteriorly • Functions to support weight • Vertebral arch, posteriorly • Formed by two pedicles and two laminae • Functions to protect neural structures

13. Biomechanics 20%Posterior 80% Anterior The 80-20 rule of Spine loading www.brain101.info

14. Ligaments • Anterior longitudinal ligament • Posterior longitudinal ligament • Ligamentum flavum • Interspinous ligament • Supraspinous ligament

15. Ligamentous Anterior longitudinal ligament

17. Sciatica is defined as… • Pain radiating up the back • Pain radiating to the thigh • Pain radiating below the knee • Pain in the butt

18. L4 • L5 • S1

19. 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

20. “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

21. Onset • Acute - Lift/twist, fall, MVA • Subacute - inactivity, occupational (sitting, driving, flying) • Pain effect on: • work/occupation • sport/activity (during or after)

22. Other History • Prior h/o back pain • Prior treatments and response • Exercise habits • Occupation/recreational activities • Cough/valsalva exacerbation

23. 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

24. Physical Examination • Inspection • Palpation • Strength testing • Neurologic examination • Special tests

25. Approach to LBP • History & physical exam • Classify into 1 of 4: • LBP from other serious causes • Cancer, infection, cauda equina, fracture • LBP from radiculopathy or spinal stenosis • Non-specific LBP • Non-back LBP • Workup or treatment

26. Diagnostic Tools 1. Laboratory: • Performed primarily to screen for other disease etiologies • Infection • Cancer • Spondyloarthropathies • No evidence to support value in first month unless with red flags • Specifics: • WBC • ESR or CRP • HLA-B27 • Tumor markers: Kidney Breast Lung Thyroid Prostate

27. Radiographs: • Pre-existing Degenerative Joint Disease (Osteoarthritis) is most common diagnosis • Usually 3 views adequate with obliques only if equivocal findings • Indications: • History of trauma with continued pain • < 20 years or > 55 years with severe or persistent pain • Noted spinal deformity on exam • Signs / symptoms suggestive of spondylo-arthropathy • Suspicion for infection or tumor

28. www.brain101.info

29. 3. Electromylogram (EMG): • Measures muscle function • Would not be appropriate in clinically obvious radiculopathy 4. Bone Scan: • Very sensitive but nonspecific • Useful for: • Malignancy screening • Detection for early infection • Detection for early or occult fracture

31. Myelogram: • Procedure of injecting contrast material into the spinal canal with imaging via plain radiographs versus CT

32. 6. CT with Myelogram: • Can demonstrate much better anatomical detail than Myelogram alone • Utilized for: • Demonstrating anatomical detail in multi-level disease in pre-operative state • Determining nerve root compression etiology of disc versus osteophyte • Surgical screening tool if equivocal MRI or CT

33. 7. CT: • Best for bony changes of spinal or foraminalstenosis • Also best for bony detail to determine: • Fracture • Degenerative Joint Disease (DJD) • Malignancy

34. 9. MRI • Bestdiagnostic tool for: • Soft tissue abnormalities: • Infection • Bone marrow changes • Spinal canal and neural foraminal contents • Emergent screening: • Caudaequina syndrome • Spinal cord injury • Vascular occlusion • Radiculopathy • Benign vs. malignant compression fractures • Osteomyelitis evaluation • Evaluation with prior spinal surgery

35. Break for Physical Examination Hands-on Session

36. 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)

37. 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

38. 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

39. PID

40. 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

41. 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

42. L2, L3, L4 testing

43. Neurologic Examination(L4 level) • Motor • Tibialis Anterior • Resisted inversion of ankle • Reflexes • Patellar Reflex (L4) • Sensory • Medial side of leg

45. Neurologic Examination(L5 level) • Motor • Extensor Hallicus Longus • Resisted dorsiflexion of great toe • dorsifexion • Reflexes - none • Sensory • Dorsum of foot in midline

47. Neurologic Examination(S1 level) • Motor • Peroneus Longus and Brevis • Resisted eversion of foot • Planter flexion • Reflexes • Achilles • Sensory • Lateral side of foot

49. Special Tests • Tests to stretch spinal cord or sciatic nerve • Tests to increase intrathecal pressure • Tests to stress the sacroiliac joint

50. Tests to Stretch the Spinal Cord or Sciatic Nerve • Straight Leg Raise • Cross Leg SLR • Kernig Test