Understanding Low Back Pain: Causes, Symptoms, and Treatment Options

1. Low Back Pain

2. What is low back pain? Pain in the low back

4. Epidemiology • 80% of the population will have at least one episode of LBP in their lifetime • Annually $20 million in direct cost and $50 million when indirect cost is added • 3% of workers’ comp case but account 30% of the cost and receive 75% of the payment

5. Common causes of LBP? • Nonspecific – ligamentous or articular structures, strain, myofascial disorders, psychosocial factors • Arthritis • Spondylolisthesis • Disc herniation - >95% L4-5, L5-S1 • Spinal stenosis • Fracture • Tumor

6. History? • Characterize the pain • Diffuse, tight, gradual onset, worse after sitting or with cold, relieved with warmth, associated stiffness – myofascial disorder • Brief, shooting, worse with coughing, standing or sitting, relieved when lying down, radiating down the leg – nerve root, sciatica • Persistent, burning, tingling, worse when lying down at night – peripheral nerve or lumbosacral plexus • Radiating to buttock, thighs, legs, worse with back extension, relieved with sitting – spinal stenosis • Associated with horse saddle – cauda equina syndrome

7. History – rule out “red flags” symptoms? • Trauma • Fever • Weight loss • Neurologic deficits – numbness, bowel/bladder incontinence • History of IVDA, cancer, steroid use • Last longer than one month • Associated with abdominal pain

8. Physical exam? • Gait • Muscle weakness – atrophy, pelvic tilt • Knee flexion – guard against root traction • ROM • Palpation – tenderness, step off

9. Physical exam • Motor strength • Heel – L5 • Tiptoe – S1 • Sensation – dermatomes • L4 – big toe • L5 – middorsum of foot • S1 – lateral foot

10. Physical exam • Reflex • Knee – L3, L4 • Ankle – S1 • Straight leg raise • Crossed straight leg raise - > specificity than straight leg raise • Rectal exam

11. Inconsistent examinations • Axial loading • Whole body rotation at the hip • Straight leg raise in sitting position

12. Tests for patients without “red flags” symptoms? • None • 90% resolve spontaneously in 4 weeks

14. Tests with “red flags” symptoms? • CBC and ESR • X-ray • CT scan – fracture, fact joint

15. Tests with “red flags” symptoms? • MRI • Infection, cancer, disc herniation • Age >50, asymptomatic, disc bulging 75-80% and 30% disc protrusion • Bone scan – cancer • EMG • Nerve root involvement after multiple back surgeries • Fastitious weakness

16. Treatments – acute LBP? • Activity versus bed rest • Without radiculopathy, activity as tolerated • With radiculopathy, may consider bed rest < 3 days

17. Treatments – acute LBP? • Medications • Acute – around the clock rather than prn • Analgesics: acetaminophen, NSAID, cox-2 inhibitor, narcotics • Muscle relaxants – short term • Subacute/chronic: TCA, SSRI, phenytoin, tramadol, gabapentin

18. Treatments – acute LBP • Soft tissue injection – controversial • Back exercise • Limited benefit • Not during acute attack

19. Treatments – acute LBP • Disc herniation • Multiple conservative modalities - >90% resolved • Discectomy • Sciatica • Conservative treatment initially for 1-3 months - 80% resolved spontaneously • 73% recurred at least once

20. Treatment – chronic LBP? • Back exercise • Antidepressants – mixed result, confounding depression • Steroid injection in • Epidural space – may help in some patients, conflicting reports • Facets – limited data, one small study showed relief at 6 months but not month 1-3 • Spinal stenosis – laminectomy • Minimally invasive procedures • Spinal fusion – multiple laminectomy, unstable

21. Treatment – chronic LBP • Lumbar disc replacement • Behavior therapy • Spinal manipulation – mildly effective in some patients but no better than other routine modalities • TENS – no benefits