Low back pain :symptoms,examination Dr.noori rheumatologist

1.HISTORY 2.PHYSICAL EXAM 3.PLAIN X-RAYS 4.SPECIAL STUDIES 1.SPECIAL STUDIES

History While it may not be possible to define a precise cause of low back symptoms for most patients, it is important to evaluate three concerns in taking a history:  Is there evidence of systemic disease?  Is there evidence of neurologic compromise?  Is there social or psychological distress that may contribute to chronic, disabling pain?

Diagnosis Obtain a thorough history Perform an appropriate physical exam Identify “Red Flags” Obtain Imaging if appropriate

Diagnosis by Age – Disc Herniation/AS >50 – OA >60 – Spinal stenosis/canser

Types of pain Based on source – Mechanical – Medical Based on affected region – Local – Referred Based on nature – Acute – Chronic

Timing Definitions Acute LBP lasts for < 6 weeks Sub-acute LBP lasts for weeks Chronic LBP lasts for > 12 weeks Acute & Sub-acute account for 90% of LBP

Referred pain Pleuritic pain Upper UTI / renal calculus Abdominal aortic aneurysm Uterine pathology (fibroids) Irritable bowel (SI pain) Hip pathology

Other Important History Occupational History Exercise History

Red Flags History of cancer, unexplained weight loss, age > 50, resting or night pain  consider new or metastasized cancer Most common primary bone cancer is multiple myeloma Cancers that metastasize to the bone – “lead kettle” (pb ktl): – P = prostate, B = breast – K = kidney, T = thyroid, L = lung

Red Flags, continued Fever, IV Drug Use, or recent infection  consider spinal (vertebral or disk) infection – Uncommon, occurs 1/100, ,000 people/year but is increasing – Can cause paralysis, significant deformity or death – Most spinal infections start in a lumbar disk – LBP is the most common presenting symptom of spinal infection

Emergent causes of back pain Cancer – Ask: 1) history of cancer; 2) pain which wakes patient from sleep, 3) weight loss, 4) new onset of pain in an elderly patient, Cauda equina – Ask: 1) bowel or bladder problems such as retention, incontinence, decreased sensation; 2) saddle numbness. Infection – Ask: 1) fevers, 2) history of epidurals or IVDU

Red Flags, Continued History of osteoporosis, use of steroids, age > 50 or recent trauma  consider vertebral compression fracture – Mortality is rare but morbidity is high

Red Flags, continued Abdominal pulsating mass  consider abdominal aneurysm Age 55

Red Flags, continued Urinary retention, fecal incontinence or saddle anesthesia  consider cauda equina syndrome – Rare – Compression of cauda equina nerve roots leading to disruption of motor & sensory function in legs, bladder & bowel – Usually due to massive disk herniation

Red Flags History of cancer Unexplained weight loss Intravenous drug use Prolonged use of corticosteroids Older age Major Trauma Osteoporosis Fever Back pain at rest or at night Bowel or bladder dysfunction 3/4/03

Physical Exam

Inspection Ideally with back and legs exposed. Posture ?Scoliosis ? Kyphosis Skin café-au-lait spots, hairy patches, signs of psoriasis. Prolapsed disc may cause a lumbar scoliosis, flattening or reversal of normal lumbar lordosis

Physical Exam Inspection – look for infection such as herpes zoster – check posture – possible scoliosis – Look for antalgic gait – check muscle symmetry – measure the calf and thigh muscle, > 2cm difference signifies possible muscle atropy – check leg length symmetry

Percussion Ask patient to bend forward Lightly percuss spine from neck to sacrum Significant pain is a feature of infections fractures and neoplasms Beware exaggerated response – may be a non organic problem Palpable steps may indicate spondylolisthesis

Palpation Attempt to localize the pain – Palpate the vertebrae for possible fractures or bone infections or mass – Palpate the paraspinal muscles for tenderness Check for muscle spasms – compare one side to the other Palpate the sciatic notch for possible sciatica

Range of Motion Check forward flexion Check extension Check lateral flexion bilaterally Check lateral rotation

Movements Flexion – schobers test <5cm = abnormal Extension – pain and restricted extension in spinal stenosis and spondylolisthesis Lateral Flexion: herniation discal Rotation – seated, movement is thoracic

Schobers Test

Motor Testing Deficit should align with areas of pain Toe Walk tests calf muscle (S1) Heel Walk tests ankle and toe dorsiflexion (L4, L5) Ankle Jerk (S1) Knee Jerk (L4)

Neuro Exam Plantar Flexion – One-legged x 3 = 5/5 strength – S1

Neuro Exam-Strength Extensor Hallucis Longus (EHL) – Big toe dorsiflexion – L5

Neuro Exam-Strength Hip Flexor Strength Testing – L1,2,3

Neuro Exam-Sensation Pinprick Sensation Testing – L5

Examination of back pain Supine Testing – Passive hip flexion – Faber position – Straight leg raise (SLR) – Passive knee flexion in a prone position – Passive internal and external hip rotation knee at 90 0 of flexion

Straight Leg Raise (SLR) Patient supine Hold the ankle and gently lift affected leg up to 70°

Straight Leg Raising

Passive hip flexion Hip hyperflexed – Lumbar spine flattened Over 90 0 of flexion Force transmission – To extensor of hip Posterior rotary movement on ilium – Spinal flexion

Fabere test

Pelvic Compression Test

Neuro Exam-reflexes Achilles Reflex – S1

Neuro Exam-reflexes Patella Reflex – L4

Examination for Radicular pain Neurologic exam: – Strength – Reflexes – Sensation Provocative tests: – Straight leg raise (SLR), contralateral SLR, Slump test

Don’t Forgot Other Reasons for LBP Abdominal exam if any complaints of nausea or vomiting or abdominal pain Palpate the abdominal aorta Rectal exam in men > 50 Pelvic exam if any menstrual abnormalities or vaginal discharge CVAT if suspicious for pyelonephritis

neurologic examination : focal weakness or muscle atrophy, focal reflex changes, diminished sensation in the legs, or signs of spinal cord injury. * The electromyography (EMG) can determine whether or not true weakness due to nerve tissue injury is present.

Diagnostic Imaging Generally NOT recommended in first 4-6 weeks Etiology of LBP is frequently not determined & Xrays don’t usually change management NOTE: XRs improve patient satisfaction!!! Key is to educate the patient about the appropriate role of imaging

Exceptions for Immediate Imaging Consider in all ages if any trauma Consider in older adults with any falls If there is a history of chronic steroid use or osteoporosis If there are any “Red Flags” and suspicion for cauda aquina, infection, cancer

Imaging modalities Xrays good first line Ix if red flags, osteoporotic fracture Bone scan (red flags) - mets, infection, pagets, CT Scan bone tumours fractures and spinal stenosis MRI spinal cord, nerve roots, discs, haemorrhage Dexa Scan Bone density