Low Back Pain Mohammad A. Saeed, M.D. M.S. University of Washington, Seattle, Washington Former Clinical Associate Professor Electrodiagnosis & Musculoskeletal Associates of Puget Sound Tacoma, Washington

Disclosures None

Introduction Back pain is a leading musculoskeletal complaint that contributes to impairment and disability Second most common reason for primary care physician office visits Clinical Course 50% resolve in 1-2 weeks 90% resolve in 6-12 weeks 85% recur in 1-2 years

Epidemiology Life time prevalence up to 75-85% Annual incidence about 5% #1 cause of disability for individuals < 45 year old Accounts for 7% of primary care visits

Natural History & Health Care Utilization 90% resolve without any treatment in 6-12 weeks Recurrence rate up to 80% ( f/u for > 1yr ) Only 5-9 % of cases last > 1 yr. but responsible for 80% of the total cost and disability days for all low back related claims Rate of spinal surgery is 40% higher in the U.S. and increased 55% between 1979 and 1990

Classification

Red Flags Gait ataxia/upper motor neuron signs – Myelopathy Bowel/bladder/sexual dysfunction – Cauda Equina Syndrome Night pain/weight loss – Tumor Fevers/chills – Infection Severe Pain Progressive motor weakness

Cauda Equina Syndrome Injury to cauda equina Usually from large central HNP Also from lumbar stenosis, epidural tumors, hematomas, abscesses, and trauma Clinical Features Lumbar, buttock, perianal discomfort, BLE weakness Bowel/bladder retention, frequency, or incontinence Sexual dysfunction Saddle anesthesia including back of legs, buttocks, soles of feet

Common back pain issues Lumbar Sprain/Strain Degenerative Disc Disease Herniated Discs Central Canal Stenosis – Lumbar Spinal Stenosis Foraminal Stenosis – Lumbar Radiculopathy Facet Arthropathy Vertebral Compression Fractures

Discogenic Pain Internal disk disruption Treated with analgesics, exercise, epidural steroid injections Disk herniation(herniated disk, disk bulge, ruptured disk, prolapsed disk) Treatment- Conservative is best Epidural steroid injections Discectomy, fusions considered if unstable ( preferably MIS )

Facet Syndrome Clinical Features – Back pain exacerbated by rotation and extension Imaging – x-ray, CT, and MRI – not reliable indicator. Most accurate diagnostic tool is MBB. Treatment – conservative care includes relative rest, pain medications, rehabilitation program (focusing on flexion based or neutral postures), manual medicine, and interventional procedures

Spinal Stenosis Neurogenic claudication Bilateral leg pain initiated by walking (esp down hill) and prolong standing Relieved by sitting Treatment - conservative, pain control, ESI (controversial) Surgery- if conservative measure failed. Laminectomy is the most common form of decompression

Evaluation (History) Hx – 85% of diagnosis is in the history Onset, Aggravating /Alleviating factors Effect of cough/sneeze, previous episodes Associated limb symptoms Bowel/Bladder disturbances Surgical and medical history ( diabetes mellitus )

Diagnostic Studies X-rays to evaluate for fractures and bony lesions Oblique view to assess spondylolysis “scottie dogs” Flex/ext views to assess stability (spondylolisthesis)

Diagnostic Studies MRI Very sensitive BUT low specificity Many with no pain have positive findings Bowden study – one third of 67 asymptomatic people found to have “ substantial abnormality ( bulges & protrusions most common)

EMG/NCS Evaluation for radiculopathy Rule out peripheral nerve disorder Good sensitivity High specificity Low cost

What is the most important tool to assess patients with LBP? The history and physical exam remains the mainstays in evaluation of LBP, despite new expensive technology Determination of flexion vs. extension based pain

Radicular “mimic-ers” Sacroiliac pathology Piriformis syndrome ITB syndrome Trochanteric bursitis Peripheral nerve disorders

Now to make this more interesting….

Case 1 63 year old Orthopedic surgeon presented with low back pain with left foot drop x 1 year. Work up included MRI and EMG. Differential diagnosis?

Case 2 54 year old Physiatrist presented with acute right low back and right buttock pain with right lower extremity numbness and tingling. Symptoms initiated after a cricket match. Work up included MRI and EMG. Differential diagnosis?

Case 3 64 year old Psychiatrist presented with bilateral hip pain to the Orthopedic surgeon and then referred for further evaluation. He had a shuffling gait on exam. Work-up included X-rays and EMG. Differential diagnosis?

Case 4 70 year old PCP presented with low back pain with right lower extremity pain, numbness, and weakness. Lumbar spine surgery at L2/3 and L3/4, with minimal improvement in symptoms. Further work-up including EMG after surgery. Differential diagnosis? Follow up 8 months and about 1 year after onset of symptoms

Treatment Relative Rest Medications: NSAIDs, oral steroids, muscle relaxants, etc. Rehabilitation program with stretching focusing on flexibility and core strengthening exercises Bracing Home exercise program Injections Surgery

Low Back Pain Prevention Exercises including core strengthening including stretching & planking

New Trends Mid level providers MSK and interventional physiatrists screening

Key Points: The truth about low back pain Degenerative discs and some of the anatomic sequelae of facet arthropathy and spurring are usual consequences of aging. They DO NOT always cause pain. The natural history of LBP is to improve with or without treatment, but certain treatments can hasten the process and are worthwhile There is little or no correlation between abnormalities as seen on imaging and the patients’ clinical symptoms and signs

Key Points: The truth about low back pain It is important to discover serious problems presenting as LBP by identifying the red flags Treatments consist of reassurance, NAIDs, and staying out of bed & active Special injection techniques are occasionally indicated in patients with LBP and corresponding pain generators when accurately diagnosed Treat the patient, not the imaging Surgical indications are indicated in certain conditions

Thank You Any Questions ??