Medhat Michail September 2017 Acute lower back pain Medhat Michail September 2017

Case 1 A 35 years old male presented with severe pain in his lower back after bending down to pick up a heavy weight. No radiation of the pain to the lower limbs PH: Nil O/E: stands with increased lordosis and reduced forward flexion, walking is painful tender over L5 and paravertebral muscles No neurological S/S What is the diagnosis? How would you manage this patient?

Case 2 A 37 years old male presented with severe pain in his lower back after bending down to pick up a heavy weight. The pain is radiating down the back of his left leg as far as the ankle PH: Nil O/E: Walks with pain ↓ back movements especially the forward flexion The muscle power was difficult to assess because of the pain Normal ankle dorsiflexion (bilaterally) but weak left ankle planter flexion and big toe flexion Altered sensation over the lateral side of the left foot No other neurological S/S What is the diagnosis? How would you manage this patient?

Dermatomes of the lower limb, Front & back

Movements generated by myotomes of the lower limb (Drake R, Vogl W, Mitchell A. Gray's anatomy for students. Churchill Livingstone, Edinburgh; 2004)

Movement Innervation Hip flexion L1 L2 Knee extension L3 L4 Knee flexion L5 S1 S2 Hindfoot inversion L4 Great toe dorsiflexion L5 Ankle plantarflexion S1 S2

Back pain Is the leading cause of occupational disability in the world The most common cause of missing work days 50 - 80% With aging population and sedentary live this situation is unlikely to change

Aim To provide an evidence based overview of low back pain to the primary health carer

Objectives By the end of this presentation you should be confident in managing patients with back pain in the ED.

Common causes of low back pain Mechanical (80 – 90%) Neurogenic (5 – 15%) Non-mechanical spinal conditions (1 – 2%) Referred visceral pain (1 – 2%) Other (2 -4 %)

Mechanical causes (80 – 90%) Unknown causes Degenerative disc or joint disease Vertebral fracture Congenital deformity Spondylolysis instability

Neurogenic causes (5 – 15%) Herniated disc Spinal stenosis Osteophytic nerve root composition Annular fissue with chemical irritation to the nerve root Failed back surgery syndrome Infections (e.g. herpes zoster)

Non-mechanical spinal conditions (1 – 2%) Neoplastic (primary or secondary) Infection (osteomyelitis, discitis or abscess) Inflammatory arthritis Paget’s disease Other (e.g. Sheuermann’s disease, Baastrup’s disease)

Referral visceral pain (1 – 2 %) GI diseases Renal diseases AAA

Other (2 - 4%) Fibromyalgia Somatoform disorder Mallingering

Classification by Edlow 2015 Simple causes Muscular & ligamentous strains Isolated sciatica (Posterolateral disc herniation) Spinal stenosis Serious causes Cancer related Infection related Spinal epidural haematoma Central disc herniation causing cauda equina syndrome Non-spine related causes

Management of acute low back pain in ED Rule out the serious causes Pain management

Red flags Cauda equina Syndrome Spine fractures Malignancy or infection

Red flag symptoms indication possible serious spinal pathology. Red flag symptoms are: •Onset at age <20 or >55 •Non-mechanical pain (i.e. unrelated to time or activity), especially if constant and worsening, and pain at night •Thoracic pain •Previous history of carcinoma, steroids or HIV infection •Fever, night sweats, weight loss •Widespread neurological symptoms especially sphincter disturbance •Structural spinal deformity

Red Flags – Cauda equina syndrome Saddle anesthesia or paresthesia Recent onset of bladder dysfunction Recent onset of faecal incontinence Perianal/perineal sensory loss Unexplained laxity of the anal sphincter Severe or progressive neurological deficits in the lower limbs

Red Flags – spinal fracture Sudden onset of severe central pain in the spine which is relieved by lying down. Major trauma such as a road accident or fall from a height. Minor trauma, or even just strenuous lifting, in people with osteoporosis. Structural deformity of the spine (such as a step from one vertebra to an adjacent vertebra). Point tenderness over the vertebral body

Red flags – Malignancy or infection Pain that remains when lying down, aching night-time pain that disturbs sleep, and thoracic pain could also be caused by an aortic aneurysm. Onset in people aged above 50 years or below 20 years. History of cancer. Constitutional symptoms, such as fever, chills, or unexplained weight loss. Recent bacterial infection - eg, urinary tract infection. Intravenous drug misuse. Immune suppression. Structural deformity of the spine (such as scoliosis). Point tenderness over the vertebral body.

Investigations No investigations are required in majority of cases Limited role of X ray in non traumatic low back pain Lab investigations if red flags are present

The Biomarkers Routine lab testing is not useful WBCs CRP & ESR elevated only in 2/3 of patients with epidural abscess CRP & ESR Highly sensitive but non specific ESR & CRP not recommended for patients with no red flags

Pharmacological treatment Simple analgesia NSAID Opiates Steroids Muscle relaxant

So the evidences……? First line agents (Paracetamol & NSAID) Paracetamol is ineffective Machado 2015 Australian Institute of health & welfare, 2010 NSAID No difference over placebo when added to paracetamol Machado 2017

So the evidences……? Steroids No benefit Muscle relaxants & Opiates In herniated disc (Goldberg 2015) In undifferentiated patients (Eskin 2014) Muscle relaxants & Opiates No benefit (Swaminathan 2017) Cyclobenzaparine & Naproxen No benefit (Friedman 2015) Opiates & Paracetamol No benefit in pain control or functional outcome at 1/52 & 3/12 (Friedman 2015)

The real Management Discussing expectations Educate your patient Likely to have pain for 6/52 (Menezes Costa 2012) Up to 60% will have pain and decrease function after one year Educate your patient Medications Discharge instructions: verbal & leaflet

Key recommendations (NICE Nov. 2016) Paracetamol Oral NSAIDs Weak opioids Imaging Physical & Psychological Programme Regular activities Group Exercise Massage & manipulation Acupuncture, electrotherapies & spinal injections Epidural injections Radiofrequency Denervation Key recommendations (NICE November 2016) 1. Paracetamol alone is no longer recommended as the primary option. Therapy should instead be initiated with NSAIDs such as ibuprofen or aspirin. 2. Oral NSAIDs should be used ‘at the lowest effective dose for the shortest possible period of time’. 3. Weak opioids like codeine should be considered for acute back pain only when NSAIDs are contraindicated or fail to work. 4. Imaging in a non-specialist setting should not be offered routinely. 5. A combined physical and psychological programme should be considered in patients not responding to previous therapies or those with psychosocial obstacles to recovery. 6. Patients should be encouraged to continue with regular activities as far as possible. 7. NICE recommends considering a group exercise programme as a part of the treatment regimen. 8. Massage and manipulation to be used only in conjunction to exercise. 9. Acupuncture, electrotherapies, and spinal injections are not recommended for managing low back pain; however, in patients with severe acute and severe sciatica, epidural injections of local anaesthetic and steroid can be considered. 10. Epidural injections should not be used for neurogenic claudication in patients with central spinal canal stenosis. 11. Patients with chronic back pain (moderate or severe localised back pain), not responding to non-surgical treatment and with pain originating from structures supplied by the medial branch nerve should be referred for assessment for radiofrequency denervation.