BACK PAIN anita choudhary pgy-1

INTRODUCTION BP occurs in 80% general population during their lifetime Acute (<4 weeks), subacute (4-12 weeks), and chronic ( lasting > 12 weeks) Most episodes are self-limited, 90% of cases will improve within 4-6 weeks Lasting > 4-6 weeks: is one of the red flag markers for more serious cause Estimates of direct health care expenditures among individuals with back pain in the USA have reached over $100 billion Prolonged episodes of back pain i.e., lasting longer than 4-6 weeks is one of the red flag markers for more serious cause of back pain

OBJECTIVES Terminology Initial approach to back pain Etiologies Diagnostic tests Management

Terminology of Radiographic changes associated with back pain Radiculopathy: refers to symptoms or impairments related to a spinal nerve root; damage to spinal nerve root from disc protrusion or degenerative changes or other causes. MC radiculopathy: L5-S1 Sciatica: The term "sciatica" refers to a sharp or burning pain radiating down from the buttock along the course of the sciatic nerve (the posterior or lateral aspect of the leg, usually to the foot or ankle). Most sciatica attributable to L5-S1 radiculopathies from a disc disorder

INITIAL EVALUATION OF BACK PAIN: HISTORY Majority of patients with back pain will have lumbar strain HISTORY is critical to ruling out serious causes, focus on determining specific underlying condition and identifying neurologic involvement based on our knowledge of the dermatome map and the location of symptoms noted by the patient Cancers that metastasize to bone include thyroid cancer, lung cancer, and renal cell cancer Recurrent episodes of bacteremia associated with IV drug users Rule out abdominal causes of back pain such as a history of a recent UTI should raise concern for pyelonephritis, alcohol use raise concern for pancreatitis or perforating ulcer, elderly patient with multiple vascular risk factors should raise concern for AAA

PHYSICAL EXAMINATION Assess functional status, evaluate for any neurological deficits, identifying the level of disc herniation in patients with radicular symptoms Motor signs and symptoms more helpful than sensory signs and symptoms in localizing the level of nerve impingement L-5 / S-1 nerve roots involved in 95% lumbar disc herniations

DERMATOME MAP

ETIOLOGIES D/D back pain is broad Anatomically, back pain can be differentiated into: Etiologies related to pathology of the msk components of the back- 98% of patients p/s with LBP will have this etiology Etiologies related to abdominal/pelvic pathology Not all back pain is related to the spine and related muscles and bones; abdominal pathology may also present with cc of back pain; can be grouped into one of three broad categories: nonspecific pain (about 85%); pain with radiculopathy or spinal stenosis (about 7%); and those having pain possible associated with another specific spine disorder, such as cancer, compression fracture, infection, or ankylosing spondylitis

Etiologies related to MSK components of the back

Lumbar strain Most common etiology LBP: Lumbar strain- 80% Acute (Overextension) and Chronic (Faulty posture) Musculoligamentous sprain or strain; occur mainly at the lumbosacral region Most commonly seen in ages 30-60; associated with overuse Improve within few weeks Lack of specific neurological deficits

HERNIATED NUCLEUS PULPOSUS Tears in the annulus, herniation of the nucleus pulposus Compression of the nerve root in the foramen leads to pain 98% disc herniations: L4-5; L5-S1 Radicular symptoms and an abnormal neurologic exam are common in patients presenting with herniated discs. Absence of radicular symptoms makes herniated disc disease an unlikely cause of low back pain Spinal stenosis, degenerative disease of the spine, malignancy, and infection may also present with radicular symptoms The level of involvement of the spine nay be discerned by history and physical findings

Straight Leg Raise Test (SLR) SLR determines if there is any evidence of nerve root irritation Patient in the recumbent position; slowly lift the leg (the knee remains extended) without assistance from the patient, that creates traction on the sciatic nerve A positive test refers to reproduction of symptoms of sciatica at an angle less than 60 degrees, with pain radiating below the knee (not merely pain in the lower back or tightness of the hamstring muscles) SLR is a sensitive test, not specific, such that its absence makes nerve root compression less likely While the straight leg raise test is not specific, it is rather sensitive 56-71%. The absence of radicular symptoms and a negative SLR in a patient are a reassuring combination of findings in the patient presenting with LBP

Compression fracture More commonly seen in the elderly (especially women) is the vertebral compression fracture of osteoporosis. Risk factor for osteoporotic fracture include advanced age, chronic glucocorticoid use, history of osteoporotic fracture Severe, non-radiating back pain is the common symptom, which may be initiated by lifting an object

Spinal Stenosis Typically affecting patients >60 years; usually secondary to degenerative process Sciatica results from nerve root compression as osteophytes or other degenerative changes impinge on the nerve root. Neurogenic claudication (“pseudo claudication”) 1 or both legs: hallmark of spinal stenosis Radiation to buttocks, thighs, lower legs Pain increase with extension (standing, walking) Pain decrease with flexion (sitting, stopping forward)

Inflammatory etiologies of low back pain/ Spondyloarthritis The most classic form of spondyloarthritis is ankylosing spondylitis Other spondyloarthritides: psoriatic arthritis, reactive arthritis and the spondyloarthritis associated with inflammatory bowel disease Common features of inflammatory arthritis: Insidious onset, presence of enthesitis include achilles tendinitis and plantar fasciitis, but inflammation may be seen at any insertion of ligaments into bone Back stiffness, worse in the morning, and improves as the day goes on. ( versus degenerative arthritis which worsens with physical activity)

Modified Schober’s Test Modified Schober’s test: Mark the patient’s back at 5cm below and 10cm above the dimples of Venus.  Then ask the patient to bend forward with knees straight and measure the new distance between your two marks.  This distance should normally increase from 15cm to 20 cm or more.

Spinal Cord or Cauda Equina Compression Most common cause of Cauda Equina is herniation of intervertebral disc Needs emergent surgical referral. Symptoms: bilateral lower extremity weakness, numbness, or progressive neurological deficit. Pain usually the first symptom, but motor (usually weakness) and sensory findings present in the majority of patients at diagnosis Bladder and bowel dysfunction generally late findings; “saddle anesthesia” Recent urinary retention (most common) or incontinence; Fecal incontinence Cauda equina syndrome results from compression of the nerves of the cauda equina Often suggests malignancy or severe herniation of an intervertebral disc, trauma Patients with cauda equina syndrome may note decreased sensation of the perineum and buttocks ("saddle anesthesia"), sciatic symptoms bilaterally associated with leg weakness, and bowel or bladder dysfunction. Patients with these symptoms require emergent imaging and follow up.

Etiologies Related to Abdominal and Pelvic Pathology

DIAGNOSTIC TESTS No recommendations for routine diagnostic tests in patients with nonspecific LBP Diagnostic tests reserved for patients with: Severe or progressive neurologic deficits, Patients for whom a serious underlying condition is suspected, or Patients who do not have symptoms improvement after 4 to 6 weeks of conservative mx The American College of Physicians recommends MRI (preferred) or CT for radiculopathy or spinal stenosis only for those patients who are candidates for epidural glucocorticoid injection or surgery

DIAGNOSTIC TESTS CONT. In patients with radiculopathy or spinal stenosis, routine imaging has not been shown to improve outcomes. MRI should be considered in patients with suspected spinal stenosis, cauda equine syndrome, or severe and progressive neurological deficits A vertebral fracture can usually be diagnosed by plain radiography AS: plain radiograph, ESR CT and MRI more sensitive for cancer and infections-also reveal herniation and stenosis CT myelogram adds contrast in the CSF and shows the spinal cord and nerves contour better

BACK PAIN MANAGEMENT Most patients with acute LBP recover quickly Overall prognosis for acute msk pain excellent Therapeutic interventions should focus on symptom mx and maintaining function Follow-up should occur within 4 weeks to determine response to therapy and whether additional treatment or evaluation is needed If no response to treatment, additional work up for spinal stenosis or radiculopathy should be considered if suggestive symptoms are present

STEP 1: PATIENT EDUCATION Patient need to be explained the natural disease process, likely improvement in few weeks, and risk of recurrence of symptoms Studies have confirmed that limiting the amount of bed rest and resuming normal activities as tolerated is associated with more rapid improvement of symptoms. Encourage to maintain daily activities; avoid bed rest

STEP 2: PHARMACOTHERAPY Acetaminophen or NSAIDs are first-line pharmacotherapy ; all NSAIDs are equally effective Opioid analgesics may be helpful when acetaminophen or NSAIDs are not adequate Medications should be given at the lowest possible dose and for the shortest possible time Muscle relaxants and benzodiazepines may be modestly beneficial for pain relief Systemic glucocorticoids have not been shown to be effective in the treatment of back pain For patients with spondyloarthritis, DMARDs may be considered. TNF- alpha blockers effective in treating both peripheral as well as spinal when NSAIDs not enough. NSAIDs remain the cornerstone of treatment for pain and stiffness. NSAIDs should be used with caution in patients at increased risk for nephrotoxicity or for GI ulcer. All nsaids are equally effective for treating back pain

Step 3 & 4: Physical Therapy/Spinal Manipulation, and other treatment Back pain interfering with home, work or recreational activities- refer to PT Other treatment: Complementary therapy: Acupuncture, Chiropractics Nerve stimulation: no improvement in mx of back pain Epidural corticosteroid injection: Provides short-term pain relief; no effect on long-term outcome FDA issued a warning in 2014: Glucocorticoid injections may result in serious adverse events; rare

When To Refer & Surgical indications Patients with progressive neurologic deficits and dysfunction, such as cauda equina syndrome, B & B dysfunction, or progressive LE sensory or motor loss, or intractable pain not controlled with conservative mx Surgery: For patients with radiculopathy, discectomy associated with improved outcomes at 6 to 12 weeks spinal stenosis: decompressive laminectomy shown to provide moderate benefit in first 1 to 2 years postop; effects diminish over time Cauda Equina: surgical decompression Most patients with low back pain do not require acute referral to a subspecialist, whether they are a neurologist, neurosurgeon, or orthopedic surgeon.

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