Back pain (causes and assessment) Bristol Orthopaedic Spine Service Core training SpR’s 2013

AIMS Identify red and yellow flags Outline natural history of acute and chronic LBP Explain degenerative LBP as a diagnosis of exclusion Refer to NICE guidelines and treatement

Definition Low back pain is pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without sciatica, and is defined as chronic when it persists for 12 weeks or more.

CSAG guidelines 1994 set the scene for the management of back and leg pain

The Symptom of Night Pain in a Back Pain Triage Clinic Harding et al Spine 2005 ‘The 1994 US Agency for Health Care Policy and Research guidelines suggest nighttime pain should be used as a red flag’ 213/482 patients had night pain and in 90 it was present every night ‘Although it is a significant and disruptive symptom for patients, these results challenge the specificity of the presence of night pain per se as a useful diagnostic indicator for serious spinal pathology in a back pain triage clinic’

Back Pain (Incidence) Life time prevalence 60-80% (Waddell 1987) Point prevalence 17-31% (Rossignol 1993) Period prevalence (2/52-3/12) 19-43%

Back Pain (Natural History) 90% settle in 6/52 and 97% in 1 year (Waddell 1987) 70% 3 or more episodes (Biering-Sorensen 1983) Recurrences tend to settle over the years Continuing problem 8% (Croft 1994) Chronic sickness 3-4% 16-44yrs 5-7% 45-64yrs

Most low back pain is effectively ‘treated’ in the primary care setting Medication Information and advice Avoid prolonged rest Encourage early return to activity and work

Back pain (aetiology) Symptom onset Risk factors Prognostic factors

Risk factors Age Occupation Driving Smoking Lack of exercise Social class Major scoliosis Genetics

Prognostic factors Job satisfaction Smoking Litigation Psycho-social disorders

Simple low back pain Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone 1998.

Evaluation (Illness behaviour): Simple low back pain Evaluation (Illness behaviour): Superficial tenderness Non-anatomical tenderness Axial loading Pain on simulated rotation Distracted SLR Regional sensory change Regional weakness Overreaction Waddell et al Spine 1980:5:117 Waddell et al Spine 1984:9:209 Waddell et al BMJ 1984:289:739

Low back pain: yellow flags Risk factors for chronicity: pre-existing psychological distress medico-legal claims other chronic pain low job satisfaction Bigos et al Spine 1991:16:1-6 Burton et al Spine 1995:20:722 Carragee et al Spine J 2005:5:24 Boos et al Spine 2000:25:24

Back pain and disc degeneration Degenerative changes at autopsy and on MRI increase with increasing age in both symptomatic and asymptomatic individuals (Bowden) Dysfunction, Instability, Stabilisation (Kirkaldy-Willis) Genetic studies suggest early severe degenerative change may be genetically determined, some suggest this may be the case in up to 80% of back pain (Videman)

The degenerative cascade

Disc “degeneration” grading schemes Pattern recognition only! 1 2 3 4 Kjaer 2004 Adams et al. 2002 Adams et al. 1986

Disc degeneration is often painful Cheung et al Disc degeneration is often painful Cheung et al. Spine 34(9) 934-40, 2009 Degenerative disc disease (DDD) is scored 0-3 and then summed over five lumbar discs

NICE guidelines Spine Imaging 2009

Evidence for Physiotherapy and exercise Manual therapy (osteopathy and chiropractic) Acupuncture In patients with symptoms for 6/52 to 12/12

No evidence for Injections Traction Corsets Ultrasound In patients with symptoms for 6/52 to 12/12

If symptoms still persist Combined Physical and Psychological programme (CPP) In patients with symptoms for 6/52 to 12/12

Then if symptoms still persist Refer for surgical assessment

NICE: Back Pain Guidelines 2009 Role of surgery: spinal fusion Back pain fusion V Unstructured physiotherapy 294 patients Greater decrease in pain and greater increase in function in fusion group @ 2 years “Excellent” 16% Fusion, 2% Physio Fritzell et al Spine 2001:26:2521

NICE: Back Pain Guidelines 2009 Role of surgery: spinal fusion Back pain fusion V Intensive physiotherapy 349 patients MRC Spine Stabilisation Trial Multi-centred No clear evidence emerged that spinal fusion surgery was any more beneficial than intensive rehabilitation Fairbank et al BMJ 2005:330:1233

Surgery for low back pain: fusion ? pain secondary to abnormal spinal movement ? remove pain generator/unload disc

Disc replacement for chronic low back pain 2 RCTs, 2 systemic reviews, 7 prospective cohort, 11 retrospective cohort, 8 case series Still unproven if ADR is superior to fusion Freeman Eur Spine J 2006:15(Suppl3):S439

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