Low Back Pain: Case Based Evaluation and Management Patrick Kortebein, M.D. Departments of PM&R and Geriatrics University of Arkansas for Medical Sciences 5/31/09 Slides: www.uams.edu/pmr

Objectives Understand the evaluation and management of common sources of low back and related pain Understand the significance of abnormal findings on lumbar spine MRI in individuals with low back and related pain. Understand the evaluation and management of chronic low back pain.

Low Back Pain Common; 2nd primary care visits Acute episodes 5-15% per year 60-80% lifetime Acute episodes 75-90% recover w/in 3 months 25-75% will have recurrence w/in 6 months

LBP: Anatomy Bone / Vertebrae Disc Muscles / Ligaments Annulus Nucleus Pulposus Muscles / Ligaments Spinal Nerve Roots

LBP Facet joint Zygopophyseal joint Synovial

LBP Sacroiliac Joint Tight, Synovial Ligaments “SI Dysfunction”

Case #1 28 yo M presents with CC: LBP Started 4 days ago while bending over to pick up his 14 mo old child PMHX: L knee arthroscopy Meds: Acetaminophen NKDA Social Hx: Married, insurance salesman What other information is important?

Acute LBP: History Location Onset: Traumatic, Insidious Duration: Axial or Radiating (Sciatica) ? Onset: Traumatic, Insidious Duration: Acute: < 12 weeks Chronic: > 12 weeks Character/Quality: Ache, Burning, etc Exacerbating / Alleviating Factors

Acute LBP: History “Red Flags” (AHCPR 1994) Fracture: Cauda Equina Major/minor trauma Age > 70 yrs (~50 yrs) Chronic corticosteroids Cauda Equina B/B dysfunction Saddle Anesthesia LE weakness

Acute LBP: History “Red Flags” (AHCPR 1994) Infection Cancer Fever Steroids / Immunosuppression / IV Drug Use UTI / Systemic Infection Cancer Hx of Cancer Unintentional Weight Loss Supine/Night Pain Age > 50

“Red Flag” Evaluation

Acute LBP: Physical Exam Lumbar Spine: Inspection Palpation ROM: Flexion / Extension +/- LE Neurologic Exam

Acute LBP: Imaging When? What imaging?

Acute LBP: Imaging When? What? Minimum 6 weeks + “Red Flags” X-ray 3-view: AP / Lat / L5 Spot Obliques: Limited information Radiation exposure

Acute LBP: Imaging Lumbar MRI

Acute LBP: Imaging Abnormal findings “Degenerative disc disease” “Bulging disc” “Herniated disc”

LBP: Imaging MRI Abnormalities in Normals / No LBP Boden et al (N=67) JBJS 1990 HNP: 21-36% Bulging Disc: 50-80% Degenerative Disc Changes: 34-93% Jensen et al (N= 98) NEJM 1994 Bulging Disc: 52% (28-100%) Disc Protrusion: 27% (21-30%)

Case #1 History Onset: 4 days ago, constant Location: R lumbosacral junction No radiation / neurological symptoms No clear exacerbating / alleviating factors Physical Exam Mild tenderness R low lumbar region Increased pain with flexion Normal LExt neuro exam

Case # 1 Diagnosis ? Management ?

LBP: Differential Diagnosis Deyo NEJM 2001

Case # 1 Diagnosis: “Mechanical” LBP Education / Activity Modification Bedrest: ~ 2 days (Deyo NEJM 1986) Analgesics: Acetaminophen NSAID’s Tramadol Muscle Relaxants Cyclobenzaprine

“Mechanical” LBP Physical Therapy Chiropractic Acupuncture Exercise Modalities Lumbar Support Chiropractic Acupuncture Back Heat

LBP: Zygapophyseal (Facet) joint History/Examination Axial LBP +/- post thigh No neuro sxs Worse w/ static posture Lumbar Extension Stand / Walk Neuro exam normal

LBP: Zygapophyseal (Facet) joint Management Analgesics Tylenol, NSAID Physical Therapy Injections Diagnostic Therapeutic

LBP: Sacroiliac (SI) Joint History Atraumatic > Traumatic Axial; Lumbosacral Uni- > Bilateral No radiation / neuro sxs Physical Exam ~ Normal Tender SI region

LBP- SI Joint Diagnosis / Treatment Physical Therapy Injection

LBP: Discogenic History / Exam Axial LBP No radiation / neuro sxs Aggravating: Static posture- Sitting or Sit to stand Normal neurological exam

LBP: Discogenic Management Physical Therapy Surgery: Core Strength Fusion Artificial Disc Not yet

Case # 2 38 yo with left LE radicular pain > LBP for ~6 weeks. Also left foot tingling and weakness. PMHx: HTN, Hyperlipidemia Meds: HCTZ, Atorvastatin Allergies: Sulfa Social Hx: Divorced, Landscaper

Case # 2 Physical Exam L-spine: Non-tender Left LExt: + SLR / Crossed SLR Neuro Motor: 5/5 except Plantar Flexion Reflex: KJ +2/+2, AJ +2 / 0 Sensory: Dec to LT lateral heel

Case # 2 Diagnosis ?

LBP: Radiculopathy Diagnosis Physical Exam MRI EMG CT Myelogram * Correlate anatomy w/ sxs and exam

LBP: Radiculopathy Neurological Exam: Motor Reflex Sensory L2/3: Hip Flex/Add Knee Med Thigh /Knee L4: Knee Ext/DFlex Knee Med Ankle L5: Great toe/EHL Int. HS Dorsum Foot S1: Plantarflex Ankle Lat Heel Functional: Squat, Heel / Toe Walk, Heel Raise

LBP: Evaluation SLR / Dural Tension

Case # 2 MRI: Left L5-S1 disc herniation impinging on S1 nerve root Management?

LBP: Radiculopathy Management Medications Steroids; NSAID’s Acetaminophen Tramadol Neuropathic Steroids; Oral (? dose) vs epidural

LBP: Radiculopathy Management Physical Therapy McKenzie Extension therapy TENS ~ No benefit

LBP: Radiculopathy Injections Epidural Selective

LBP: Radiculopathy Surgery Indications SPORT trial Cauda equina Progressive neuro deficits No relief w/ conservative treatment SPORT trial JAMA 2006

LBP: Spinal Stenosis History (Neurogenic claudication) Physical Exam Prox LE Pain +/- Neuro sxs Walk / Stand Uphill > Downhill Grocery Cart Physical Exam ~ Normal Stand / Walk

LBP: Spinal Stenosis Diagnosis Management MRI EMG Medications PT Neuropathic PT Epidural Injection Surgery: (SPORT trial)

Case # 3 51 yo M truck driver injured at work 2 years ago lifting a 30# box, and applying for disability Continued axial LBP and “numb” R LE No “Red Flags” Treatments to date: Medications: NSAIDs, Tramadol, Hydrocodone Physical Therapy: 24 sessions Work restrictions; not working Injections: Epidural / Facet / Sacroiliac

Case # 3 Physical Examination Lower Extremity Neurologic Lumbar: Diffuse tenderness to light palpation Exaggerated pain behavior w/ trunk rotation Lower Extremity Neurologic 50% decreased sensation entire LExt Normal strength / reflexes Supine SLR: LBP; Seated SLR: No pain

Case # 3 Lumbar MRI: Diagnosis? Treatment? Mild DD changes with diffuse disc bulge at L4-5 and L5-S1 Diagnosis? Treatment?

Chronic LBP Duration Poor Correlation > 12 weeks Symptoms Objectives Finding

Chronic LBP Strong Association Depression Anxiety Poor Coping Skills “My back hurts, but I’m here because I can’t cope with this episode, as well as the turmoil at home (or work)”- N Hadler “Last Well Person”

Chronic LBP

Chronic LBP **Goal** Improve Function Minimize focus on treating pain itself Biopsychosocial Model of Pain Maladaptive Behavior Neuroplasticity

Chronic LBP

Case # 3 Multidisciplinary Pain Management Education Medications PT Chronic Opioids ? PT Functional Restoration Psychology Pain Management

Recommended Reading Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician 2007; 75:1181-8, 1190-2. Deyo et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22:62-8. LBP Handbook 2003 Cole & Herring

LBP

Questions ?

Other

LBP: Evaluation Waddell’s Signs (Non-organic PE) Tenderness Overreaction Regional Distraction Simulation > 3/5 * Behavioral Component of Pain Spine 1980