Low Back Pain Elizabeth Chang, MD PGY-2

46 yo male p/w LBP x 6 mo -Started 6 mo. ago while lifting boxes at his delivery job -Located middle of lower back, radiates to right buttock and right lateral aspect of right foot -Pain worsened with sneezing/coughing -Difficult to stand on tip toes -Absent right ankle jerk -Straight leg test, cannot elevate right leg above 35 degrees -No urinary/bowel incontinence, fevers, weight loss -Otherwise healthy

“Fun” Facts #2 reason patients show up in your office 84% of adults in US have LBP at some point Up to 85% no definitive cause found Costs the economy $100 BILLION per year Substantial impact on lifestyle and quality of life <5% have serious systemic pathology

Differential for LBP

Red Flags History of cancer Age > 50 Unexplained weight loss Symptoms of neurological compromise Pain lasting >3 mo. Nighttime pain Unresponsiveness to previous therapies History of AAA Risk factors for spinal infection (HIV, IVDA, etc)

Radiological/Anatomic Spondylosis: arthritis of the spine – disc space narrowing, arthritic changes in joint facet Spondylolisthesis: anterior displacement of a vertebra on the one beneath it. Graded I – IV Sponylolysis: fracture in the pars interarticularis that protects the nerve Spinal stenosis: narrowing of the central spinal canal (bony enlargement or thickened ligamentum flavum). Shopping cart sign.

Ankylosing Spondylitis Chronic inflammatory disease of axial skeleton Sacroiliac joint involvement, bamboo spine on imaging Males, 20-30s, HLA-B27 Dull vague stiffness, slowly progressive over years, worse at night, better with light activity Elevated ESR, CRP No cure, conservative management

Physical Lumbar lordosis – inward curve Kyphosis – outward curve Scoliosis – sideways curve (always abnormal)

Neurologic Sciatica – set of symptoms, not a dx – compression/irritation of one of the 5 spinal roots – affects posterior/lateral aspect of leg to the foot/ankle Radiculopathy – impairment of nerve root causing radiating pain, numbness/tingling, muscle weakness corresponding to specific nerve root. Most often herniated disc. Worsened with bending over.

Cauda Equina Syndrome Saddle anesthesia Recent onset bladder dysfunction Severe or progressive neurologic deficit in lower extremity Surgery

Classifications Acute: <4 weeks – Excellent prognosis, 90% full recovery Subacute: 4-12 weeks Chronic: >12 weeks

The Physical Exam 1

The Physical Exam 2 Reflexes – Achilles tests S1 nerve root – Patellar tests L4 – Upgoing toes may indicate upper motor neuron instead Straight Leg Test (for sciatic nerve irritation) – Pain below knee at <70 degrees worsened by ankle dorsiflexion  suggests L5/S1 tension from disc herniation Sitting Knee Extension Test – Should reproduce any findings from the SLT, helps clinician discover inconsistent findings

Non-pharmacological treatments Exercise/PT/OT – Proven modest benefits in subacute/chronic LBP – Yoga, pilates, tai chi Spinal manipulation – Serious adverse effects rare (<1/1,000,000) Acupuncture Massage TENS (transcutaneous electrical nerve stimulation) – large study showed no difference

1 st Line Pharmacotherapy NSAIDS – Ibuprofen mg QID or Naproxen mg BID or IM ketoralac 60 mg (ER) – Caution in elderly, nephrotoxic, GI Acetaminophen as alternative – Max 4g/day – Hepatotoxicity risk

Centrally-acting skeletal muscle relaxants Limit use to 3 weeks Anti-cholinergic side effects – Cyclobenzaprine – Methocarbamol – Carisoprodol Baclofen Benzos – less evidence supporting efficacy, high risk abuse

Opioids Norco, percocet, MS Contin Tramadol – non-opioid that acts on opioid receptors Sedation, confusion, nausea, constipation, respiratory depression in high doses Misuse and abuse (30-45%) – scheduled rather than prn Short-term only

Anti-depressants & Anti-epileptics Tricyclics (amitriptyline) – Drowsiness, dry mouth, dizziness Radiculopathic pain – Gabapentin, pregabalin, topiramate

Glucocorticoids Limited data on efficacy and safety Not recommended

The End