Approach to the patient with Low Back Pain in Primary Care

Objectives Differentiate between concerning and non- concerning causes for acute low back pain Identify historical red flags Identify examination red flags Briefly review evidence-based treatment options for low back pain

Acute Low Back Pain Easy Visit??? Frustrating Visit???

Acute Low Back Pain Easy Usually not serious Limited management options Often quick exam Frustrating Difficult patients Limited management options Can feel unsatisfying

Differential Diagnosis: 30 seconds List differential diagnosis for Low back pain 30 seconds List differential diagnosis for “bad” causes of Low back pain

Differential Diagnosis of Low Back Pain Mechanical low back pain (97%) Lumbar strain or sprain (≥ 70%) Diffuse pain in lumbar muscles; some radiation to buttocks Degenerative disc or facet process (10%) Localized lumbar pain; similar findings to lumbar strain Herniated disc (4%) Leg pain often worse than back pain; pain radiating below knee Osteoporotic compression fracture (4%) Spine tenderness; often history of trauma Spinal stenosis (3%) Pain better when spine is flexed or when seated, aggravated by walking downhill more than uphill; symptoms often bilateral Spondylolisthesis (2%) Pain with activity, usually better with rest; usually detected with imaging; controversial as cause of significant pain

Differential Diagnosis of Low Back Pain Nonmechanical spinal conditions (1%) Neoplasia (0.7%) Spine tenderness; weight loss Inflammatory arthritis (0.3%) Morning stiffness, improves with exercise Infection (0.01%) Spine tenderness; constitutional symptoms

Differential Diagnosis of Low Back Pain Nonspinal/visceral disease (2%) Pelvic organs—prostatitis, pelvic inflammatory disease, Endometriosis-Lower abdominal symptoms common Renal organs—nephrolithiasis, pyelonephritis Usually involves abdominal symptoms; abnormal urinalysis Aortic aneurysm - Epigastric pain; pulsatile abdominal mass Gastrointestinal system—pancreatitis, cholecystitis, peptic ulcer Epigastric pain; nausea, vomiting Shingles – (zona) Unilateral, dermatomal pain; distinctive rash

Differential Take-Home 97% is mechanical 4% Herniated disc (95% L4-L5; L5-S1) 2% Non-back sources 1% Cancer and Infection 0.2% Cauda Equina

Our Job… In 15 minutes, differentiate benign from serious causes of low back pain

We Need a Strategic Timeline Good history – 3-5 minutes Focused Exam – 2-4 minutes Treatment options and patient education – 4-5 minutes

The Case Begins: 87 year old Mehmet bey presents to clinic for back pain Located mid to low back Started about 3-4 days ago

Outline List essential components of a LBP history, including Red flags Review Physical Examination for LBP Identify Red flags Review proper indications for lab and imaging Discuss acute management options

General Questions Onset Location Mechanism of Injury Radiation Positional change Numbness, tingling Weakness

Diagnoses & Red Flags* Cancer Age > 50 History of Cancer Weight loss Unrelenting night pain Failure to improve Infection IVDU Steroid use Fever Unrelenting night pain Failure to improve Fracture Age >50 Trauma Steroid use Osteoporosis Cauda Equina Syndrome Saddle anesthesia Bowel/bladder dysfunction Loss of sphincter control Major motor weakness

Diagnoses & Red Flags Cancer Age > 50 History of Cancer Weight loss Unrelenting night pain Failure to improve Infection IVDU Steroid use Fever Unrelenting night pain Failure to improve Fracture Age >50 Trauma Steroid use Osteoporosis Cauda Equina Syndrome Saddle anesthesia Bowel/bladder dysfunction Loss of sphincter control Major motor weakness

Our case Red flags Age 87 Hx/o Non-Hodgkin’s Remission for the past 4 years

Our Case No hx/o back problems No trauma No radiation No focal weakness No numbness or tingling No change in bowel or bladder function

Outline List essential components of a LBP history, including Red flags Review Physical Examination for LBP Identify Red flags Review proper indications for lab and imaging Discuss acute management options

Physical Exam* Rule-out most concerning things Concerning features Decreased strength Diminished reflexes Sensory loss Reassuring features Paraspinal muscle spasm Full strength No sensory deficits

Six-Point MSK Exam Inspection Palpation ROM Strength Neurovascular Special Tests

Inspection Ensure No obvious deformities No erythema Skin lesions (Zoster)

Palpation Soft Tissue 4 clinical zones Paraspinal muscles Gluteal muscles Sciatic area Anterior abdomen/abdominal wall Bones Primarily palpating spinous processes and facets

Neurologic Testing Sensation Strength Reflexes

Special Tests Tests to stretch spinal cord or sciatic nerve Tests to stress the sacroiliac joint

Straight Leg Raise The straight leg raise, also called Lasègue's sign, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk, often located at L5 (fifth lumbar spinal nerve).Lasèguelow back painherniated disk lumbar

Straight leg raise Looking for lumbar disk herniation Performed supine for best sensitivity Positive when radiating pain observed at degress of hip flexion Very high sensitivity, but low specificity Should also do the crossed-leg straight leg raise Positive when they have pain when you lift and adduct the opposite leg

FABER test: To assess for the sacroiliac joint or hip joint being the source of the patient's pain If pain is elicited on the ipsilateral side anteriorly, it is suggestive of a hip joint disorder on the same side. If pain is elicited on the contralateral side posteriorly around the sacroiliac joint, it is suggestive of pain mediated by dysfunction in that joint. Flexion A-Bduction External Rotation

Tests Lab Based on clinical picture Think Red Flags Imaging XR CT MRI

Imaging Guidelines Choice to do imaging based on: Historical red flags Trauma, chronic steroid use = XRay Suspect abscess, cauda equina = MRI Exam red flags New/severe sensory or strength loss = consider MRI

Outline List essential components of a LBP history, including Red flags Review Physical Examination for LBP Identify Red flags Review proper indications for lab and imaging Discuss acute management options

Back pain treatment NSAIDs (A) Improve pain vs. placebo in controlled trials No difference between them NNT for 50% pain relief is 2-3 Muscle relaxants (A) Most beneficial in the first week Shown effective in trials Work best when combined w/ NSAIDs

Treatment Pain relievers Both opioid and non-opioid Steroids No benefit shown w/ orals Short-term benefit shown for epidural Bed rest NO!!! Activity increases functional status and decreases time missed from work and pain

Treatment Exercise plan No benefit during the acute phase, but helpful afterwards for prevention in MSK back pain (although USPSTF is neither for nor against) Massage Mixed evidence, but not harmful Acupuncture Most good studies show no benefit, but overall results are mixed Ice/Heat (B) Equivalent in a Cochrane review

Clinical recommendation and Evidence rating In the absence of “red flag” findings or signs of cauda equina syndrome, four to six weeks of conservative care is appropriate for patients with acute low back pain. C Nonsteroidal anti-inflammatory drugs, acetaminophen, and skeletal muscle relaxants are effective first-line medications in the treatment of acute, nonspecific low back pain. A A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series.

Clinical recommendation and Evidence rating Bed rest for more than two or three days in patients with acute low back pain is ineffective and may be harmful. Patients should be instructed to remain active. A Education about activity, aggravating factors, natural history, and expected time course for improvement may speed recovery of patients with acute low back pain and prevent chronic back pain. C Specific back exercises for patients with acute low back pain are not helpful. A

Clinical recommendation and Evidence rating Heat therapy may be helpful in reducing pain and increasing function in patients with acute low back pain. B Spinal manipulative therapy for acute low back pain may offer some short-term benefits but probably is no more effective than usual medical care. B

Conclusions History is very important Don’t forget your red flags Look for focal findings on exam There is evidence to help with treatment Pt’s w/ low back pain or sciatica w/o red flag SYMPTOMS should try conservative management for about 6 wks prior to imaging or intervention

References Evaluation and Treatment of Acute Low Back Pain. AAFP. 75(8), Acute Lumbar Disk Pain. AAFP. 78(7), When to Consider Osteopathic Manipulation. JFP. 59(9), ACSM Primary Care Sports Medicine. Physical Exam of the Spine and Extremities. Hoppenfeld, S. et al.

Questions???