1. Low Back Pain Mohammad A. Saeed, M.D. M.S.
University of Washington, Seattle, Washington
Former Clinical Associate Professor
Electrodiagnosis & Musculoskeletal Associates of Puget Sound
Tacoma, Washington

2. Disclosures
None

3. Introduction
Back pain is a leading musculoskeletal complaint that contributes to impairment and disability
Second most common reason for primary care physician office visits
Clinical Course
50% resolve in 1-2 weeks
90% resolve in 6-12 weeks
85% recur in 1-2 years

4. Epidemiology Life time prevalence up to 75-85%
Annual incidence about 5%
#1 cause of disability for individuals < 45 year old
Accounts for 7% of primary care visits

5. Natural History & Health Care Utilization
90% resolve without any treatment in 6-12 weeks
Recurrence rate up to 80% ( f/u for > 1yr )
Only 5-9 % of cases last > 1 yr. but responsible for 80% of the total cost and disability days for all low back related claims
Rate of spinal surgery is 40% higher in the U.S. and
increased 55% between 1979 and 1990

6. Classification

7. Red Flags Gait ataxia/upper motor neuron signs – Myelopathy
Bowel/bladder/sexual dysfunction – Cauda Equina Syndrome
Night pain/weight loss – Tumor
Fevers/chills – Infection
Severe Pain
Progressive motor weakness

8. Cauda Equina Syndrome Injury to cauda equina
Usually from large central HNP
Also from lumbar stenosis, epidural tumors, hematomas, abscesses, and trauma
Clinical Features
Lumbar, buttock, perianal discomfort, BLE weakness
Bowel/bladder retention, frequency, or incontinence
Sexual dysfunction
Saddle anesthesia including back of legs, buttocks, soles of feet

9. Common back pain issues
Lumbar Sprain/Strain
Degenerative Disc Disease
Herniated Discs
Central Canal Stenosis – Lumbar Spinal Stenosis
Foraminal Stenosis – Lumbar Radiculopathy
Facet Arthropathy
Vertebral Compression Fractures

10. Discogenic Pain Internal disk disruption
Treated with analgesics, exercise, epidural steroid injections
Disk herniation(herniated disk, disk bulge, ruptured disk, prolapsed disk)
Treatment- Conservative is best Epidural steroid injections
Discectomy, fusions considered if unstable ( preferably MIS )

11. Facet Syndrome
Clinical Features – Back pain exacerbated by rotation and extension
Imaging – x-ray, CT, and MRI – not reliable indicator. Most accurate diagnostic tool is MBB.
Treatment – conservative care includes relative rest, pain medications, rehabilitation program (focusing on flexion based or neutral postures), manual medicine, and interventional procedures

12. Spinal Stenosis Neurogenic claudication
Bilateral leg pain initiated by walking (esp down hill) and prolong standing
Relieved by sitting
Treatment - conservative, pain control, ESI (controversial)
Surgery- if conservative measure failed.
Laminectomy is the most common form of decompression

13. Evaluation (History) Hx – 85% of diagnosis is in the history
Onset, Aggravating /Alleviating factors
Effect of cough/sneeze, previous episodes
Associated limb symptoms
Bowel/Bladder disturbances
Surgical and medical history ( diabetes mellitus )

14. Diagnostic Studies X-rays to evaluate for fractures and bony lesions
Oblique view to assess spondylolysis “scottie dogs”
Flex/ext views to assess stability (spondylolisthesis)

15. Diagnostic Studies MRI Very sensitive BUT low specificity
Many with no pain have positive findings
Bowden study – one third of 67 asymptomatic people found to have “ substantial abnormality ( bulges & protrusions most common)

16. EMG/NCS Evaluation for radiculopathy
Rule out peripheral nerve disorder
Good sensitivity
High specificity
Low cost

17. What is the most important tool to assess patients with LBP?
The history and physical exam remains the mainstays in evaluation of LBP, despite new expensive technology
Determination of flexion vs. extension based pain

18. Radicular “mimic-ers”
Sacroiliac pathology
Piriformis syndrome
ITB syndrome
Trochanteric bursitis
Peripheral nerve disorders

19. Now to make this more interesting….

20. Case 1
63 year old Orthopedic surgeon presented with low back pain with left foot drop x 1 year.
Work up included MRI and EMG.
Differential diagnosis?

21. Case 2
54 year old Physiatrist presented with acute right low back and right buttock pain with right lower extremity numbness and tingling. Symptoms initiated after a cricket match.
Work up included MRI and EMG.
Differential diagnosis?

22. Case 3
64 year old Psychiatrist presented with bilateral hip pain to the Orthopedic surgeon and then referred for further evaluation. He had a shuffling gait on exam.
Work-up included X-rays and EMG.
Differential diagnosis?

23. Case 4
70 year old PCP presented with low back pain with right lower extremity pain, numbness, and weakness.
Lumbar spine surgery at L2/3 and L3/4, with minimal improvement in symptoms.
Further work-up including EMG after surgery.
Differential diagnosis?
Follow up 8 months and about 1 year after onset of symptoms

24. Treatment Relative Rest
Medications: NSAIDs, oral steroids, muscle relaxants, etc.
Rehabilitation program with stretching focusing on flexibility and core strengthening exercises
Bracing
Home exercise program
Injections
Surgery

25. Low Back Pain Prevention
Exercises including core strengthening including stretching & planking

26. New Trends Mid level providers
MSK and interventional physiatrists screening

27. Key Points: The truth about low back pain
Degenerative discs and some of the anatomic sequelae of facet arthropathy and spurring are usual consequences of aging. They DO NOT always cause pain.
The natural history of LBP is to improve with or without treatment, but certain treatments can hasten the process and are worthwhile
There is little or no correlation between abnormalities as seen on imaging and the patients’ clinical symptoms and signs

28. Key Points: The truth about low back pain
It is important to discover serious problems presenting as LBP by identifying the red flags
Treatments consist of reassurance, NAIDs, and staying out of bed & active
Special injection techniques are occasionally indicated in patients with LBP and corresponding pain generators when accurately diagnosed
Treat the patient, not the imaging
Surgical indications are indicated in certain conditions

29. Thank You
Any Questions ??