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

2. 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

3. 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.

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

6. 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’

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

8. 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

9. 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

10. Back pain (aetiology)
Symptom onset
Risk
factors
Prognostic
factors

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

12. Prognostic factors Job satisfaction Smoking Litigation
Psycho-social disorders

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

14. 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

15. 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

16. 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)

17. The degenerative cascade

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

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

20. NICE guidelines
Spine Imaging 2009

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

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

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

24. Then if symptoms still persist
Refer for surgical assessment

25. 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 2 years
“Excellent” 16% Fusion, 2% Physio
Fritzell et al Spine 2001:26:2521

26. 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

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

28. 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

29. Thank you