2. A Syndrome Approach to Low Back Pain
Hamilton Hall MD FRCSC
Professor, Department of Surgery, University of Toronto
Executive Director, Canadian Spine Society

3. Faculty/Presenter Disclosure
Faculty: Hamilton Hall
Relationships with commercial interests:
Consultant: Stryker Spine USA
Consultant: Medtronic
Consultant: rti Surgical
Medical Director, Pure Healthy Back
Medical Director, CBI Health Group

4. Disclosure of Financial Support
This program has received no financial support.
This program has received no in-kind support
Potential for conflict of interest:
Hamilton Hall receives compensation as Medical Director of CBIHG.

5. Mitigating Potential Bias
This program does not discuss or recommend surgical devices.
CBIHG acknowledges that the Pattern Approach to Low Back Pain was developed by Dr. Hall during his time with CBIHG and that its development included contributions for many CBIHG staff members over many years.

6. Our current approach isn’t working
The medical paradigm hasn’t solved the problem of low back pain.
Guideline: discordant indicators
23,918 primary care visits for back pain
Jan 1999 – Dec 2010
MRI increase use 7.2% to 11.3%
Mafi J et al. JAMA 2013

7. Our current approach isn’t working

8. Our current approach isn’t working
Guideline: discordant indicators
23,918 primary care visits for back pain
Jan 1999 – Dec 2010
MRI increase use 7.2% to 11.3%
NSAID/acetaminophen decrease use 36.9% to 24.5%
Narcotic increase use 19.3% to 29.1%
Specialist referrals increase 6.8% to 14.0%
Mafi J et al. JAMA 2013

9. Our current approach isn’t working
Specialist referrals increase 6.8% to 14.0%
Less than 30% of referrals to a spine surgeon are appropriate for spine surgery.
Wai E et al. Can J Surg 2009

10. Our current approach isn’t working
Back pain remains an enormous social burden.
More than 13 types of health care provider with over 30 treatment approaches.
Still the commonest cause of recurrent lost time from work.

11. Our current approach isn’t working
There is no correlation between degenerative changes on plain x-ray and back pain.
CT has a 30% false positive rate.
MRI has a 60-90% false positive rate.
Early MRI without indication has a strong iatrogenic effect in acute LBP… it provides no benefits, and worse outcomes are likely.
Webster BS et al. Spine 2013

12. Our current approach isn’t working
With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.
Everything else is labeled “non-specific” back pain.

13. Our current approach isn’t working
With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.
Everything else is labeled “non-specific” back pain. It is treated “non-specifically”,

14. Our current approach isn’t working
With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.
Everything else is labeled “non-specific” back pain. It is treated “non-specifically”, which doesn’t work.

15. Our current approach isn’t working
In most cases it doesn’t give the patient what the patient needs:
immediate pain relief
reassurance
a clear prognosis
a method of control

16. And our current approach is wrong
Most back pain is not the result of
tumour
infection
major trauma
or any medical problem
Most back pain begins spontaneously.
In a study of over 11,000 patients, 2/3rds of the subjects could not recall any cause for the pain.
Hall et al. Clin J Pain 1998

17. But we still memorize the Red Flags
Sphincter disturbance: bowel or bladder
History of cancer
Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent onset of structural deformity
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

18. So why don’t we look there first?
There is another way
Over 90% of back pain is caused by minor altered mechanics.
Most back pain is mechanical.
So why don’t we look there first?

19. It means there is a sore thing in the back.
There is another way
Over 90% of back pain is caused by minor altered mechanics.
Mechanical back pain is pain
related to movement
related to position
related to a physical structure
It means there is a sore thing in the back.

20. There is another way
We can all recognize there is a sore thing. We just can’t agree on which sore thing. And for all the non-invasive treatments locating the sore thing isn’t even necessary.

21. There is another way
“Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.”
Quebec Task Force 1987

22. Patterns of back pain
“Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.”

23. Syndromes of back pain
“Distinct syndromes of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” What is a syndrome?

24. A syndrome is a constellation of signs and symptoms that appear together in a consistent manner

25. A syndrome is a constellation of signs and symptoms that appear together in a consistent manner and respond to treatment in a predictable fashion.

26. A syndrome is a constellation of signs and symptoms that appear together in a consistent manner and respond to treatment in a predictable fashion What is the difference between a disease and a syndrome?

27. The only difference is that we know the etiology of a disease.
A disease has an etiology.
Does a syndrome have an etiology?
Do you think that constellation of signs and symptoms just appears in exactly the same way every time merely by chance?
Of course, a syndrome has an etiology.
We just don’t know what it is yet.

28. Syndrome recognition The key to syndrome recognition is the history.
and that begins with three questions.
Where is your pain the worst?

29. Where is your pain the worst?
Is it back or leg dominant?
Back dominant pain is referred pain from a physical structure.
Back dominant:
back
buttocks
coccyx
greater trochanters
groin

30. Where is your pain the worst?
Is it back or leg dominant?
Back dominant pain is referred pain from a physical structure.
Sites of referred pain can become locally tender.
Trochanteric bursitis
Piriformis syndrome

31. Where is your pain the worst?
Is it back or leg dominant?
Leg dominant pain is radicular pain from nerve root involvement.
Leg dominant:
Around or below the gluteal fold, to the:
thigh
calf
ankle
foot

32. Where is your pain the worst?
Is it back or leg dominant?
The patient will often report both.
But it must be one or the other.
“ If I could stop only one pain, which one do I stop?
“I have a back pill and a leg pill, which one do you want?”

33. Syndrome recognition The key to syndrome recognition is the history.
and that begins with three questions.
Where is your pain the worst?
Is your pain constant or intermittent?

34. Part A
Is there ever a time when you are in your best position, in your best time of your day and everything is going well when your pain stops even for a moment? I know it comes right back but is there ever a time, even a short time when the pain is gone?

35. Part B
When your pain stops does it stop completely? Is it all gone? Are you completely without your pain?

36. When the pain is constant consider:
Malignancy
Systemic conditions
Pain disorder
Constant mechanical pain

37. Does bending forward make your typical pain worse?
Syndrome recognition
The key to syndrome recognition is the history.
and that begins with three questions.
Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?

38. Does bending forward make your typical pain worse?
Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?
What are the aggravating movements/positions?

39. Has there been a change in your bowel or bladder function
Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?
Has there been a change in your bowel or bladder function
since the start of your pain?

40. Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?
Has there been a change in your bowel or bladder function
What can’t you do now that you could do before you were in pain and why?

41. What are the relieving movements/ positions?
Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?
Has there been a change in your bowel or bladder function
What can’t you do now that you could do before you were in pain and why?
What are the relieving movements/ positions?

42. Have you had this same pain before?
Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?
Has there been a change in your bowel or bladder function
What can’t you do now that you could do before you were in pain and why?
What are the relieving movements/ positions?
Have you had this same pain before?

43. What treatment have you had? Did it work?
Where is your pain the worst?
Is your pain constant or intermittent?
Does bending forward make your typical pain worse?
Has there been a change in your bowel or bladder function
What can’t you do now that you could do before you were in pain and why?
What are the relieving movements/ positions?
Have you had this same pain before?
What treatment have you had? Did it work?

44. History takes precedence over physical examination
History takes precedence over physical examination. But the physical examination must support the history.

45. Physical Examination Observation general activity and behaviour
back specific:
contour
colour
scars
palpation (if you must)

46. Physical Examination
Observation
Movement
flexion
extension

47. Physical Examination Nerve root irritation tests straight leg raising
Observation
Movement
Nerve root irritation tests
straight leg raising

48. A positive straight leg raise:
Passive test - the examiner lifts the leg
Reproduction/exacerbation of typical leg dominant pain
Back pain is not relevant
Produced at any degree of leg elevation
To reduce confusion with hamstring tightness, flex the opposite hip and knee.

49. Physical Examination Nerve root irritation tests straight leg raising
Observation
Movement
Nerve root irritation tests
straight leg raising
femoral stretch test-when history indicates

50. Physical Examination Nerve root conduction tests Observation Movement
Nerve root irritation tests
Nerve root conduction tests L4 L5 S1
knee reflex
great toe extension
hip abduction
ankle dorsiflexion (+ L4)
great toe flexion
hip extension-gluteus maximus power
ankle reflex
ankle plantar flexion

51. Physical Examination Upper motor test Observation Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
plantar response
clonus

52. Physical Examination Saddle sensation Observation Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
Saddle sensation
lower sacral nerve roots (2,3,4) test

53. Physical Examination High-Low tests Observation Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
Saddle sensation
High-Low tests

54. Physical Examination Sensory testing (if indicated) Observation
Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
Saddle sensation
Sensory testing (if indicated)

55. Physical Examination Ancillary testing (if indicated) Observation
Movement
Nerve root irritation tests
Nerve root conduction tests
Upper motor test
Saddle sensation
Sensory testing (if indicated)
Ancillary testing (if indicated)
hip, abdomen, peripheral pulses

56. Three questions – two tests to rule out the Red Flags
Where is your pain the worst?
Is your pain constant or intermittent?
Has there been a change in your bowel or bladder function?
Test upper motor function.
Test lower sacral sensation.

57. There are four mechanical patterns
Pattern 1 PEP
Pattern 1 PEN
Pattern 4 PEP
Pattern 4 PEN

58. Pattern 1
Probably discogenic

59. History Back dominant pain Worse with flexion Constant or Intermittent
Pattern 1

60. Physical Examination Back dominant pain Worse with flexion
Neurological examination is normal
or unrelated to the pattern
Pattern 1

61. The patient has a directional preference.
Physical Examination
Back dominant pain
Worse with flexion
Neurological examination is normal
Better with 5 prone passive extensions
Pattern 1 Prone Extension Positive
PEP
The patient has a directional preference.
Pattern 1

62. Physical Examination Back dominant pain Worse with flexion
Neurological examination is normal
No change/worse with 5 prone passive extensions
Pattern 1 Prone Extension Negative
PEN
The patient has no directional preference.
Pattern 1

63. Pattern 1
Pattern 1 PEP
Pattern 1 PEN

64. Pattern 2
Have no idea

65. History Back dominant pain Worse with extension
Never worse with flexion
Always intermittent
Pattern 2

66. History Back dominant pain Worse with extension
Never worse with flexion
Always intermittent
If the pain is constant or if there is any pain
on flexion the patient is Pattern 1
Pattern 2

67. Physical Examination Back dominant pain Worse with extension
Neurological examination is normal or unrelated to the pattern
No effect or better with flexion
Pattern 2

68. Pattern 1
Pattern 2
Pattern 1 PEP
Pattern 1 PEN

69. Certainly nerve root irritation
Pattern 3
Certainly nerve root irritation
“sciatica”

70. History Leg dominant pain Always constant
Affected by back movement/position
Pattern 3

71. Physical Examination Leg dominant pain
Leg pain affected by back movement
Positive irritative test
and/or conduction loss
Pattern 3

72. Pattern 1
Pattern 2
Pattern 3
Pattern 1 PEP
Pattern 1 PEN

73. Pattern 4
PEP

74. History Leg dominant pain Always intermittent Worse with flexion
Pattern 4 PEP

75. Leg dominant pain that responds to mechanical treatment.
Physical Examination
Rarely a positive irritative test and/or conduction loss
Always better with unloaded back extension movement or position
Leg dominant pain that responds to mechanical treatment.
Pattern 4 PEP

76. Neurogenic claudication
Pattern 4
PEN
Neurogenic claudication

77. History Leg dominant pain Always intermittent
Worse with activity in extension
Better with rest in flexion
May have transient weakness
Pattern 4 PEN

78. Physical Examination Negative irritative tests
Possible permanent conduction loss
Pattern 4 PEN

79. Constant /Intermittent
Back dominant
Leg dominant
Constant /Intermittent
Intermittent
Constant
Intermittent
Pattern 1
Pattern 4
Pattern 2
Pattern 3
Pattern 1 PEP
Pattern 1 PEN
Pattern 4 PEP
Pattern 4 PEN

80. That’s all there is
There are only four Mechanical Syndromes

81. That’s all there is Mechanical Syndromes Unequivocal history
Anticipated
treatment response
Concordant
physical examination

82. Start with the patterns
There will be a pattern in ninety percent of your patients.
If it responds as expected, you have your solution.
If there is no syndrome or it doesn’t respond as anticipated, that is the group that needs to be investigated.
That is the time to consider the Red Flags.

83. Red Flags Sphincter disturbance: bowel or bladder History of cancer
Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent onset of structural deformity
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

84. Red Flags - History of cancer Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent onset of structural deformity
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

85. Red Flags - History of cancer Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent onset of structural deformity
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

86. Red Flags - History of cancer Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

87. Red Flags - History of cancer Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

88. Red Flags - History of cancer Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent or on-going infection
Fever
Night sweats
Non-mechanical pattern of pain
Constant pain
Wide spread neurological signs or symptoms
Disproportionate night pain
Lack of treatment response
Thoracic dominant pain
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

89. Red Flags - History of cancer Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent or on-going infection
Fever
Night sweats
Constant pain
Lack of treatment response
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

90. Red Flags - History of cancer Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent or on-going infection
Fever
Night sweats
Constant pain
Lack of treatment response
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

91. Red Flags - History of cancer Unexplained weight loss
Immunosuppression
Intravenous drug use
Recent or on-going infection
Fever
Night sweats
Constant pain
Lack of treatment response
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

92. Red Flags - Immunosuppression Intravenous drug use
Lack of treatment response
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

93. Red Flags - Immunosuppression Intravenous drug use
Lack of treatment response
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

94. Red Flags - Immunosuppression Intravenous drug use
Under 20 and over 55
Noseworthy J.N.
Neurological Therapeutics

95. Red Flags - Immunosuppression Intravenous drug use Noseworthy J.N.
Neurological Therapeutics

96. Start with the Pattern. If it responds as anticipated you have your solution. Further investigation is unnecessary.