1. The evaluation and management of low back pain  Asgar Ali Kalla  Professor and Head  Division of Rheumatology  University of Cape Town

2. Some helpful statistics  Backpain affects two thirds of adults  Second to URTI in frequency  Affects men and woman equally  Most common between 30 and 50 years  Expensive cause of work related disability  Uncertainty about optimal approach

3. 90% of low back pain is mechanical  Musculoligamentous injuries  Age-related degeneration in the intervertebral discs and facet joints  Spinal stenosis  Disc herniation  Osteoporotic compression fractures  Spondylolysis and spondylolisthesis

5. Natural history  Spontaneous improvement is the rule  50% better at 1 week  > 90% better at 8 weeks  7-10% persist beyond 6 months

6. Medical causes  Uncommon but important not to miss them  Spondylarthropathy  Spinal infection  Osteoporosis  Malignancy  Referred visceral pain pelvis, renal, aortic aneurysm, pancreatitis pelvis, renal, aortic aneurysm, pancreatitis

7. Clinical evaluation  Precise anatomical diagnosis often elusive  Is a systemic disease causing the pain?  Is there neurological compromise that may require surgical evaluation?  Is there social or psychological distress that may amplify or prolong pain?

8. BACK PAIN serious neurology serious neurology serious medical serious medical systemic symptoms systemic symptoms conservative management conservative management

9. Management: Watchful waiting  Patient education  Spontaneous recovery is the rule  Those who remain active despite pain have less future chronic pain  Exercise has prevention power  Rest: 2 days or less  Analgesics to permit activity  Reassess if pain worsens or neurological symptoms develop

10. Why not get imaging studies?  Imaging can be misleading: many abnormalities as common in pain-free individuals as in those with back pain  If under age 60  low yield: unexpected Xray findings 1: 2500  bulging disc in 1 of 3  herniated disc in 1 of 5

11.  Over age 60 and pain-free  herniated disc in 1 of 3  bulging disc in 80%  all have age-related disc and apophyseal joint degeneration  spinal stenosis in 1 of 5 cases

12. BACK PAIN conservative management PERSISTENT PAIN DEVELOPING NEUROLOGY PERSISTENT PAIN DEVELOPING NEUROLOGY red flags imaging lab tests

13. Red flags for serious back pain  Fever, weight loss  Pain with recumbency, nocturnal pain  Morning stiffness  Persistent pain lasting > 6 weeks  Age over 50 with new onset pain  Abnormal neurology  Point tenderness

14. Further evaluation  Goal is to discriminate between “ benign” cases and disorders that require further diagnostic studies  Radiological imaging: Xray/ CT Scan/ MRI  Useful lab tests:  FBC, ESR  Calcium, ALP  protein electrophoresis

15. What should I be worried about?  Herniated disc  Spinal stenosis  Cauda equina syndrome  Inflammatory spondylarthropathy  Spinal infection  Vertebral fracture  Cancer  Referred visceral pain

16.  CT scan shows spinal stenosis due to hypertrophic changes in the facet joints  CT myelogram reveals canal occlusion with flexion due to spondylolisthesis Imaging Studies: Spinal Stenosis

17.  MRI image shows a protruding disk (arrow) that compresses the thecal sac (short arrow) Disk Herniation

18. Ankylosing Spondylitis: X-Ray Changes

19. Spinal infection — X-Rays

20. Multiple compression fractures Osteoporosis- X-Ray

21. RRed flags for spinal malignancy PPain worse at night OOften associated local tenderness CFBC, ESR, protein electrophoresis if ESR elevated Multiple Myeloma

22. When is surgical referral indicated?  Sciatica and probable herniated discs  Cauda equina syndrome  Progressive or severe neurological deficit  Persistent neuromotor deficit after 4-6 weeks conservative treatment  Persistent sciatica with consistent neurologic and clinical findings

23. When is surgical referral indicated?  Spinal Stenosis  Progressive or severe neurological deficit  Persistent back and leg pain improving with flexion and associated with spinal stenosis on imaging  Spondylolisthesis  Progressive or severe neurological deficit  Severe back pain/ sciatica with functional impairment that persists > 1 year

24. Key Points about low back pain  90% are due to mechanical causes and will resolve spontaneously within 6 weeks to 6 mths  Pursue diagnostic workup if any red flags found during initial evaluation  If ESR elevated, evaluate for malignancy or infection  In older patients initial Xray useful to diagnose compression fracture or tumuor

25. Key Points about low back pain  Bed rest is not recommended for low back pain or sciatica, with a rapid return to normal activities usually the best course  Back exercises are not useful for the acute phase but help to prevent recurrences and treat chronic pain  Surgery is appropriate for a small portion of patients with low back pain

26. Further reading  Deyo RA, Weinstein JN. Low back pain. NEJM 2001;344:363-370  Malmivaara A, Hakkinen U, et al. The treatment of acute low back pain. NEJM 1995;332:351-355  Borenstein DG. Low back pain. In:Klippel J, Dieppe P, editors. Rheumatology. London : Mosby; 1994. p.5.4.1-5.4.26