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Published byNorah Shaw Modified over 9 years ago
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Low Back Pain
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What is low back pain? Pain in the low back
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Epidemiology 80% of the population will have at least one episode of LBP in their lifetime Annually $20 million in direct cost and $50 million when indirect cost is added 3% of workers’ comp case but account 30% of the cost and receive 75% of the payment
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Common causes of LBP? Nonspecific – ligamentous or articular structures, strain, myofascial disorders, psychosocial factors Arthritis Spondylolisthesis Disc herniation - >95% L4-5, L5-S1 Spinal stenosis Fracture Tumor
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History? Characterize the pain Diffuse, tight, gradual onset, worse after sitting or with cold, relieved with warmth, associated stiffness – myofascial disorder Brief, shooting, worse with coughing, standing or sitting, relieved when lying down, radiating down the leg – nerve root, sciatica Persistent, burning, tingling, worse when lying down at night – peripheral nerve or lumbosacral plexus Radiating to buttock, thighs, legs, worse with back extension, relieved with sitting – spinal stenosis Associated with horse saddle – cauda equina syndrome
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History – rule out “red flags” symptoms? Trauma Fever Weight loss Neurologic deficits – numbness, bowel/bladder incontinence History of IVDA, cancer, steroid use Last longer than one month Associated with abdominal pain
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Physical exam? Gait Muscle weakness – atrophy, pelvic tilt Knee flexion – guard against root traction ROM Palpation – tenderness, step off
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Physical exam Motor strength Heel – L5 Tiptoe – S1 Sensation – dermatomes L4 – big toe L5 – middorsum of foot S1 – lateral foot
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Physical exam Reflex Knee – L3, L4 Ankle – S1 Straight leg raise Crossed straight leg raise - > specificity than straight leg raise Rectal exam
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Inconsistent examinations Axial loading Whole body rotation at the hip Straight leg raise in sitting position
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Tests for patients without “red flags” symptoms? None 90% resolve spontaneously in 4 weeks
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Tests with “red flags” symptoms? CBC and ESR X-ray CT scan – fracture, fact joint
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Tests with “red flags” symptoms? MRI Infection, cancer, disc herniation Age >50, asymptomatic, disc bulging 75- 80% and 30% disc protrusion Bone scan – cancer EMG Nerve root involvement after multiple back surgeries Fastitious weakness
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Treatments – acute LBP? Activity versus bed rest Without radiculopathy, activity as tolerated With radiculopathy, may consider bed rest < 3 days
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Treatments – acute LBP? Medications Acute – around the clock rather than prn Analgesics: acetaminophen, NSAID, cox- 2 inhibitor, narcotics Muscle relaxants – short term Subacute/chronic: TCA, SSRI, phenytoin, tramadol, gabapentin
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Treatments – acute LBP Soft tissue injection – controversial Back exercise Limited benefit Not during acute attack
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Treatments – acute LBP Disc herniation Multiple conservative modalities - >90% resolved Discectomy Sciatica Conservative treatment initially for 1-3 months - 80% resolved spontaneously 73% recurred at least once
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Treatment – chronic LBP? Back exercise Antidepressants – mixed result, confounding depression Steroid injection in Epidural space – may help in some patients, conflicting reports Facets – limited data, one small study showed relief at 6 months but not month 1-3 Spinal stenosis – laminectomy Minimally invasive procedures Spinal fusion – multiple laminectomy, unstable
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Treatment – chronic LBP Lumbar disc replacement Behavior therapy Spinal manipulation – mildly effective in some patients but no better than other routine modalities TENS – no benefits
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