1. Jacobi Ambulatory Care Service Low Back Pain Intern Ambulatory Block Susan Dresdner, M.D.

2. Jacobi Ambulatory Care Service Low Back Pain Lifetime prevalence of 80% 5 th most common cause for MD visits Increasing costs without improved outcomes

3. Jacobi Ambulatory Care Service Most due to nonspecific musculoskeletal strain, resolve within few days to weeks Up to 1/3 have persistent pain of at least moderate intensity 1 yr after acute episode 1/5 have substantial limitations in activity

4. Jacobi Ambulatory Care Service What’s associated with development of back pain? Obesity Physical inactivity Occupational factors Depression/ other psychological conditions No evidence available that maintaining nl body wt and fitness, and avoidance of activities that can injure back, will decrease risk.

5. Jacobi Ambulatory Care Service Obesity

6. Jacobi Ambulatory Care Service Environmental Factors

7. Jacobi Ambulatory Care Service Work Related Pain

8. Jacobi Ambulatory Care Service Are Preventive Measures Effective at Work? Studies include educational interventions and mechanical supports No large benefits shown in primary or secondary prevention Large RCT of educational program for mail carriers who did or did not have previous LBP did not show any benefits Trial in workers with physically demanding jobs did not show benefits Education and lumbar suppports showed no reduction in LBP Evidence is also lacking for external back support (ie. belt or brace)

9. Jacobi Ambulatory Care Service Bottom Line: Regular exercise and maintenance of fitness MAY be helpful, but evidence is insufficient to support use of any specific preventive interventions

10. Jacobi Ambulatory Care Service History and PE Hx and PE should place patient in 1 of 3 categories: nonspecific LBP back pain potentially assoc with radiculopathy or spinal stenosis back pain potentially assoc with another systemic or spinal cause

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12. Jacobi Ambulatory Care Service History Inciting event/ trauma? Duration Hx systemic disease (rheumatologic, cancer, immunocompromise) Systemic symptoms (fever, wt loss) Location of pain, radiation Infectious source Hx osteoporosis or steroid use Bowel or bladder retention (or overflow incontinence), LE weakness Social hx

13. Jacobi Ambulatory Care Service Physical exam Observe Posture Gait Muscle atrophy Palpate Point tenderness over muscle/ bone/ muscle insertions Range of motion Reflexes, sensory exam Strength (great toe, ankle, quadriceps) Straight leg raise Don’t forget possibility of abdominal source/ hip

14. Jacobi Ambulatory Care Service Neurologic Exam: Nerve Roots L3-L4 –Sensory – medial foot –Motor - knee extension (squat and rise) –Reflex - patellar L4-L5 –Sensory – dorsal foot –Motor – dorsiflexion ankle and great toe (heel walk) L5-S1 –Sensory – lateral foot –Motor – plantarflexion (toe walk) –Reflex - Achilles

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16. Jacobi Ambulatory Care Service Mechanical 97% –Lumbar strain or sprain >70% –Degenerative disk disease/ facet arthropathy 10% –Herniated disk 4% –Osteoporotic compression fracture 4% –Spinal stenosis 3% –Spondylolisthesis 2%

17. Jacobi Ambulatory Care Service Nonmechanical Spinal Conditions 1% Neoplasm 0.7% Inflammatory arthritis 0.3% Infection 0.01%

18. Jacobi Ambulatory Care Service Red Flags Hx of trauma Systemic signs of infection Neurological signs Unexplained weight loss Hx of cancer Hx of immunosuppressants or chronic steroids Hx of IVDU

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22. Jacobi Ambulatory Care Service Imaging Radiographic exams are usually of limited use unless hx or PE suggest underlying cause Xray findings correlate poorly Spinal imaging studies in asymptomatic people commonly reveal bulging or herniated disks, spinal stenosis, annular tears and disk degeneration which may not be clinically relevant and reduce specificity of imaging tests

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24. Jacobi Ambulatory Care Service Imaging: American College of Radiology Appropriateness Criteria Choose test with the highest numeric rating Clinical Scenario Uncomplicated LBP Low-Velocity Trauma, Osteoporosis, or age >70 Suspicion of cancer or immunosup- pression RadiculopathyPast Lumbar surgery Cauda Equina Syndrome X-ray 265353 CT without contrast 264564* (with and without contrast) MRI without contrast 288869 MRI with and without contrast 237588 Nuclear bone scan, targeted 245252 X-ray myelography 212222 CT myelography 212556

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26. Jacobi Ambulatory Care Service Non-Pharmacologic Therapy