Review evaluation and differential diagnosis of low back pain Discuss when to obtain imaging Discuss...

Review evaluation and differential diagnosis of low back pain

Discuss when to obtain imagingDiscuss selected etiologies/radiography of

back painDiscuss treatment modalitiesHave trivial Pennsylvania fun

Image Challenge

What is the diagnosis?

1. Atlanto-occipital dislocation2. Atlanto-axial subluxation3. Pillar fracture4. Spinous process avulsion5. Wedge fracture

Q:

Answer:

Image Challenge

What is the diagnosis? Q:

1. Atlanto-occipital dislocation

This computed tomogram of the cervical spine shows major atlanto-occipital dislocation in the lateral view that proved to be fatal.

Treatment for low back pain dated to Hippocrates (460-370 BCE), who reported joint manipulation and use of traction

Second most common office visit2/3 of all adults will suffer from85% idiopathic “strain/sprain”Most common pain syndromeRisk factors: heavy lifting, twisting, bodily

vibration, obesity, and poor conditioningDeyo R and Weinstein J. N Engl J Med

2001;344:363-370Firestein: Kelley's Textbook of

Rheumatology,8th ed. WB Saunders 2008

Deyo R and Weinstein J. N Engl J Med 2001;344:363-370

Differential Diagnosis of Low Back Pain

Mechanical Low Back Pain 97%:HNP: 4%Spinal Stenosis 3%

Cancer: 0.7%Infection: 0.1%Inflammatory Arthritis: 0.3%

Strain and sprain have never been anatomically or histologically characterized, should be referred to as “idiopathic low back pain”

Deyo R and Weinstein J. N Engl J Med 2001;344:363-370

Common Pathoanatomical Conditions of the Lumbar Spine

Observed walkHeel and toe walkingSkin exam…focused-zoster-café au lait spots-hair tuft “faun’s beard”-scoliosis

Palpate all of the spinous processes of the thoracolumbar spine

Neurologic, muscle strength and reflex testing

Straight leg testingBowstring signDistracted straight leg test, positive with

Tripod sign or Flip signFemoral Stretch TestAnal Wink

Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier

2006.

Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier

2006.

With onset of pain posterior tibial nerve is stretched like a bowstring across the popliteal fossa

Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier

2006.

Pain in the anterior thigh or L2/3 region indicates a positive test (tests for HNP compressing nerve roots L2/3/4)

Gaenslen testPatrick testSI distractionSI compressionSpondylitis measuring

Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier

2006.

Normal Finger to Floor: 0-5 cm

Normal Finger to Fibula: 0-5 cm

Normal Modified Schobers 15 increases to 20 cm

Normal Occiput to Wall: 0-2 cm

Is there a serious underlying illness?Does the back pain have a neurogenic

claudication or sciatic-type syndrome?

Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders

2008

Limited to patients with systemic disease or trauma

Guidelines recommend plain radiography for patients:

-with fever-unexplained weight loss-history of cancer-neurologic deficits-alcohol or injection-drug abuse-age of more than 50 years-trauma Bigos S, Bowyer O, Braen G, et al.

Rockville, Md.: Agency for Health Care Policy and Research, December 1994.

(AHCPR publication no. 95-0642.)

Recent significant trauma Milder trauma age >50 Unexplained weight loss Unexplained fever Immunosuppression History of cancer Intravenous (IV) drug use OsteoporosisProlonged use of corticosteroids Age >70 Focal neurologic deficit progressive or disabling

symptomsDuration greater than 6 weeksLow back pain. American College of

Radiology. ACR Appropriateness Criteria. Copyright ©2005 American College of

Radiology

There is no evidence that plain xrays in patients with nonspecific low back pain are associated with improvement in patient outcomes over selective imaging

RCT 421 patients with lumbago x 6 weeksExclusion criteria:-if they had xrays of spine within 1 year-unexplained weight loss or fever, were taking oral

steroids, had a history of malignancy, tuberculosis, injecting drug use, or a positive result on a HIV test

-symptoms or signs of a cauda equina lesion-were pregnant or planning a pregnancy

Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. BMJ. 2001;322:400-

5.

Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. BMJ. 2001;322:400-

5

Researchers evaluated patients with baseline MRI

Repeated MRI when developed low back painLess than 5% developed new pathologic

lesion

Deyo R and Weinstein J. N Engl J Med 2001;344:363-370

Representative Results of Magnetic Resonance Imaging Studies in Asymptomatic Adults

Degenerative Disc DiseasePaget’sDISHOchronosisRenal OsteodystrophySickle CellScheuermann KyphosisInfectious, brieflyIdiopathic hemispherica sclerosis?

Rajeev K Patel, MD. Lumbar Degenerative Disk Disease: Differential

Diagnoses & Workup. emedicine.com, updated 03 Aug 2009

Signs of degeneration include loss of disk height, sclerosis of the endplates, or osteophytic ridging

Intervertebral Osteochondrosis (dehydration and dessication of the nucleus

pulposis) leads to the vaccuum phenomenom, nitrogen gas formation, bone

sclerosis and disc space loss. This cavity then becomes surrounded by a rim of

sclerosis (Schmorl’s node)

Copyright © 2006 by the American Roentgen Ray Society

Schellinger, D. et al. Am. J. Roentgenol. 2004;183:1761-1765

MR images of lumbar spine with degenerative changes at L1

Results from disturbance in bone modelling and remodelling due to increase in osteoblastic and osteoclastic activity

Spine is the second most common site of bone involvement (Pelvis #1)

Lumbar spine (L4 and L5 levels) are the most frequently involved sites (58%)

Thoracic (45%) Cervical vertebrae (14%) Why does Paget’s hurt? -Periosteal stretching -Vascular engorgement -Microfractures -Facet arthritis -Intervertebral disc disease-Overt fractures -Spondylolysis/-listhesis -Sarcoma—very rareLangston A, Ralston SH .Rheumatology

(Oxford). 2004 Aug;43(8):955-9. Epub 2004 Jun 8. C. Dell’Atti, V. N. et al Skeletal

Radiol. 2007 July; 36(7): 609–626.

C. Dell’Atti, V. N. et al Skeletal Radiol. 2007 July; 36(7): 609–626.

Axial CT sections in different patients showing the various mechanisms and their effect on marrow size (long white arrow) and cortical thickness (short white arrow). a Periosteal apposition, normal endosteum. b Periosteal apposition, endosteal resorption. c Periosteal and endosteal apposition. d Pumice stone type (dashed arrow) of focal periosteal apposition. Similar focal periosteal apposition of the spinous process is seen

C. Dell’Atti, V. N. et al Skeletal Radiol. 2007 July; 36(7): 609–626.

a Lateral and b antero-posterior radiographs demonstrate expansion of the vertebra with characteristic sclerotic lines parallel to the end-plates due to trabecular hypertrophy, an “early” sign of PD. c Lateral radiograph in a different patient demonstrates the “picture frame” vertebra due to thickening of the cortex and trabecular hypertrophy at the end-plates

Graham T S Radiology 2005;235:614-615Langston A, Ralston SH .Rheumatology

(Oxford). 2004 Aug;43(8):955-9. Epub 2004 Jun 8. C. Dell’Atti, V. N. et al Skeletal

Radiol. 2007 July; 36(7): 609–626.

Differential diagnoses of “ivory vertebra” include, Paget’s, metastasis, osteosarcoma, carcinoid and Hodgkin’s lymphoma . This is a case of metastatic prostate CA

Most patients present with stiff back or non-specific back pain

Dysphagia, stridor, chronic pneumonia, and vascular compression are all complications from advanced disease

Khozaim Nakhoda Diffuse Idiopathic Skeletal Hyperostosis. emedicine .com

Clinical Criteria:- Flowing calcifications/ossifications along

anterolateral aspect of 4 contiguous vertebral bodies, with or without osteophytes

-Preservation of disk height in involved areas and abscence of excessive disk disease

-Absence of bony ankylosis of facet joints and absence of sacroiliac erosion, sclerosis, or bony fusion (narrowing and sclerosis of facet joints ok)

Khozaim Nakhoda Diffuse Idiopathic Skeletal Hyperostosis. emedicine .com

Paraspinal ligaments undergo attrition, degenerate then ossify

Three clinical variants of spinal enthesopathy1.Forestier’s disease involves the anterior

longitudinal ligament2.DISH involves extra-axial sites3.Ossification of the posterior longitudinal

ligament

Khozaim Nakhoda Diffuse Idiopathic Skeletal Hyperostosis. emedicine .com

Etiology is unknown however there are some associations:

-Hyperglcyemia and Diabetes- Dyslipidemia-Hyperuricemia -Vitamin A derivatives used to treat acne-Chronic fluoride intoxication

Vezyroglou G, Mitropoulos A, Antoniadis C. A . J Rheumatol. Apr 1996;23(4):672-6.

DiGiovanna JJ SO J Am Acad Dermatol 2001 Nov;45(5):S176-82.

Utsinger PD; Resnick D; Shapiro R . Arch Intern Med 1976 Jul;136(7):763-8.  

Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders

2008

Syndesmophytes arise from anterosuperior and anteroinferior margins of the vertebral body

Syndesmophytes may be best seen in the frontal projection

The presence of sacroiliac joint erosions and extensive intra-articular bony ankylosis of the sacroiliac and apophyseal joints in ankylosing spondylitis

The ossification in DISH attaches to the vertebral body several millimeters from these margins

Changes are most prominent on the lateral radiographic projection

None

DISH

Diffuse idiopathic skeletal hyperostosis. There is bone formation along the anterior aspects of more than four vertebral bodies. The disk spaces are maintained, and the sacroiliac joints were normal.

Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders

2008

Absence of homogentisic acid oxidase Consequent accumulation of

homogentisic acidAutosomal recessive inheritance

discovered by Garod in 1902

Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders

2008Garrod, AE. The incidence of alkaptonuria:

a study in chemical individuality. Lancet 1902; 2:1616.

Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders

2008

Dystrophic (hydroxyapatite crystal) calcification involving disks but calcification also seen in cartilage, tendons, and ligaments. The most specific is in spine, which appears osteoporotic with dense disk calcification. Other joints involved show changes of mild degenerative joint disease, but this is a much less specific .

University of Washington Department of Radiology website. Musculoskeletal

Radiology

Sclerosis is noted adjacent to the endplates (rugger-jersey spine) in a patient with renal osteodystrophy -- of osteoid in these areas.DDX osteomalacia and hyperparathyroidism.

BONUS: What type of fish is pictured to the right of the screen?

Scheuermann kyphosis is defined as anterior wedging of ≥5º in at least three adjacent vertebral bodies, as measured on lateral spine radiographs

Most common cause of structural kyphosis in adolescence. The mode of inheritance is likely autosomal dominantEtiology remains largely unknown Indications for treatment remain controversial because

the true natural history of the disease has not been clearly defined

Brace treatment appears to be very effective if the diagnosis is made early

Surgical treatment is rarely indicated for severe kyphosis (>75 degrees ) with curve progression, refractory pain, or neurologic deficit 

Lowe TG Orthop Clin North Am 1999 Jul;30(3):475-87, ix

This lateral radiograph of the thoracic spine demonstrates moderate endplate

irregularity, preserved vertebral disc spaces, and mild anterior wedging of the

vertebral bodies, all of which are consistent with Scheuermann kyphosis.

Courtesy of Jeanne Chow, MD, and Children's Hospital Boston.

DiscitisEpidural AbscessOsteomyelitis

To differentiate from vaccuum phenomenom look for gas, extension,

osteophytes that occur in the upper outer annular attachmentgrowing horizontal then

vertical (traction vs claw)

Occurs in young womenVertebral level L4Appears as gas in an intervertebral bodyPneumocyst vs AVN

NSAID’sTylenolNarcoticsTricyclic AntidepressantsMuscle RelaxantsPhysical TherapyNon-Surgical Intervention therapySurgery

In a study of primary care patients80% of patients prescribed at least 1

medication Greater than 1/3 were prescribed 2 or more

drugs

Cherkin DC, Wheeler KJ, Barlow W, Deyo RA. Spine. 1998;23:607-14.

5 acetaminophen trials57 NSAID trials10 trials of duloxetine and venlafaxine8 trials of benzodiazepines2 trials gabapentin2 trials topiramate36 trials of muscle relaxants9 opiod trials3 trials of tramadol4 trials of systemic corticosteroids...so what is the bottom line Dave?

Good evidence of short-term effectiveness for acute low back pain are:

- NSAIDs -acetaminophen-skeletal muscle relaxant*tricyclic antidepressants for chronic low back

painEvidence that opioids, tramadol,

benzodiazepines, and gabapentin are effective for pain relief of radiculopathy.

Good evidence that systemic corticosteroids are ineffective.Chou, Roger MD; Huffman, Laurie Hoyt MS

Annals of Internal MedicineIssue: Volume 147(7), 2 October 2007, pp

505-514

Tylenol first lineNSAID’s for more severe painOpioids in select patients with more severe

painMy treatment regimen-NSAID and muscle relaxant for mild to

moderate pain followed by manipulation-Narcotic plus benzodiazepine followed by

manipulation for severe pain

Chou, Roger MD; Huffman, Laurie Hoyt MS Annals of Internal Medicine

Issue: Volume 147(7), 2 October 2007, pp 505-514

Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain,

-Spinal manipulation; for chronic or subacute low back pain-Intensive interdisciplinary rehabilitation-Exercise therapy-Acupuncture-Massage therapy-Spinal manipulation-Yoga-Cognitive-behavioral therapy-Progressive relaxation ***(weak recommendation, moderate-quality evidence).

Chou, roger et al. Diagnosis. Ann Intern Med October 2, 2007 vol. 147 no. 7

478-491

One RCT39 patientsResults:-The individuals in the specific-exercise-training

group reported a significant decrease in LBP and disability

-Maintained over a 12-month follow-up period-Treatment with a modified Pilates-based

approach was more efficacious than usual care in a population with chronic, unresolved LBP

Rydeard R Leger A, Smith DJ Orthop Sports Phys Ther. 2006

Jul;36(7):472-84

For low back pain with radiculopathy, 10 of 17 trials found no difference in pain or function between epidural glucocorticoid and placebo injection

Similar findings for facet and nerve branch blocksDiscography or injection of the disc at the level of

pain remains unprovenOther therapies out there:-Chemonucleolysis-Electrothermal-Radiotherapy-Botulinum toxin

Chou R; Atlas SJ; Stanos SP; Rosenquist RW Spine (Phila Pa 1976). 2009 May

1;34(10):1078-93UptoDate.com

Deyo R and Weinstein J. N Engl J Med 2001;344:363-370

Indications for Surgical Referral among Patients with Low Back Pain

Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories:

-Nonspecific low back pain

-Back pain potentially associated with radiculopathy or spinal stenosis

-Back pain potentially associated with another specific spinal cause

The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).

  Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).

  Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).

  Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).

 Chou, Roger MD et al. Annals of Internal

MedicineIssue: Volume 147(7), 2 October 2007, pp

478-491

Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).

  Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.

  Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

 Chou, Roger MD et al. Annals of Internal

MedicineIssue: Volume 147(7), 2 October 2007, pp

478-491

Gibbus

Chou, R et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society . Ann Intern Med October 2, 2007 vol. 147 no. 7 478-491 Deyo R and Weinstein. Low Back Pain. J. N Engl J Med 2001;344:363-370