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Low Back Pain:Approach to the patient in the E.D.
Lala M. Dunbar, M.D., Ph.D.Clinical Professor of Medicine
LSU HSC
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Epidemiology
60 90% of adults experience back pain atsome point in their
life.- incidence age 35- 55 y.o.- 90% resolve in 6 weeks
- 7% become chronic- M/ F equally affected
85% never given precise pathoanatomical dx 5th Leading reason
for medical office visits 2nd to respiratory illness as reason
for
symptom-related MD visits
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#1 Cause and #1 Cost of work relateddisability
Healthcare expenditures $90 Billion (1998)
- $26.3 Billion attributable to back pain
Epidemiology (cont.)
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Important Questions
1. Is systemic disease the cause?
2. Is there social or psycological distressthat prolongs or
amplifies symptoms?
3. Is there neurologic compromise thatrequires surgical
intervention?
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To Answer These ImportantQuestions
1. Careful History and Physical Exam
2. Imaging and Labs WHEN indicated
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Differential Diagnosis of Low Back Pain
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Evaluation in older adults
Probabilities change
Cancer, compression fractures, spinalstenosis, aortic aneurysms
more common
Osteoporotic fractures without trauma Spinal Stenosis secondary
to
degenerative processes and
spondylolisthesis more common Increased AAA associated with
CAD
Early radiography recommended
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Clues To Systemic Disease
Age
History of Cancer
Fever
Unexplained Weight Loss Injection Drug Use
Chronic Infection Elsewhere
Duration and Quality of Pain
-Infection and Cancer not relieved supine Response to previous
therapy
h/o inflammatory arthritis elsewhere
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Imaging
Plain Radiography limited to patients with:
-findings suggestive of systemic disease
-trauma
Failure to improve after 4 to 6 weeks
CT and MRI more sensitive for cancer andinfections also reveal
herniation and stenosis
Reserve for suspected malignancy,infection orpersistent
neurologic defecit
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MRI
Shows tumors and soft tissues (e.g.,herniated discs) much better
than CT scan
Almost never an emergency
Exception: Cauda equina syndrome
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CT Scan
Shows bone (e.g., fractures) very well
Good in acute situations (trauma)
Sagittal reconstruction is mandatory Soft tissues (discs, spinal
cord) are poorly
visualized
CT-myelogram adds contrast in the CSFand shows the spinal cord
and nervescontour better
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Abdomen, X-ray, Anteroposterior
View1. 1st Lumbar vertebra
2. 2nd Lumbar vertebra
3. 3rd Lumbar vertebra
4. 4th Lumbar vertebra
5. 5th Lumbar vertebra
6. T127. Twelfth rib
8. Sacroiliac joint
9. Sacrum
10. Sacral foramen
11. Ilium12. Pelvic brim
13.Superior ramus of
pubic bone
14. Pubic symphysis
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1. Vertebral body
2. Spinal cord
3. Conus medullaris
4. Intervertebral disc
5. Filum terminale
(internum)
6. Subarachnoid
space
Lower Third of Spinal Cord, MRI
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Sagittal Section through the
Spinal Cord
1. Intervertebral disc
2. Vertebral body
3. Dura mater
4. Extradural or epidural
space
5. Spinal cord
6. Subarachnoid space
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Lumbrosacral Dermatones
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Common Pathoanatomical Conditions of the Lumbar Spine
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Disc Herniation Physiology
Tears in the annulus
Herniation of nucleuspulposus
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Disc Herniation Physiology
Compression of thenerve root in theforamen leads to pain
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Lumbar Disc HerniationTreatment
Conservative Tx.
Moderate bed rest
Spinalmanipulation
Physical therapy
Medication NSAIDs
Muscle relaxants
Rarely narcotics
Surgical Tx.
Microdiscectomy
Less than half of an
inch incision
Go home the same or
next day
Good results in up to90% of cases
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Results of Surgical Treatment
Good outcome in 80-90% of cases
Residual pain may last up to 6 months postop
Results are worse if pain was present for over 8
months before the operation (permanent nervedamage?)
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Low Back Pain
Second most commoncause of missed workdays
Leading cause of disabilitybetween ages of 19-45
Number one impairment inoccupational injuries
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Low Back Pain
Most episodes of LBP areself limited
These episodes becomemore frequent with age
LBP is usually due torepeated stress on thelumbar spine over
manyyears (degeneration),
although an acute injury may
cause the initiation of pain
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Disc Degeneration Physiology
With age andrepeated efforts,the lower lumbar
discs lose theirheight and watercontent (bone onbone)
Abnormal motionbetween the bonesleads to pain
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Disc Degeneration Treatment
Conservative Tx.
Moderate bed rest
Spinalmanipulation
Physical therapy
Medication NSAIDs
Muscle relaxants
Rarely narcotics
Surgical Tx.
Lumbar fusion
OR
Replacement with
artificial disc
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Indications for SurgicalTreatment
Low back pain for at least 2 years
Incapacitating
Resistant to physical therapy and medication
Positive MRI findings (degenerative changes) at
L4-5 and/or L5-S1
For selected cases:
Concordant pain on discography
Psychological evaluation
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Natural History
Recovery from nonspecific LBP generallyrapid 90% within 2 weeks
somestudies less rapid (2/3 at 7 weeks)
Herniated Discs slower to improve onlyabout 10% considered for
surgery after 6weeks
With surgery, no earlier return to worksymptomatic and
functional outcomesometimes better
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Physical Examination Fever possible infection
Vertebral tenderness - not specific and notreproducible between
examiners
Limited spinal mobility not specific (may help inplanning
P.T.
If sciatica or pseudoclaudication present do straightleg
raise
Positive test reproduces the symptoms of sciaticapain that
radiates below the knee (not just back or
hamstring) Ipsilateral test sensitive not specific: crossed leg
is
insensitive but highly specific
L-5 / S-1 nerve roots involved in 95% lumbar disc
herniations
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Assessment of Function
98% disc herniations: L4-5; L5-S1
Impairment: Motor and Sensory L5-S1
L5: Weakness of ankle and great toedorsaflexion
S1: Decrease ankle reflex
L5 & S1: Sensory loss in the feet
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STRAIGHT LEG RAISE TEST
The straight leg
raise test is positive
if pain in the sciatic
distribution is
reproduced
between 30 and 70
passive flexion of
the straight leg.
Dorsiflexion of thefoot exacerbates
the pain
STRAIGHT LEG RAISE TEST
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Waddell Signs For Non-organic Pain
Superficial non-anatomic tenderness Pain from maneuvers that
should notellicit pain
Distraction maneuvers that should ellicitpain BUTdont
Disturbances not consistent with known
patterns of pain Over-reacting during the exam
Not definitive to rule out organic disease
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Imaging Studies
Progressive Neurologic Defecits
Failure to Improve
Hx of Trauma
Risk for Malignancy or infection
N R t P i
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Nerve Root Pain Associated w/ Radiculopathy
Sciatica-herniated disk-foramenal or spinal stenosis-ligamentous
hypertrophy-other space filling lesions: cysts, tumor,
abscess-viral or immune inflammation-can occur w/ peripheral nerve
involvement
Spinal stenosis
-neurogenic claudication (pseudo claudication)1 or both legs
-radiation to buttocks, thighs, lower legs-pain increase with
extension (standing, walking)-pain decrease with flexion (sitting,
stooping forward)
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Indications for Surgical Referral
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Therapy: Non-specific LBP
NSAIDS
Muscle relaxants
Use on schedule than p.r.n.
Spinal manipulation/ P.T. (effects limited)
Delay referral until pain persists >3 weeks 50% will improve
b/f this time period
Rapid return to normal activities
Avoid heavy lifting, trunk twisting, vibrations
Alternative Tx: acupuncture and massage Surgery- ineffective
unless:
sciatica, pseudoclaudication, spondylolisthesis
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Therapy: Herniated Disks
If no evidence cauda equina or progressiveneurologic defecit:
Treat non-surgically minimum one month Treat similar to
non-specific LBP Limited narcotics
Epidural steroids (helps in some) If severe pain or neuro
defecits persist:
CT/ MRI / consider for surgery
Diskectomy
Improved relief vs. non-surgery at 4 yrs./ ? 10yrs. Percutaneous
and laser less effective than std. Arhroscopic techniques
techniques comparable to
std. surgery
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Therapy: Spinal Stenosis
Conservative management may be useful
For severe persistant pain decompressivelaminectomy
Surgery better pain relief and functionalrecovery
30% recurrent severe pain in 4 years
10% reoperated
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Therapy: Chronic LBP
Sx often difficult to explain
Intensive exercises help (hard to maintain)
Anti-depressant therapy useful if
depressed Long term opioids not recommended
Referral to pain center
Massage therapy is promising Therapeutic goals optimize daily
function
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Long Term Outcomes
Herniated Discs w/o neurologic deficits
Diskectomy - > relief at 4 yrs; ? Better at 10 yrs
Microdiskectomy similar to standard Laser Diskectomy less
effective
Arthroscopic diskectomy - promising
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