EVALUATION AND MANAGEMENT OF LOW BACK PAINGregory M Yoshida MD

LOW BACK PAIN

•Low back pain is a symptom

LOW BACK PAIN• 90% of Americans will experience at some

time• Leading cause of disability in persons

under age 45• 1-2% is operative• Cost is in the billions• Only a problem in industrialized nations• Cocktail medicine

LOW BACK PAIN

• Self-limiting• Resolution▫ 40% @ 1 mo▫ 60% @ 2 mo▫ 75% @ 3 mo

• Remaining 25% accounts for 85% of the cost

PEARL

LOW BACK PAIN

• Non-orthopedic causes▫ Pyelonephritis▫ AAA▫ Pancreatitis/pancreatic CA

LOW BACK PAIN – RED FLAGS

• Pain radiating past the knee• Pain radiating out the front• Fevers/chills• Weakness/numbness in the LE’s• Bowel/bladder incontinence or retention

PATIENT EVALUATION

• History• PMH• PE• Diagnostic tests

HISTORY

•“OLD CARTS”

ONSET

• Sudden vs gradual• Mechanism• Body position▫ Flexion▫ Rotation

LOCATION

• Midline• Paraspinous• Hip/buttocks• Flank

PEARL

LOCATION

• Greater trochantericbursitis

• Iliotibial band syndrome

DURATION

• Total duration• Time of each episode

CHARACTERISTICS

• Open-ended question• Sharp, dull, stabbing, throbbing, aching, electrical, burning, etc.• Get a “feel” of the pt’s pain

AGGRAVATING AND ALLEVIATING FACTORS

• Posture▫ Sit/stand/supine▫ Flexion/extension

• Activity• Lifting• Valsalva• Medications

RADIATION

• Dermatomal• Sclerotomal• Past the knee• Out the front

TEMPORAL RELATIONS

• AM vs PM• Time after aggravating or alleviating factor• Night pain

ASSOCIATED Sx

• Weight loss• Fever/chills• Numbness/weakness• Bowel/bladder problems

PAST MEDICAL Hx

• Previous back surgery• Malignancy• Foreign travel

PHYSICAL EXAM

•Confirm your hypothesis

INSPECTION• Pt posture and attitude• Scoliosis• Pt’s behavior during interview

GAIT ANALYSIS

• Antalgic▫ Weak gastroc

• Drop foot▫ Toe stub▫ Circumduction▫ High step

• Back knee• Gluteal lurch

PE - STANDING• Palpation▫ Midline▫ Paraspinous▫ Spasm▫ Buttocks▫ Sciatic notch

• ROM▫ Flexion/extension▫ Rotation▫ Lateral bend

• Fluidity• Reversal of lordosis

PE - SITTING

•Sitting straight leg raise (SLR)•Neurologic exam

NEUROLOGIC EXAMMOTOR SENSORY

• Manual muscle test (MMT)▫ 0 – nothing▫ 1 – fasciculation▫ 2 – full ROM, no gravity▫ 3 – full ROM, against gravity▫ 4 – between 3 and 5▫ 5 - normal

• Test pin prick and light touch▫ 0 – absent▫ 1 – impaired▫ 2 - normal

NEUROLOGIC EXAMMOTOR SENSORY

• L1 – none• L2 – psoas• L3 – quads• L4 – Tibialis anterior• L5 – ext hallicis longus• S1 – gastroc, peroneals• S2 – medial hamstrings• S3 – anal sphincter• S4 – anal sphincter

• Inguinal crease• Anterolateral thigh• Patella• Medial malleolus• 1st dorsal webspace• Sole of foot• Posteromedial thigh• Scrotum/labia majora• Glans/clitoris

NEUROLOGIC EXAM

•Reflexes▫PatellaL3,L4▫AchillesS1,S2

•Look for asymmetry

PEARL

PE - SUPINE

• SLR• Must recreate radicular pain past the knee• Less than 40 degrees is non-physiologic

RELIABILITY TEST

• Hold both heels off table

• Ask pt to quickly lift one leg up

• Downward pressure should be exerted by the other leg

DIAGNOSTIC TESTS

•Patient dependent

•Diagnosis dependent

BACK PAIN

• Lumbar sprain/strain• Lumbosacral strain• Lumbago• Mechanical back pain• Most common Dx

LS STRAIN

• Antecedent event▫ MVA, lifting, slip and fall, etc.

• Isolated back pain• No red flags

PEARL

LS STRAIN

• Hip DJD can be confused with back pain

• Pain typically in the groin• Reproduce Sx with int

rotation of the hip

TREATMENT• Initial▫ One day bed rest▫ Medrol dose pack

• One week F/U▫ NSAID▫ PT▫ +/- antispasmodics

• One month F/U▫ 40% improved

• Not improved▫ X-rays▫ PT▫ Meds

TREATMENT

• Three month F/U▫ 75% improved

• Not improved▫ LS MRI▫ Refer

HERNIATED DISC (HNP)

• Pain radiating down LE in a dermatomal distribution

• Flexion and rotation• Standing more comfortable• Increased pain with

valsalva

HNP

• PE▫ Pain with forward flexion▫ + SLR▫ Cross SLR Raise uninvolved LE – create

pain in involved LE

▫ +/- neuro findings

HNP

• Affects the traversing nerve root▫ L5-S1 gets S1▫ L4-5 gets L5

PEARL

HNP

• 76% will resolve on their own within 3-4 mo

SPORT STUDY

• Spine Patient Outcomes Research Trial▫ 90-95% good and excellent results at 8 years▫ Surgery had slightly better results Level dependent L2-3, L3-4 surgery most beneficial L4-5 equivocal L5-S1 surgery less indicated

TREATMENT• Without a deficit▫ Medrol

• If improved▫ Rx like a strain▫ PT

• If not improved▫ ESI

• With a deficit▫ Medrol▫ LS MRI

• Follow previous algorithm

SURGICAL REFERAL

• Patients failing conservative treatment • L2-3 or L3-4 level• Increasing neurological deficit• Bowel/bladder problems▫ EMERGENCY

SPONDYLOLISTHESIS

• Forward slippage of a vertebra on the one below

• Six types▫ Isthmic▫ Degenerative

SPONDYLOLISTHESIS• Isthmic▫ Stress fracture of the pars interarticularis▫ Repetitive hyperextension▫ Age 6 to 16▫ L5-S1 most common

• Degenerative▫ Incompetence of the facets▫ Women > men▫ L4-5 most common

ISTHMIC SPONDY

• Pain with extension• Tight hamstrings• Hx of extension activities▫ Gymnastics▫ Football interior linemen

• Oblique X-rays▫ Scotty dog

ISTHMIC SPONDY

ISTHMIC SPONDY

ISTHMIC SPONDY

ISTHMIC SPONDY

• Any child with back pain > 3 mo with normal X-rays requires a bone/spect scan

DEGEN SPONDY

• Results from incompetence of the facets

• Presents like stenosis

SPONDYLOLISTHESIS

• Any patient with spondylolisthesis should be referred

STENOSIS

• Narrowing of the spinal canal from degeneration

STENOSIS

• Neurogenic claudication• Pain radiating down LE

with standing or walking• Sleep in fetal position

STENOSIS

• Differentiate from vascular claudication▫ Riding a seated exercise bike▫ Walking uphill

• LS MRI• refer

SPORT

• PT and ESI provide temporary relief at best• ESI not recommended• Surgery provided 85-90% good and excellent results up to 6 years• By 8 years op and non op groups converged

ANKYLOSING SPONDYLITIS

• Young adults• Male > female• AM stiffness, improves as day progresses• Primarily hips/buttocks

ANKYLOSING SPONDYLITIS

• PE▫ Decreased lumbar and

chest excursion

• AP Pelvis• CBC, ESR, CRP, HLA-B27

ANKYLOSING SPONDYLITIS

COMPRESSION FRACTURE

• Osteoporosis• Minimal trauma• Pain centered • X-ray all elderly patients

with back pain

COMPRESSION FRACTURE

• Must r/o pathologic fracture

• CBC, Chem-20, SPEP, UPEP

• Hx of wt loss• Night pain

PATHOLOGIC FRACTURE

•Most common tumor of the spine is metastatic disease

•Most common primary tumor of the spine is multiple myeloma/plasmacytoma

PEARL

PATHOLOGIC FRACTURE

• Tumors most likely to metastasize to bone• P. T. Barnum Loves Little Kids▫ Prostate▫ Thyroid▫ Breast▫ Lung▫ Lymphoma▫ Kidney

• Refer

COMPRESSION FRACTURE

• Brace• Kyphoplasty▫ Acute▫ Thoracic

DEGENERATIVE DISC DISEASE

• Dx of exclusion• Spondylosis• Discogenic pain• Retrolisthesis• Facet syndrome

DEGENERATIVE DISC DISEASE

• Conservative care• PT• NSAIDs• Pain management• Surgery is 65% successful

at best

THE FUTURE

• Disc regeneration therapy• Improve minimally

invasive surgery• Robotics

CONCLUSION

• Back pain is common• The majority of pts can be treated successfully conservatively• Differentiate from extremity problems• Some pts require early referral

THANK YOU