Low Back Pain Ppt

5/27/2018 Low Back Pain Ppt

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Diagnosing LowBack Pain

Fritz Sumantri Usman

Neurologist & Interventional Neurologist


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I. History:


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Mechanism of injury

Associated symptoms:

Bladder / bowel function

Fevers / chills Sleep disturbance

Numbness / tingling

Prior injuries, treatment and outcomes

Medications

Family history

Social history:

Vocational

Education

Tobacco / ETOH / Illicit drugs Function: ADLs & Mobility

Litigation


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Pain Specifics:

Quality: sharp, dull, shooting, burning, etc. Location / Distribution:

Radicular: Dermatomal distribution, dysesthesias

Radiating: Nondermatomal

Onset:

Gradual: DDD

Acute:Disc abnormality, strain, compression fractures

Severity / Intensity

Frequency: Constant vs. Intermittent

Duration Exacerbating and Alleviating Factors

Time of Day: If nocturnal, consider malignancy


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Red Flags:

Significant trauma history, or minor in older adults Nocturnal pain in supine position with history of cancer

Bladder or bowel incontinence or dysfunction

Constitutional symptoms:

Fever / chills

Weight loss

Lymph node enlargement

Risk factors for spinal infection

Recent infection

IV drug use Immunosuppression

Major motor weakness


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II. Examination:


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A. Physical:

Posture: Splinting

Body language

Gait:

Antalgia

Heel / Toe pattern

Trendelenberg

Musculoskeletal:

ROM

Leg length

Vascular

Atrophy


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Abdomen:

Presence of masses

Back:

Inspection

Palpation

ROM

Scoliosis

Neurological: Sensation

Motor

DTRs

Rectal if indicated:

Evaluation of sphincter tone


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C. Pathological Examination:

Spurlings maneuver: Lateral rotation and extension of spine resultingin neuroforaminal narrowing and nerve root encroachment, clinicallyreproducing extremity pain, usually in dermatomal distribution

Straight-leg raise (SLR): Elevation of lower extremity, seated or

standing, resulting in neural tension at S1 nerve root with extremity pain

Patricks maneuver: Crossed leg with unilateral pain indicative ofsacro-iliac (SI) joint dysfunction

Femoral stretch: Hip extension stretch with heel pushed to buttock inlateral supine or prone position resulting in anterior thigh pain


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III. Low Back Pain:


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A. Epidemiology:

Incidence of LBP: 60-90 %lifetime incidence

5 %annual incidence

90 %of cases of LBP resolve without treatment within 6-12weeks

40-50 %LBP cases resolve without treatment in 1 week

75 %of cases with nerve root involvement can resolve in 6months

LBP and lumbar surgery are:

2ndand 3rdhighest reasons for physician visits 5thleading cause for hospitalization

3rdleading cause for surgery


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B. Disability:

Age and LBP:

Leading cause of disability of adults < 45 years old

Third cause of disability in those > 45 years old

Prevalence rate:

Increased 140 %from 1970 to 1981 with only125 % population growth

Nearly 5 millionpeople in the U.S. are ondisability for LBP


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C. Lifetime Return to Work:

Success of less than 50 % if off work greaterthan 6 months

25 % success rate if off work greater than 1 year

Nearly 0 % success if return to work has notoccurred in 2 years


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D. Occupational Risk Factors:

Low job satisfaction

Monotonous or repetitious work

Educational level

Adverse employer-employee relations

Recent employment

Frequent lifting

Especially exceeding 25 pounds

Utilization of poor body mechanics in technique


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E. Differential Diagnoses:

Lumbar strain Disc bulge / protrusion / extrusion

producing radiculopathy

Degenerative disc disease

Spinal stenosis

Spondyloarthropathy

Spondylosis

Spondylolisthesis Sacro-iliac dysfunction


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F. Diagnostic Tools:

1. Laboratory: Performed primarily to screen for other disease etiologies

Infection

Cancer

Spondyloarthropathies

No evidence to support value in first 7 weeks unless with red flags

Specifics:

WBC

ESR or CRP

HLA-B27 Tumor markers: Kidney Breast Lung Thyroid Prostate


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2. Radiographs: Pre-existing DJD is most common diagnosis

Usually 3 views adequate with obliques only if equivocal findin

Indications:

History of trauma with continued pain

Less than 20 years or greater than 55 years with severe orpersistent pain

Noted spinal deformity on exam

Signs / symptoms suggestive of spondyloarthropathy

Suspicion for infection or tumor


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3. EMG / NCV ( Electrodiagnostics): Can demonstrate radiculopathy or peripheral nerve

entrapment, but may not be positive in the extremitiesfor the first 3-6 weeks and paraspinals for the first 2 weeks

Would not be appropriate in clinically obvious radiculopathy

4. Bone scan:

Very sensitive but nonspecific

Useful for:

Malignancy screening

Detection for early infection Detection for early or occult fracture


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5. Myelogram: Procedure of injecting contrast material into the spinal canal

with imaging via plain radiographs versus CT

In past, considered the gold standard for evaluation of the spinacanal and neurological compression

With potential complications, as well as advent of MRI and CTis less utilized:

More common: Headache, nausea / vomiting

Less common: Seizure, pain, neurological change, anaphylaxis

Myelogram alone is rarely indicated

Hitselberger study 1968 Journal of Neurosurgery:

24 %of asymptomatic subjects with defects


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7. CT: Best for bony changes of spinal or foraminal stenosis

Also best for bony detail to determine:

Fracture

DJD

Malignancy

SW Wiesel study 1984 Spine:

36 %of asymptomatic subjects had HNP at L4-L5and L5-S1 levels


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8. Discography (Diagnostic disc injection):

Less utilized as initial diagnostic tool due to high incidence offalse positives as well as advent of MRI

Utilizations: Diagnose internal disc derangement with normal MRI / myelo Determine symptomatic level in multi-level disease

Criteria for response: Volume of contrast material accepted by the disc, with normals of 0.5 to

1.5 cc

Resistance of disc to injection

Production of pain---MOST SIGNIF ICANT

Usually followed by CT to evaluate internal architecture, butalso may utilize MRI

As outcome predictor (Coulhoun study 1988 JBJS):

89 %of those with pain response received benefit from surgery

52 %of those with structural change received surgical benefit


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9. MRI:

Bestdiagnostic tool for:

Soft tissue abnormalities: Infection

Bone marrow changes

Spinal canal and neural foraminal contents

Emergent screening:

Cauda equina syndrome

Spinal cored injury

Vascular occlusion

Radiculopathy

Benign vs. malignant compression fractures

Osteomyelitis evaluation

Evaluation with prior spinal surgery


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Has essentially replaced CT and myelograms for initialevaluations

Boden study 1990 JBJS:

20 %of asymptomatic population less than 60 years with HNP

36 %of asymptomatic population of 60 years

Jensen study 1995 NEJM:

52 %of asymptomatic patients with disc bulge atone or more levels

27 %of asymptomatic patients with disc protrusion

1 %of asymptomatic patients with disc extrusion


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MRI with Gadolinium contrast:

Gadolinium is contrast material allowing enhancement ofintrathecal nerve roots

Utilization:

Assessment of post-operative spine---most frequent use

Identifying tumors / infection within / surrounding spinal cord

Diagnosis of radiculitis

Post-operatively can take 2-6 months for reduction of masseffect on posterior disc and anterior epidural softtissues which can resemble pre-operative studies

Only indications in immediate post-operative period:

Hemorrhage Disc infection


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10. Psychological tools:

Utilized in case scenarios where psychological or emotional

overlay of pain is suspected Symptom magnification

Grossly abnormal pain drawing

Non-responsive to conservative interventions but with essentiallynormal diagnostic studies

Includes: Pain Assessment Report, which combines:

McGill Pain Questionnaire

Mooney Pain Drawing Test

MMPI

Middlesex Hospital Questionnaire

Cornell Medical Index

Eysenck Personality Inventory


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MRI Nomenclature: (PER NASS) Anular fissure: Focal disruption of anular fibers in concentric, radial or

transverse distribution

Disc bulge: Circumferential, diffuse, symmetric extension of anulus beyondthe adjacent vertebral end plates by 3 or more mm, usually due to weakened or laxanular fibers

Disc protrusion: Focal, asymmetric extension of disc segment beyondmargin of vertebral end plates into the spinal canal with most of anular fibers intact

Disc extrusion: Focal, asymmetric extension of disc segment and / or nucleupulposis through the anular containment into the epidural space

Disc sequestration:Extruded disc segment that is detached from original

with migration into the canal Disc degeneration: Irreversible structural and histiological changes in

nucleus seen on MRI T2WI images (commonly associated with bulge)


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Specificity / Sensitivity

Diagnosis Test Sensitivity Specificity

CT 0.90 0.70

MRI 0.90 0.70

DiscHerniation

CT Myelo 0.90 0.70

CT 0.90 0.80-0.95

MRI 0.90 0.75-0.95

SpinalStenosis

Myelogram 0.77 0.70


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G. Treatment

Medications NSAIDS

Membrane stabilizers

TCA / Neurontin

re-establish sleep pain

reduce radicular dysesthesias

Muscle relaxers:

re-establish sleep patterns

more useful in myofascial/muscular pain

Narcotics: rarely indicated Steroids: more useful for radiculitis

Non-narcotic analgesics: Ultram


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Surgery:

Laminectomy

Fusion Discectomy

Percutaneous Lumbar Discectomy

Success rate variable 50 -85 %

Low rate of complications:

Infection

Peripheral nerve injury

Benefits:

Outpatient procedure

Minimal to no epidural scarring

No general anesthesia Spine stability preservation

Decreased cost


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IV. Specific Disorder

Considerations


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A. Sacroiliitis: History:

Trauma is very common

Repetitive LS motion--lumbar rotation or axial loading

No specific correlation with exacerbating activities

Commonly have leg length discrepancy or condition contributing

Biomechanics: Movement of the SIJ is involuntary, usually from muscle imbalances

Can occur at multiple levels: lower extremities, hip, LS spine

Motion is complex and not single-axis based


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Differential Diagnosis:

a. Fracture

Traumatic

Insufficiency stress fractures: elderly patient with osteoporosiswithout history of trauma

Fatigue stress fractures: usually athletes / soldiersb. Infection

Hematogenous spread with predisposing history

Usually unilateral symptoms present

c. Degenerative joint disease

d. Metabolic disease

e. Referred pain


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f. Seronegative spondyloarthropathies

RA--usually not until late in course of disease

Ankylosing spondylitis

Psoriatic arthritis

g. Primary SI tumor

Rare and usually synovial villoadenomas

h. Iatrogenic instability

Via pelvic tumor resection or bone graft site

i. Osteitis condensans ilii

Prevalence of 2.2 %,primarily in multiparous women

Usually self-limiting and bilateral

j. Reactive diseaseas sequellae of PID


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Diagnostic Tools:

X-rays: Up to 25 % of asymptomatic adults over 50 years

can have abnormalities

MRI / CT: Only if looking for tumor

Bone scan: Good for fractures but less favorable for inflammation

Treatment: Medications:NSAIDS

Physical therapy

Correct limb discrepancy

Injection:Fluoroscopy-guided vs. local

Surgical fusion:Few figures for efficacy


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B. Cauda Equina Syndrome:

History: Sudden, partial or complete loss of voluntary bladder function

due to massive disc impingement on spinal nerves

Can include loss of sensation as well as sphincter tone

Treatment: Urgent decompression is mandatoryfor prevention of

irreparable / irreversible bladder damage

12 hoursis the maximum time prior to irreversible changes


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C. DDD and Spondylosis:

Clinical: Up to 75 % of involvement of the spine occurs at 2 levels:L5-S1 and L4-L5

Possiblefactors that contribute to development:

Changes with maturation in:

Nutrition Disc chemistry

Hormones

Occupational forces

Progression of disc narrowing leads to degenerative changes ofbony structures, especially posterior components, leadingto spondylosis


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Treatment: Medications

Physical therapy

Lifestyle changes:

Smoking cessation

Weight loss

Vocational changes

Injections:

Less helpful if pain is limited to central low back only

Surgery: Laminectomy

Fusion


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D. Spinal Stenosis:

Clinical: Results from narrowing of spinal canal and / or neural foramina(CONGENITAL OR DEGENERATIVE)

Most common complaint is leg pain limiting walking

Neurogenic / Pseudoclaudication= pain in lower extremities with g

Relief can occur with: stopping activity

sitting, stooping or bending forward

Common are complaints of weakness and numbness of extremities

Usually becomes symptomatic in 6th decade


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Diagnosis: CT and MRI may yield false-positive results, therefore EMG /

NCV can be helpful to confirm diagnosis

Myelography also can be confirmatory and pre-surgicalscreening tool

Treatment: Medications

Physical therapy

TENS

Epidural injections Surgical decompression laminectomy


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E. HNP:

Clinical: Low back pain wit associated leg symptoms

Positions can induce radicular symptoms

Posterolateral disc pathology most common:

Area where anular fibers least protected by PLL

Greatest shear forces occur with forward or lateral bend

Central disc pathology:

Usually with LBP only without radicular symptoms, unlessa large defect is present


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Treatment: Conservative treatment:

Saul and Saul study 1989 Spine:

> 90 %success rate of symptom resolution withnon-operative management

Bozzao study 1992 Radiology: 69 patients with HNP studied longitudinally with MRI

63 % with >30 % reduction with 48 % > 70 % reductionover time

Medications

Physical therapy Injections

Surgery


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F. Pars Interarticularis Defects:

Spondylolysis: Anatomic defect in the bony pars interarticularis within the lamina

May uni- or bilateral

Can be congenital or induced

Usually without clinical symptoms with incidental findings onradiographs


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Spondylolisthesis

Progression of spondylolysis with separation

Grades assigned I-IV for level of translation

Most common levels are L5-S1 (70 %) and L4-L5 (25 %)

May be asymptomatic, but can result in

Spondylosis

DDD

Radiculopathy

Treatment: Medication

Physical Therapy

Injections

Surgery


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V. Chronic Pain Issues


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A. Pain Reinforcing Factors:

Secondary gain: Support system allows passive / inactive role forpatient via catering to needs and hence fostering dependency

Environmental: Inadequate opportunity or skills to compete in theprofessional community

Physician knowledge deficit: In areas of diagnosis and appropriatetreatment, can prolong symptoms and validate pain behavior

Workers compensation:Laws have become counterproductive-- financial compensation or open claim may discourage desire for return

work and impede recovery

Litigation: Anticipation of large financial settlement can reinforce painbehavior and develop into learned pain behavior


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B. Risk Factors for DelayedRecovery:

Occupational Psychosocial Medical

Job availability Anger with system History of narcotic orsubstance abuse

Patient perception ofwork load

Disabled spouse Poor fitness

Job dissatisfaction Poor English

proficiency History of prior

injury

Time off of work


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C. Discouraging Chronic Pain:

Requiring employer to accommodate restrictions to allowcontinued working during treatment and recovery

Rapid abjudication of disability and compensation claims

Physician education re: appropriate treatments and limiting use ofpotentially addictive medications

Ergonomic work environments

Patient education re: disease process and treatment options

D C id i f


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D. Considerations ofPM & R Treatment:

Physical therapy is initially usually one of modalities with progressioninto more active exercise

Pre-conditioning therapy is more functional with transition into WorkConditioning (Work Hardening) program

Alwaysconsider return to work, whether modified duty with restrictionor limiting hours worked

If patients poorly tolerate standard therapy, consider pool therapyintervention which allows elimination of gravity effects

Functional Capacity Evaluations utilized if patients are not progressingthrough therapy or if have reached a plateau and abilities as

well as restrictions need to be assessed

Job site evaluations appropriate if concerns re: ergonomics


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E. Final Thoughts:

It is the patient,not the diagnostic test,that is treated

80 %of patients will recover from acutelow back pain within 3 days to 3 weeks,with or w ithout treatment, with up to 90 %resolved in 6-12 weeks

Documents

Low Back Pain Ppt