Transcript Low Back Pain 201 - University of Arkansas for Medical

Low Back Pain:
Case Based Evaluation
and Management
Patrick Kortebein, M.D.
Departments of PM&R and Geriatrics
University of Arkansas for Medical Sciences
5/31/09
Slides: www.uams.edu/pmr
Objectives
• Understand the evaluation and management of
common sources of low back and related pain
• Understand the significance of abnormal
findings on lumbar spine MRI in individuals
with low back and related pain.
• Understand the evaluation and management of
chronic low back pain.
Low Back Pain
• Common; 2nd primary care visits
• 5-15% per year
• 60-80% lifetime
• Acute episodes
• 75-90% recover w/in 3 months
• 25-75% will have recurrence w/in 6 months
LBP: Anatomy
• Bone / Vertebrae
• Disc
• Annulus
• Nucleus Pulposus
• Muscles / Ligaments
• Spinal Nerve Roots
LBP
• Facet joint
• Zygopophyseal joint
• Synovial
LBP
• Sacroiliac Joint
• Tight, Synovial
• Ligaments
• “SI Dysfunction”
Case #1
28 yo M presents with CC: LBP
• Started 4 days ago while bending over to
pick up his 14 mo old child
• PMHX: L knee arthroscopy
• Meds: Acetaminophen
• NKDA
• Social Hx: Married, insurance salesman
What other information is important?
Acute LBP: History
• Location
• Axial or Radiating (Sciatica) ?
• Onset: Traumatic, Insidious
• Duration:
• Acute: < 12 weeks
• Chronic: > 12 weeks
• Character/Quality: Ache, Burning, etc
• Exacerbating / Alleviating Factors
Acute LBP: History
“Red Flags” (AHCPR 1994)
• Fracture:
• Major/minor trauma
• Age > 70 yrs (~50 yrs)
• Chronic corticosteroids
• Cauda Equina
• B/B dysfunction
• Saddle Anesthesia
• LE weakness
Acute LBP: History
“Red Flags” (AHCPR 1994)
• Infection
• Fever
• Steroids / Immunosuppression / IV Drug Use
• UTI / Systemic Infection
• Cancer
•
•
•
•
Hx of Cancer
Unintentional Weight Loss
Supine/Night Pain
Age > 50
“Red Flag” Evaluation
Acute LBP: Physical Exam
• Lumbar Spine:
• Inspection
• Palpation
• ROM: Flexion / Extension
• +/- LE Neurologic Exam
Acute LBP: Imaging
• When?
• What imaging?
Acute LBP: Imaging
When?
• Minimum 6 weeks
• + “Red Flags”
What?
• X-ray
3-view:
• AP / Lat / L5 Spot
Obliques:
• Limited information
• Radiation exposure
Acute LBP: Imaging
• Lumbar MRI
Acute LBP: Imaging
Abnormal findings
• “Degenerative disc disease”
• “Bulging disc”
• “Herniated disc”
LBP: Imaging
MRI Abnormalities in Normals / No LBP
• Boden et al (N=67) JBJS 1990
• HNP: 21-36%
• Bulging Disc: 50-80%
• Degenerative Disc Changes: 34-93%
• Jensen et al (N= 98) NEJM 1994
• Bulging Disc: 52% (28-100%)
• Disc Protrusion: 27% (21-30%)
Case #1
History
• Onset: 4 days ago, constant
• Location: R lumbosacral junction
• No radiation / neurological symptoms
• No clear exacerbating / alleviating factors
Physical Exam
• Mild tenderness R low lumbar region
• Increased pain with flexion
• Normal LExt neuro exam
Case # 1
• Diagnosis ?
• Management ?
LBP: Differential Diagnosis
Deyo NEJM 2001
Case # 1
Diagnosis: “Mechanical” LBP
• Education / Activity Modification
• Bedrest: ~ 2 days (Deyo NEJM 1986)
• Analgesics:
• Acetaminophen
• NSAID’s
• Tramadol
• Muscle Relaxants
• Cyclobenzaprine
“Mechanical” LBP
• Physical Therapy
• Exercise
• Modalities
• Lumbar Support
• Chiropractic
• Acupuncture
Back Heat
LBP: Zygapophyseal (Facet) joint
• History/Examination
• Axial LBP +/- post thigh
• No neuro sxs
• Worse w/ static posture
• Lumbar Extension
• Stand / Walk
• Neuro exam normal
LBP: Zygapophyseal (Facet) joint
Management
• Analgesics
• Tylenol, NSAID
• Physical Therapy
• Injections
• Diagnostic
• Therapeutic
LBP: Sacroiliac (SI) Joint
• History
•
•
•
•
Atraumatic > Traumatic
Axial; Lumbosacral
Uni- > Bilateral
No radiation / neuro sxs
• Physical Exam
• ~ Normal
• Tender SI region
LBP- SI Joint
• Diagnosis / Treatment
• Physical Therapy
• Injection
LBP: Discogenic
History / Exam
• Axial LBP
• No radiation /
neuro sxs
• Aggravating:
• Static postureSitting or Sit to
stand
• Normal
neurological exam
LBP: Discogenic
Management
• Physical Therapy
• Core Strength
• Surgery:
• Fusion
• Artificial Disc
• Not yet
Case # 2
• 38 yo with left LE radicular pain > LBP for
~6 weeks. Also left foot tingling and
weakness.
• PMHx: HTN, Hyperlipidemia
• Meds: HCTZ, Atorvastatin
• Allergies: Sulfa
• Social Hx: Divorced, Landscaper
Case # 2
Physical Exam
• L-spine: Non-tender
• Left LExt: + SLR / Crossed SLR
• Neuro
• Motor: 5/5 except Plantar Flexion
• Reflex: KJ +2/+2, AJ +2 / 0
• Sensory: Dec to LT lateral heel
Case # 2
• Diagnosis ?
LBP: Radiculopathy
Diagnosis
• Physical Exam
• MRI
• EMG
• CT Myelogram
* Correlate anatomy w/ sxs and exam
LBP: Radiculopathy
Neurological Exam:
Motor
L2/3: Hip Flex/Add
Reflex
Knee
L4: Knee Ext/DFlex
L5: Great toe/EHL
S1: Plantarflex
Knee
Int. HS
Ankle
Sensory
Med Thigh
/Knee
Med Ankle
Dorsum Foot
Lat Heel
Functional: Squat, Heel / Toe Walk, Heel Raise
LBP: Evaluation
• SLR / Dural Tension
Case # 2
• MRI: Left L5-S1 disc
herniation impinging
on S1 nerve root
Management?
LBP: Radiculopathy
Management
• Medications
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•
•
•
NSAID’s
Acetaminophen
Tramadol
Neuropathic
• Steroids;
• Oral (? dose) vs epidural
LBP: Radiculopathy
Management
• Physical Therapy
• McKenzie
Extension therapy
• TENS
~ No benefit
LBP: Radiculopathy
• Injections
Epidural
Selective
LBP: Radiculopathy
Surgery
• Indications
• Cauda equina
• Progressive neuro
deficits
• No relief w/
conservative
treatment
• SPORT trial
• JAMA 2006
LBP: Spinal Stenosis
• History (Neurogenic claudication)
•
•
•
•
Prox LE Pain +/- Neuro sxs
Walk / Stand
Uphill > Downhill
Grocery Cart
• Physical Exam
• ~ Normal
• Stand / Walk
LBP: Spinal Stenosis
• Diagnosis
• MRI
• EMG
• Management
• Medications
• Neuropathic
• PT
• Epidural Injection
• Surgery: (SPORT trial)
Case # 3
• 51 yo M truck driver injured at work 2 years
ago lifting a 30# box, and applying for
disability
• Continued axial LBP and “numb” R LE
• No “Red Flags”
• Treatments to date:
•
•
•
•
Medications: NSAIDs, Tramadol, Hydrocodone
Physical Therapy: 24 sessions
Work restrictions; not working
Injections: Epidural / Facet / Sacroiliac
Case # 3
Physical Examination
• Lumbar: Diffuse tenderness to light palpation
• Exaggerated pain behavior w/ trunk rotation
• Lower Extremity Neurologic
• 50% decreased sensation entire LExt
• Normal strength / reflexes
• Supine SLR: LBP; Seated SLR: No pain
Case # 3
• Lumbar MRI:
• Mild DD changes with diffuse disc bulge
at L4-5 and L5-S1
• Diagnosis?
• Treatment?
Chronic LBP
• Duration
• > 12 weeks
• Poor Correlation
• Symptoms
• Objectives Finding
Chronic LBP
• Strong Association
• Depression
• Anxiety
• Poor Coping Skills
“My back hurts, but I’m here because I can’t cope
with this episode, as well as the turmoil at home
(or work)”- N Hadler “Last Well Person”
Chronic LBP
Chronic LBP
**Goal**
• Improve Function
• Minimize focus
on treating pain itself
• Biopsychosocial Model of Pain
• Maladaptive Behavior
• Neuroplasticity
Chronic LBP
Case # 3
Multidisciplinary Pain Management
• Education
• Medications
• Chronic Opioids ?
• PT
 Functional Restoration
• Psychology
• Pain Management
Recommended Reading
• Kinkade S. Evaluation and treatment of
acute low back pain. Am Fam Physician
2007; 75:1181-8, 1190-2.
• Deyo et al. Overtreating chronic back pain:
time to back off? J Am Board Fam Med
2009; 22:62-8.
• LBP Handbook 2003
• Cole & Herring
LBP
Questions ?
Other
LBP: Evaluation
• Waddell’s Signs (Non-organic PE)
• Tenderness
• Overreaction
• Regional
• Distraction
• Simulation
• > 3/5
* Behavioral Component of Pain
Spine 1980