Low Back Pain
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Transcript Low Back Pain
Low Back Pain
What is low back pain?
Pain in the low back
Epidemiology
80% of the population will have at
least one episode of LBP in their
lifetime
Annually $20 million in direct cost
and $50 million when indirect cost is
added
3% of workers’ comp case but
account 30% of the cost and receive
75% of the payment
Common causes of LBP?
Nonspecific – ligamentous or articular
structures, strain, myofascial disorders,
psychosocial factors
Arthritis
Spondylolisthesis
Disc herniation - >95% L4-5, L5-S1
Spinal stenosis
Fracture
Tumor
History?
Characterize the pain
Diffuse, tight, gradual onset, worse after sitting or
with cold, relieved with warmth, associated stiffness
– myofascial disorder
Brief, shooting, worse with coughing, standing or
sitting, relieved when lying down, radiating down the
leg – nerve root, sciatica
Persistent, burning, tingling, worse when lying down
at night – peripheral nerve or lumbosacral plexus
Radiating to buttock, thighs, legs, worse with back
extension, relieved with sitting – spinal stenosis
Associated with horse saddle – cauda equina
syndrome
History – rule out “red flags”
symptoms?
Trauma
Fever
Weight loss
Neurologic deficits – numbness,
bowel/bladder incontinence
History of IVDA, cancer, steroid use
Last longer than one month
Associated with abdominal pain
Physical exam?
Gait
Muscle weakness – atrophy, pelvic tilt
Knee flexion – guard against root
traction
ROM
Palpation – tenderness, step off
Physical exam
Motor strength
Heel – L5
Tiptoe – S1
Sensation – dermatomes
L4 – big toe
L5 – middorsum of foot
S1 – lateral foot
Physical exam
Reflex
Knee – L3, L4
Ankle – S1
Straight leg raise
Crossed straight leg raise - >
specificity than straight leg raise
Rectal exam
Inconsistent examinations
Axial loading
Whole body rotation at the hip
Straight leg raise in sitting position
Tests for patients without “red
flags” symptoms?
None
90% resolve spontaneously in 4
weeks
Tests with “red flags” symptoms?
CBC and ESR
X-ray
CT scan – fracture, fact joint
Tests with “red flags” symptoms?
MRI
Infection, cancer, disc herniation
Age >50, asymptomatic, disc bulging 7580% and 30% disc protrusion
Bone scan – cancer
EMG
Nerve root involvement after multiple
back surgeries
Fastitious weakness
Treatments – acute LBP?
Activity versus bed rest
Without radiculopathy, activity as
tolerated
With radiculopathy, may consider bed
rest < 3 days
Treatments – acute LBP?
Medications
Acute – around the clock rather than prn
Analgesics: acetaminophen, NSAID, cox2 inhibitor, narcotics
Muscle relaxants – short term
Subacute/chronic: TCA, SSRI, phenytoin,
tramadol, gabapentin
Treatments – acute LBP
Soft tissue injection – controversial
Back exercise
Limited benefit
Not during acute attack
Treatments – acute LBP
Disc herniation
Multiple conservative modalities - >90%
resolved
Discectomy
Sciatica
Conservative treatment initially for 1-3
months - 80% resolved spontaneously
73% recurred at least once
Treatment – chronic LBP?
Back exercise
Antidepressants – mixed result,
confounding depression
Steroid injection in
Epidural space – may help in some patients,
conflicting reports
Facets – limited data, one small study showed
relief at 6 months but not month 1-3
Spinal stenosis – laminectomy
Minimally invasive procedures
Spinal fusion – multiple laminectomy,
unstable
Treatment – chronic LBP
Lumbar disc replacement
Behavior therapy
Spinal manipulation – mildly effective
in some patients but no better than
other routine modalities
TENS – no benefits