Transcript Low Back Pain

 Review evaluation and differential diagnosis of low
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back pain
Discuss when to obtain imaging
Discuss selected etiologies/radiography of back pain
Discuss treatment modalities
Have trivial Pennsylvania fun
Image Challenge
Q What is the diagnosis?
:
1. Atlanto-occipital dislocation
2. Atlanto-axial subluxation
3. Pillar fracture
4. Spinous process avulsion
5. Wedge fracture
Image Challenge
Q What is the diagnosis?
:
Answer:
1. Atlanto-occipital dislocation
This computed tomogram of the cervical spine shows major atlanto-occipital dislocation in
the lateral view that proved to be fatal.
 Treatment for low back pain dated to Hippocrates
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(460-370 BCE), who reported joint manipulation and
use of traction
Second most common office visit
2/3 of all adults will suffer from
85% idiopathic “strain/sprain”
Most common pain syndrome
Risk factors: heavy lifting, twisting, bodily vibration,
obesity, and poor conditioning
Deyo R and Weinstein J. N Engl J Med
2001;344:363-370
Firestein: Kelley's Textbook of
Rheumatology,8th ed. WB Saunders 2008
Differential Diagnosis of Low Back Pain
Mechanical Low
Back Pain 97%:
HNP: 4%
Spinal Stenosis
3%
Strain and sprain
have never been
anatomically or
histologically
characterized,
should be
referred to as
“idiopathic low
back pain”
Cancer: 0.7%
Infection: 0.1%
Inflammatory
Arthritis: 0.3%
Deyo R and Weinstein J. N Engl J Med 2001;344:363-370
Common Pathoanatomical Conditions of the Lumbar Spine
Deyo R and Weinstein J. N Engl J Med 2001;344:363-370
 Observed walk
 Heel and toe walking
 Skin exam…focused
-zoster
-café au lait spots
-hair tuft “faun’s beard”
-scoliosis
 Palpate all of the spinous processes of the
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thoracolumbar spine
Neurologic, muscle strength and reflex testing
Straight leg testing
Bowstring sign
Distracted straight leg test, positive with Tripod sign or
Flip sign
Femoral Stretch Test
Anal Wink
Fam. Musculoskeletal Examination and Joint
Injection techniques. Mosby Eslevier 2006.
With onset of
pain posterior
tibial nerve is
stretched like a
bowstring across
the popliteal fossa
Fam. Musculoskeletal Examination and Joint
Injection techniques. Mosby Eslevier 2006.
Pain in the
anterior
thigh or L2/3
region
indicates a
positive test
(tests for
HNP
compressing
nerve roots
L2/3/4)
Fam. Musculoskeletal Examination and Joint
Injection techniques. Mosby Eslevier 2006.
 Gaenslen test
 Patrick test
 SI distraction
 SI compression
 Spondylitis measuring
Normal
Finger
to Floor:
0-5 cm
Normal
Modified
Schobers 15
increases to
20 cm
Normal
Finger to
Fibula: 0-5
cm
Normal
Occiput to
Wall: 0-2 cm
Fam. Musculoskeletal Examination and Joint
Injection techniques. Mosby Eslevier 2006.
 Is there a serious underlying illness?
 Does the back pain have a neurogenic claudication or
sciatic-type syndrome?
Firestein: Kelley's Textbook of
Rheumatology,8th ed. WB Saunders 2008
 Limited to patients with systemic disease or trauma
 Guidelines recommend plain radiography for patients:
-with fever
-unexplained weight loss
-history of cancer
-neurologic deficits
-alcohol or injection-drug abuse
-age of more than 50 years
-trauma
Bigos S, Bowyer O, Braen G, et al. Rockville, Md.:
Agency for Health Care Policy and Research,
December 1994. (AHCPR publication no. 95-0642.)
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Recent significant trauma
Milder trauma age >50
Unexplained weight loss
Unexplained fever
Immunosuppression
History of cancer
Intravenous (IV) drug use
Osteoporosis
Prolonged use of corticosteroids
Age >70
Focal neurologic deficit progressive or disabling symptoms
Duration greater than 6 weeks
Low back pain. American College of Radiology.
ACR Appropriateness Criteria. Copyright ©2005
American College of Radiology
 There is no evidence that plain xrays in patients with
nonspecific low back pain are associated with
improvement in patient outcomes over selective imaging
 RCT 421 patients with lumbago x 6 weeks
 Exclusion criteria:
-if they had xrays of spine within 1 year
-unexplained weight loss or fever, were taking oral steroids,
had a history of malignancy, tuberculosis, injecting drug
use, or a positive result on a HIV test
-symptoms or signs of a cauda equina lesion
-were pregnant or planning a pregnancy
Kendrick D, Fielding K, Bentley E, Kerslake R,
Miller P, Pringle M. BMJ. 2001;322:400-5.
Kendrick D, Fielding K, Bentley E, Kerslake R,
Miller P, Pringle M. BMJ. 2001;322:400-5
 Researchers evaluated patients with baseline MRI
 Repeated MRI when developed low back pain
 Less than 5% developed new pathologic lesion
Representative Results of Magnetic Resonance Imaging Studies in Asymptomatic Adults
Deyo R and Weinstein J. N Engl J Med 2001;344:363-370
 Degenerative Disc Disease
 Paget’s
 DISH
 Ochronosis
 Renal Osteodystrophy
 Sickle Cell
 Scheuermann Kyphosis
 Infectious, briefly
 Idiopathic hemispherica sclerosis?
Signs of degeneration
include loss of disk height,
sclerosis of the endplates,
or osteophytic ridging
Rajeev K Patel, MD. Lumbar Degenerative Disk
Disease: Differential Diagnoses & Workup.
emedicine.com, updated 03 Aug 2009
Intervertebral Osteochondrosis (dehydration and
dessication of the nucleus pulposis) leads to the
vaccuum phenomenom, nitrogen gas formation,
bone sclerosis and disc space loss. This cavity then
becomes surrounded by a rim of sclerosis
(Schmorl’s node)
MR images of lumbar spine with degenerative changes at L1
Schellinger, D. et al. Am. J. Roentgenol. 2004;183:1761-1765
Copyright © 2006 by the American Roentgen Ray Society
 Results from disturbance in bone modelling and remodelling due to increase in
osteoblastic and osteoclastic activity
 Spine is the second most common site of bone involvement (Pelvis #1)
 Lumbar spine (L4 and L5 levels) are the most frequently involved sites (58%)
 Thoracic (45%)
 Cervical vertebrae (14%)
 Why does Paget’s hurt?
-Periosteal stretching
-Vascular engorgement
-Microfractures
-Facet arthritis
-Intervertebral disc disease
-Overt fractures
-Spondylolysis/-listhesis
-Sarcoma—very rare
Langston A, Ralston SH .Rheumatology (Oxford).
2004 Aug;43(8):955-9. Epub 2004 Jun 8. C.
Dell’Atti, V. N. et al Skeletal Radiol. 2007 July;
36(7): 609–626.
Axial CT sections in different patients
showing the various mechanisms
and their effect on marrow size
(long white arrow) and cortical thickness
(short white arrow).
a Periosteal apposition, normal endosteum.
b Periosteal apposition, endosteal resorption.
c Periosteal and endosteal apposition.
d Pumice stone type (dashed arrow) of
focal periosteal apposition. Similar focal
periosteal apposition of the spinous process
is seen
C. Dell’Atti, V. N. et al Skeletal Radiol. 2007 July;
36(7): 609–626.
a Lateral and b antero-posterior radiographs demonstrate expansion of the vertebra with
characteristic sclerotic lines parallel to the end-plates due to trabecular hypertrophy, an
“early” sign of PD. c Lateral radiograph in a different patient demonstrates the “picture
frame” vertebra due to thickening of the cortex and trabecular hypertrophy at the endplates
C. Dell’Atti, V. N. et al Skeletal Radiol. 2007 July;
36(7): 609–626.
Differential diagnoses of “ivory vertebra” include, Paget’s,
metastasis, osteosarcoma, carcinoid and Hodgkin’s
lymphoma . This is a case of metastatic prostate CA
Graham T S Radiology 2005;235:614-615
Langston A, Ralston SH .Rheumatology (Oxford).
2004 Aug;43(8):955-9. Epub 2004 Jun 8. C.
Dell’Atti, V. N. et al Skeletal Radiol. 2007 July;
36(7): 609–626.
 Most patients present with stiff back or non-specific
back pain
 Dysphagia, stridor, chronic pneumonia, and vascular
compression are all complications from advanced
disease
Khozaim Nakhoda Diffuse Idiopathic Skeletal
Hyperostosis. emedicine .com
 Clinical Criteria:
- Flowing calcifications/ossifications along anterolateral
aspect of 4 contiguous vertebral bodies, with or
without osteophytes
-Preservation of disk height in involved areas and
abscence of excessive disk disease
-Absence of bony ankylosis of facet joints and absence of
sacroiliac erosion, sclerosis, or bony fusion (narrowing
and sclerosis of facet joints ok)
Khozaim Nakhoda Diffuse Idiopathic Skeletal
Hyperostosis. emedicine .com
 Paraspinal ligaments undergo attrition, degenerate
then ossify
 Three clinical variants of spinal enthesopathy
1. Forestier’s disease involves the anterior longitudinal
ligament
2. DISH involves extra-axial sites
3. Ossification of the posterior longitudinal ligament
Khozaim Nakhoda Diffuse Idiopathic Skeletal
Hyperostosis. emedicine .com
 Etiology is unknown however there are some
associations:
-Hyperglcyemia and Diabetes
- Dyslipidemia
-Hyperuricemia
-Vitamin A derivatives used to treat acne
-Chronic fluoride intoxication
Vezyroglou G, Mitropoulos A, Antoniadis C. A . J
Rheumatol. Apr 1996;23(4):672-6.
DiGiovanna JJ SO J Am Acad Dermatol 2001
Nov;45(5):S176-82.
Utsinger PD; Resnick D; Shapiro R . Arch Intern
Ankylosing Spondylitis
DISH
 Syndesmophytes arise from
 The ossification in DISH attaches
anterosuperior and
anteroinferior margins of the
vertebral body
 Syndesmophytes may be best
seen in the frontal projection
 The presence of sacroiliac joint
erosions and extensive intraarticular bony ankylosis of the
sacroiliac and apophyseal joints
in ankylosing spondylitis
to the vertebral body several
millimeters from these margins
 Changes are most prominent on
the lateral radiographic
projection
 None
Firestein: Kelley's Textbook of
Rheumatology,8th ed. WB Saunders 2008
Diffuse idiopathic
skeletal
hyperostosis.
There is bone
formation along
the anterior
aspects of more
than four
vertebral bodies.
The disk spaces
are maintained,
and the sacroiliac
joints were
normal.
Firestein: Kelley's Textbook of
Rheumatology,8th ed. WB Saunders 2008
 Absence of homogentisic acid oxidase
 Consequent accumulation of homogentisic acid
 Autosomal recessive inheritance discovered by
Garod in 1902
Firestein: Kelley's Textbook of
Rheumatology,8th ed. WB Saunders 2008
Garrod, AE. The incidence of alkaptonuria: a study
in chemical individuality. Lancet 1902; 2:1616.
Dystrophic
(hydroxyapatite crystal)
calcification involving
disks but calcification
also seen in cartilage,
tendons, and ligaments.
The most specific is in
spine, which appears
osteoporotic with dense
disk calcification. Other
joints involved show
changes of mild
degenerative joint
disease, but this is a much
less specific .
Firestein: Kelley's Textbook of
Rheumatology,8th ed. WB Saunders 2008
Sclerosis is noted adjacent to the endplates (ruggerjersey spine) in a patient with renal osteodystrophy -- of
osteoid in these areas.
DDX osteomalacia and hyperparathyroidism.
University of Washington Department of Radiology
website. Musculoskeletal Radiology
BONUS: What type of fish is pictured to the right of the screen?
 Scheuermann kyphosis is defined as anterior wedging of ≥5º in at
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least three adjacent vertebral bodies, as measured on lateral
spine radiographs
Most common cause of structural kyphosis in adolescence.
The mode of inheritance is likely autosomal dominant
Etiology remains largely unknown
Indications for treatment remain controversial because the true
natural history of the disease has not been clearly defined
Brace treatment appears to be very effective if the diagnosis is
made early
Surgical treatment is rarely indicated for severe kyphosis (>75
degrees ) with curve progression, refractory pain, or neurologic
deficit
Lowe TG Orthop Clin North Am 1999
Jul;30(3):475-87, ix
This lateral radiograph of the thoracic spine
demonstrates moderate endplate irregularity,
preserved vertebral disc spaces, and mild anterior
wedging of the vertebral bodies, all of which are
consistent with Scheuermann kyphosis.
Courtesy of Jeanne Chow, MD, and Children's
Hospital Boston.
 Discitis
 Epidural Abscess
 Osteomyelitis
To differentiate from vaccuum phenomenom look
for gas, extension, osteophytes that occur in the
upper outer annular attachmentgrowing horizontal
then vertical (traction vs claw)
 Occurs in young women
 Vertebral level L4
 Appears as gas in an intervertebral body
 Pneumocyst vs AVN
 NSAID’s
 Tylenol
 Narcotics
 Tricyclic Antidepressants
 Muscle Relaxants
 Physical Therapy
 Non-Surgical Intervention therapy
 Surgery
 In a study of primary care patients
 80% of patients prescribed at least 1 medication
 Greater than 1/3 were prescribed 2 or more drugs
Cherkin DC, Wheeler KJ, Barlow W, Deyo RA.
Spine. 1998;23:607-14.
 5 acetaminophen trials
 57 NSAID trials
 10 trials of duloxetine and venlafaxine
 8 trials of benzodiazepines
 2 trials gabapentin
 2 trials topiramate
 36 trials of muscle relaxants
 9 opiod trials
 3 trials of tramadol
 4 trials of systemic corticosteroids
 ...so what is the bottom line Dave?
 Good evidence of short-term effectiveness for acute
low back pain are:
- NSAIDs
-acetaminophen
-skeletal muscle relaxant
*tricyclic antidepressants for chronic low back pain
 Evidence that opioids, tramadol, benzodiazepines, and
gabapentin are effective for pain relief of
radiculopathy.
 Good evidence that systemic corticosteroids are
ineffective.
Chou, Roger MD; Huffman, Laurie Hoyt MS Annals
of Internal Medicine
Issue: Volume 147(7), 2 October 2007, pp 505-514
 Tylenol first line
 NSAID’s for more severe pain
 Opioids in select patients with more severe pain
 My treatment regimen
-NSAID and muscle relaxant for mild to moderate pain
followed by manipulation
-Narcotic plus benzodiazepine followed by manipulation
for severe pain
Chou, Roger MD; Huffman, Laurie Hoyt MS Annals
of Internal Medicine
Issue: Volume 147(7), 2 October 2007, pp 505-514
 Recommendation 7: For patients who do not improve with self-care
options, clinicians should consider the addition of nonpharmacologic
therapy with proven benefits—for acute low back pain,
-Spinal manipulation; for chronic or subacute low back pain
-Intensive interdisciplinary rehabilitation
-Exercise therapy
-Acupuncture
-Massage therapy
-Spinal manipulation
-Yoga
-Cognitive-behavioral therapy
-Progressive relaxation
***(weak recommendation, moderate-quality evidence).
Chou, roger et al. Diagnosis. Ann Intern Med
October 2, 2007 vol. 147 no. 7 478-491
 One RCT
 39 patients
 Results:
-The individuals in the specific-exercise-training group
reported a significant decrease in LBP and disability
-Maintained over a 12-month follow-up period
-Treatment with a modified Pilates-based approach was
more efficacious than usual care in a population with
chronic, unresolved LBP
Rydeard R Leger A, Smith D
J Orthop Sports Phys Ther. 2006 Jul;36(7):472-84
 For low back pain with radiculopathy, 10 of 17 trials
found no difference in pain or function between
epidural glucocorticoid and placebo injection
 Similar findings for facet and nerve branch blocks
 Discography or injection of the disc at the level of pain
remains unproven
 Other therapies out there:
-Chemonucleolysis
-Electrothermal
-Radiotherapy
-Botulinum toxin
Chou R; Atlas SJ; Stanos SP; Rosenquist RW Spine
(Phila Pa 1976). 2009 May 1;34(10):1078-93
UptoDate.com
Indications for Surgical Referral among Patients with Low Back Pain
Deyo R and Weinstein J. N Engl J Med 2001;344:363-370
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Recommendation 1: Clinicians should conduct a focused history and physical examination to help
place patients with low back pain into 1 of 3 broad categories:
-Nonspecific low back pain
-Back pain potentially associated with radiculopathy or spinal stenosis
-Back pain potentially associated with another specific spinal cause
The history should include assessment of psychosocial risk factors, which predict risk for chronic
disabling back pain (strong recommendation, moderate-quality evidence).
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Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in
patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).
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Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low
back pain when severe or progressive neurologic deficits are present or when serious underlying
conditions are suspected on the basis of history and physical examination (strong recommendation,
moderate-quality evidence).
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Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or
symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or
computed tomography only if they are potential candidates for surgery or epidural steroid injection
(for suspected radiculopathy) (strong recommendation, moderate-quality evidence).
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Chou, Roger MD et al. Annals of Internal Medicine
Issue: Volume 147(7), 2 October 2007, pp 478-491
Recommendation 5: Clinicians should provide patients with evidence-based information
on low back pain with regard to their expected course, advise patients to remain active,
and provide information about effective self-care options (strong recommendation,
moderate-quality evidence).
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Recommendation 6: For patients with low back pain, clinicians should consider the use
of medications with proven benefits in conjunction with back care information and selfcare. Clinicians should assess severity of baseline pain and functional deficits, potential
benefits, risks, and relative lack of long-term efficacy and safety data before initiating
therapy (strong recommendation, moderate-quality evidence). For most patients, firstline medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
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Recommendation 7: For patients who do not improve with self-care options, clinicians
should consider the addition of nonpharmacologic therapy with proven benefits—for
acute low back pain, spinal manipulation; for chronic or subacute low back pain,
intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage
therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive
relaxation (weak recommendation, moderate-quality evidence).
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Chou, Roger MD et al. Annals of Internal Medicine
Issue: Volume 147(7), 2 October 2007, pp 478-491
 Gibbus
Chou, R et al. Diagnosis and Treatment of Low
Back Pain: A Joint Clinical Practice Guideline from
the American College of Physicians and the
American Pain Society . Ann Intern Med October 2,
2007 vol. 147 no. 7 478-491
Deyo R and Weinstein. Low Back Pain. J. N Engl J
Med 2001;344:363-370