Transcript Low Back Pain 26.05.15

Approach to the
patient with
Low Back Pain
in Primary Care
Objectives
Differentiate between concerning and non-
concerning causes for acute low back pain
Identify historical red flags
Identify examination red flags
Briefly review evidence-based treatment
options for low back pain
Acute Low Back Pain
 Easy Visit???
 Frustrating Visit???
Acute Low Back Pain
 Easy
 Usually not serious
 Limited management
options
 Often quick exam
 Frustrating
 Difficult patients
 Limited management
options
 Can feel unsatisfying
Differential Diagnosis:
 30 seconds
 List differential diagnosis for Low back pain
 30 seconds
 List differential diagnosis for “bad” causes of Low back
pain
Differential Diagnosis of Low Back Pain
Mechanical low back pain (97%)
 Lumbar strain or sprain (≥ 70%) Diffuse pain in lumbar muscles; some
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radiation to buttocks
Degenerative disc or facet process (10%) Localized lumbar pain; similar
findings to lumbar strain
Herniated disc (4%) Leg pain often worse than back pain; pain
radiating below knee
Osteoporotic compression fracture (4%) Spine tenderness; often
history of trauma
Spinal stenosis (3%) Pain better when spine is flexed or when seated,
aggravated by walking downhill more than uphill; symptoms often
bilateral
Spondylolisthesis (2%) Pain with activity, usually better with rest;
usually detected with imaging; controversial as cause of significant
pain
Differential Diagnosis of Low Back Pain
Nonmechanical spinal conditions (1%)
 Neoplasia (0.7%) Spine tenderness; weight loss
 Inflammatory arthritis (0.3%) Morning stiffness,
improves with exercise
 Infection (0.01%) Spine tenderness; constitutional
symptoms
Differential Diagnosis of Low Back Pain
Nonspinal/visceral disease (2%)
 Pelvic organs—prostatitis, pelvic inflammatory disease,
Endometriosis-Lower abdominal symptoms common
 Renal organs—nephrolithiasis, pyelonephritis Usually
involves abdominal symptoms; abnormal urinalysis
 Aortic aneurysm - Epigastric pain; pulsatile abdominal
mass
 Gastrointestinal system—pancreatitis, cholecystitis,
peptic ulcer Epigastric pain; nausea, vomiting
 Shingles – (zona) Unilateral, dermatomal pain; distinctive
rash
Differential Take-Home
 97% is mechanical
 4% Herniated disc (95% L4-L5; L5-S1)
 2% Non-back sources
 1% Cancer and Infection
 0.2% Cauda Equina
Our Job…
 In 15 minutes, differentiate benign from serious causes
of low back pain
We Need a Strategic Timeline
 Good history – 3-5 minutes
 Focused Exam – 2-4 minutes
 Treatment options and patient education – 4-5
minutes
The Case Begins:
 87 year old Mehmet bey presents to clinic for back
pain
 Located mid to low back
 Started about 3-4 days ago
Outline
 List essential components of a LBP history, including
Red flags
 Review Physical Examination for LBP
 Identify Red flags
 Review proper indications for lab and imaging
 Discuss acute management options
General Questions
 Onset
 Location
 Mechanism of Injury
 Radiation
 Positional change
 Numbness, tingling
 Weakness
Diagnoses & Red Flags*
Cancer
 Age > 50
 History of Cancer
 Weight loss
 Unrelenting night
pain
 Failure to improve
Infection
 IVDU
 Steroid use
 Fever
 Unrelenting night
pain
 Failure to improve
Fracture
 Age >50
 Trauma
 Steroid use
 Osteoporosis
Cauda Equina
Syndrome
 Saddle anesthesia
 Bowel/bladder
dysfunction
 Loss of sphincter control
 Major motor weakness
Diagnoses & Red Flags
Cancer
 Age > 50
 History of Cancer
 Weight loss
 Unrelenting night
pain
 Failure to improve
Infection
 IVDU
 Steroid use
 Fever
 Unrelenting night
pain
 Failure to improve
Fracture
 Age >50
 Trauma
 Steroid use
 Osteoporosis
Cauda Equina
Syndrome
 Saddle anesthesia
 Bowel/bladder
dysfunction
 Loss of sphincter control
 Major motor weakness
Our case
 Red flags
 Age 87
 Hx/o Non-Hodgkin’s
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Remission for the past 4 years
Our Case
 No hx/o back problems
 No trauma
 No radiation
 No focal weakness
 No numbness or tingling
 No change in bowel or bladder function
Outline
 List essential components of a LBP history, including
Red flags
 Review Physical Examination for LBP
 Identify Red flags
 Review proper indications for lab and imaging
 Discuss acute management options
Physical Exam*
Rule-out most concerning things
 Concerning features
 Decreased strength
 Diminished reflexes
 Sensory loss
 Reassuring features
 Paraspinal muscle
spasm
 Full strength
 No sensory deficits
Six-Point MSK Exam
Inspection
Palpation
ROM
Strength
Neurovascular
Special Tests
Inspection
Ensure
No obvious deformities
No erythema
Skin lesions (Zoster)
Palpation
 Soft Tissue
 4 clinical zones
 Paraspinal muscles
 Gluteal muscles
 Sciatic area
 Anterior
abdomen/abdominal
wall
 Bones
 Primarily palpating
spinous processes and
facets
Neurologic Testing
 Sensation
 Strength
 Reflexes
Special Tests
Tests to stretch spinal cord or
sciatic nerve
Tests to stress the sacroiliac joint
Straight Leg Raise
 The straight leg raise, also called Lasègue's sign, is a
test done during the physical examination to
determine whether a patient with low back pain has an
underlying herniated disk, often located at L5 (fifth
lumbar spinal nerve).
Straight leg raise
 Looking for lumbar disk herniation
 Performed supine for best sensitivity
 Positive when radiating pain observed at 30-70 degress
of hip flexion
 Very high sensitivity, but low specificity
 Should also do the crossed-leg straight leg raise
 Positive when they have pain when you lift and adduct
the opposite leg
FABER test:
To assess for the sacroiliac joint or hip joint being
the source of the patient's pain
If pain is elicited on the ipsilateral side anteriorly, it
is suggestive of a hip joint disorder on the same
side. If pain is elicited on the contralateral side
posteriorly around the sacroiliac joint, it is
suggestive of pain mediated by dysfunction in that
joint.
Flexion
A-Bduction
External
Rotation
Tests
 Lab
 Based on clinical picture
 Think Red Flags
 Imaging
 XR
 CT
 MRI
Imaging Guidelines
 Choice to do imaging based on:
 Historical red flags
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Trauma, chronic steroid use = XRay
Suspect abscess, cauda equina = MRI
 Exam red flags
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New/severe sensory or strength loss = consider MRI
Outline
 List essential components of a LBP history, including
Red flags
 Review Physical Examination for LBP
 Identify Red flags
 Review proper indications for lab and imaging
 Discuss acute management options
Back pain treatment
 NSAIDs (A)
 Improve pain vs. placebo in controlled trials
 No difference between them
 NNT for 50% pain relief is 2-3
 Muscle relaxants (A)
 Most beneficial in the first week
 Shown effective in trials
 Work best when combined w/ NSAIDs
Treatment
 Pain relievers
 Both opioid and non-opioid
 Steroids
 No benefit shown w/ orals
 Short-term benefit shown for epidural
 Bed rest
 NO!!!
 Activity increases functional status and decreases time
missed from work and pain
Treatment
 Exercise plan
 No benefit during the acute phase, but helpful
afterwards for prevention in MSK back pain (although
USPSTF is neither for nor against)
 Massage
 Mixed evidence, but not harmful
 Acupuncture
 Most good studies show no benefit, but overall results
are mixed
 Ice/Heat (B)
 Equivalent in a Cochrane review
Clinical recommendation
and Evidence rating
 In the absence of “red flag” findings or signs of
cauda equina syndrome, four to six weeks of
conservative care is appropriate for patients with
acute low back pain. C
 Nonsteroidal anti-inflammatory drugs,
acetaminophen, and skeletal muscle relaxants are
effective first-line medications in the treatment of
acute, nonspecific low back pain. A
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A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented
evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series.
Clinical recommendation and
Evidence rating
 Bed rest for more than two or three days in
patients with acute low back pain is ineffective and
may be harmful. Patients should be instructed to
remain active. A
 Education about activity, aggravating factors,
natural history, and expected time course for
improvement may speed recovery of patients with
acute low back pain and prevent chronic back
pain. C
 Specific back exercises for patients with acute low
back pain are not helpful. A
Clinical recommendation
and Evidence rating
 Heat therapy may be helpful in reducing pain and
increasing function in patients with acute low back
pain. B
 Spinal manipulative therapy for acute low back pain
may offer some short-term benefits but probably is no
more effective than usual medical care. B
Conclusions
 History is very important
 Don’t forget your red flags
 Look for focal findings on exam
 There is evidence to help with treatment
 Pt’s w/ low back pain or sciatica w/o red flag
SYMPTOMS should try conservative management for
about 6 wks prior to imaging or intervention
References
 Evaluation and Treatment of Acute Low Back Pain.
AAFP. 75(8), 2007.
 Acute Lumbar Disk Pain. AAFP. 78(7), 2008.
 When to Consider Osteopathic Manipulation. JFP.
59(9), 2010.
 ACSM Primary Care Sports Medicine.
 Physical Exam of the Spine and Extremities.
Hoppenfeld, S. et al.
Questions???