low back pain: diagnosis to treatment!

Low Back Pain

Objectives

• General Knowledge (facts, stats, etiology, definition)

• Examination and Diagnostic Modality Options with the Low Back Pain Patient

• Treatment Options

Low Back Pain Defined

• Pain felt in your lower back may come from the spine, muscles, nerves, or other structures in that region. It may also radiate from other areas like the mid or upper back, a inguinal hernia, or a problem in the testicles or ovaries.

• A variety of symptoms may exist in the presence of back pain. There may be a tingling or burning sensation, a dull aching, or sharp pain. Weakness in the legs or feet may also exist.

• There won't necessarily be one event that actually causes low back pain. The patient may have engaged in common activities of daily living improperly -- like standing, sitting, or lifting -- for a long time. Then suddenly, one simple movement, like reaching for something in the shower or bending from your waist, leads to the feeling of pain.

Numbers

• Low back pain affects 60-80% of U.S. adults at some time during their lives, and up to 50% have back pain within a given year

• Back symptoms are among the 10 leading reasons for patient visits to emergency rooms, hospital outpatient departments, and physicians' offices

• Back pain is the most frequent cause of activity limitation in people younger than 45 years old

• Fifteen million American adults currently suffer lower back pain

Co$t

• Low-back pain (LBP) is the most common condition leading to workers' compensation claims associated with time loss (i.e., injuries sufficiently severe to lead a worker

to miss days from work • Americans spend at least $90 billion each year on back

pain

• Each year, Americans lose 93 million days of work, at a cost of $11 billion, due to low back injuries. They spend another $5 to $24 billion in direct medical expenses

Adding Up The Numbers

A billion dollars is more than 10,000 dollars a day for 300 years!

Perspective…..

Now Multiply That By 90!

Etiology(Shedding light on the subject)

• Non - Spinal Causes of Low Back Pain

• Spine Related Causes of Back Pain

Non-Spinal Related Causes

Bladder Infection Kidney Disease

Ovarian Cancer Ovarian Cyst

Testicular Torsion Fibromyalgia

Pelvic Infections Appendicitis

Pancreatitis Prostate Disease

Gall Bladder Disease

Abdominal Aortic Aneurysm

Spine Related Causes

Arthritis

Fibromyalgia

Kyphosis

Lordosis

Rheumatoid Arthritis

Ankylosing Spondylitis

Arachnoiditis

Bone Cancer

Chiari Malformation

Compression Fractures

Discitis

Epidural Abscess

Facet Joint Syndrome

Fixed Sagittal Imbalance

Osteomyelitis

Osteophytes

Pinched Nerve

Ruptured Disc

Spina Bifida

Spinal Cord Injury

Spinal Tumor

Spondylolisthesis

Spinal Stenosis

Spinal Cord Injury

Spinal Tumor

Sprain or Strain

Synovial Cysts

Wedge Fractures

Low Back Pain….The Patient

History

Physical Exam

Diagnostic Studies

History

Location

Specific Point vs. Across Back

Superficial vs. Deep

Involve Any other region (lower extremity)

History

Quality

Dull Ache (tooth ache)

Sharp/Stabbing

Burning

Tearing/Pop

History

Quality/Severity

Intermittent

Constant

Pain Scale 1-10

History

Setting

Time of day when worst/better

After strenuous activity

History

Aggravating/Relieving Factors

What Makes Better What Makes Worse

BEWARE OF THE PATIENT THAT SAYS NOTHING MAKES PAIN BETTER!

History

Associated Manifestations

Numbness

Tingling(pins/needles)

Burning

WeaknessIncontinence

Falls

THE EXAM

Physical Exam

General Survey

Muscle Bulk/Wasting

Posture

Alignment

Gait*

Patient Should always be examined in an examination gown

Gait **Foot Drop**

Physical ExamMotor Assessment

• Motor Strength - assess to breaking

• Tone

• Bulk Measurements

• Rapid Alternating Movements

• Point-to-Point Discrimination

Physical ExamTesting Muscle Strength

•0 - No muscular contraction detected•1 - Barley detectable trace or flicker of contraction

•2 - Active movement of body part with gravity eliminated

•3 - Active movement against gravity•4 - Active movement against gravity with some resistance•5 - Active movement against full resistance without evidence of fatigue

Physical ExamMotor Strength Feedback

Muscle Nerve of Innervation

Muscle Nerves of Innervation

Iliopsoas L2 – L4 Hip Adductors

L2 - L4

Hip

Abductors L4 - S1 Gluteus

Max. S1

Quads L2 – L4 Hamstrings L4 – S1

Dorsiflexors L4 – L5 Plantar

Flexiors S1

Physical ExamSensory

Pain

Light Touch

Position Sense

Vibration

Temperature Spinothalamic Tract

Posterior Column

Physical ExamReflexes

•Patellar - mediated by L2, L3, L4

•Achilles - mediated by S1

•Babinski - ⇑ toes = upper motor neuron dysfunction

•Clonus - rhythmic oscillation between dorsi & plantar flexion indicates central nervous system disease

Physical ExamReflexes

• Usually graded on a 0 to 4+ scale

• 4+ Very Brisk, Hyperactive with clonus

• 3+ Brisker than average, possibly, but not indicative of disease

• 2+ Average; Normal

• 1+ Somewhat diminished; low normal

• 0 No Response

• ** There is no minus in this score system

Diagnostic Studies

Diagnostic Studies

• Plain X-Ray

• MRI

• CAT Scan

• Myelogram

• Discogram

• Bone Scan

• Facet Block

• SI Joint Block

• EMG

• SSEP

• DEXAscan

• Bone Scan

Diagnostic StudiesX-Ray

• taken to assess the structure of the spine and to determine the alignment of the vertebra

Diagnostic StudiesX-Ray

Diagnostic StudiesMRI

• Extremely Sensitive for assessment of Soft tissue structures (nerves, disc)

• One of the most commonly ordered test to assess low back pain

• $$$$$$$$$$$$$

Diagnostic StudiesMRI

Diagnostic StudiesCAT Scan

• Most often used to assess bone structures of spine.

• Faster and cheaper than MRI

• Can be very effective tool when using reconstruction images or combined with other modalities

Diagnostic StudiesMyelogram & Post CT

• myelogram consists of a series of plain xrays with a contrast agent injected into the thecal sac.

• The C.A.T. scan that usually follows the myelogram depicts this same anatomy from a C.A.T. scan perspective

Diagnostic StudiesMyelogram & Post CT

The injection of iodine based contrast into the thecal sac containing the nerves and/or spinal cord, promotes better definition of those structures than the images obtained on the regular C.A.T. scan. Cross-sections and reconstructions of the images in different planes (including 3-D) allows different perspectives on the anatomy. This test is often used to visualize the spinal cord and nerves in relation to the surrounding spine structures (bone, joint, disc, etc)

Diagnostic StudiesDiscogram

• Involves the injection of contrast material into the disc space

• Concordant vs. Discordant Pain…..??

• Helpful in assessing discogenic pain

• VERY “uncomfortable” test

Conditions

• Strains & Sprains

• Stenosis

• Disc Herniation• Spondylolisthesis

Signs & Symptoms

Diagnostic Findings

Treatment Options}

Strains & Sprains

• Muscle strains and lumbar sprains are the most common causes of low back pain

• May refer to both injuries as a category called "musculoligamentous injuries“ (it doesn't matter what you call the problem because the treatment and prognosis for both back strains and sprains is the same)

Strains & SprainsSigns & SX

• Pain isolated to low back, which may increase with flexion or extension of the lumbar spine

• generally relieved with sitting, but symptoms are exacerbated with activities such as prolonged standing or bending

• Pain described as deep, dull, sharp at times

• P.E. usually shows normal motor and sensory function although pt. may appear weak 2° to pain

• P. E. may reveal point tenderness and evidence of spasm

Strains & SprainsDiagnostic Findings

• No tests are typically necessary during the first 4 weeks of symptoms if the injury is non-traumatic

• If, however one is ordered, evidence of edema on MRI will be seen in severe musculoligamentous injury, as well as straightening (flattening) of the lordotic curve is presence of spasm

Strains & SprainsTreatment

• Initial treatment involves rest from aggravating activities, medication for pain control, and modalities to decrease pain and inflammation.

• The use of cold packs to decrease edema during the first 48 hours after sprain/strain and the application of moist heat or cold thereafter to reduce pain and muscle spasm can be helpful.

• Bed rest for up to 48 hours may be beneficial but prolonged bed rest is discouraged. (Extremely Controversial) Relative rest by avoiding activities that exacerbate pain is preferable to complete bed rest.

• Temporary use of a lumbosacral support when out of bed may reduce pain and muscle spasm and increase activity tolerance.

• A short course of NSAIDs, acetaminophen, or muscle relaxants may be beneficial. Narcotics are generally not necessary but may be used in the very acute stage

Lumbar Spinal Stenosis

• The disorder can be congenital or acquired• Acquired lumbar stenosis usually is caused by

degenerative disease of the spine and is typically associated with hyperplasia, fibrosis, and cartilaginous changes in the annulus, posterior longitudinal ligament, and ligamentum flavum

• Also can be caused by Spondylolisthesis, spondylolysis, a defect in the pars interarticularis, may be related to injury, bony overgrowth such as occurs in Paget's disease, ankylosing spondylitis, rheumatoid arthritis, and diffuse idiopathic skeletal hyperostosis

Lumbar Spinal StenosisSigns & SX

•Patients present with pain that is brought on by activity and released by rest or leaning forward

•The pain involves the lower back and one or both legs, typically in a radicular distribution, and may be accompanied by numbness or weakness

•Examination often reveals no abnormality, except perhaps for a depressed knee or ankle reflex. SLR is usually negative

Lumbar Spinal StenosisDiagnostic Findings

Lumbar Spinal StenosisDiagnostic Findings

• MRI is the most sensitive technique for detecting the disorder

• Stenosis may be multifactorial….. Which will impact upon treatment options

Lumbar Spinal StenosisTreatment

• Conservative Management– Non-steroidal anti-inflammatory drugs, such as aspirin, naproxen

(Naprosyn), ibuprofen (Motrin, Nuprin, Advil), to reduce inflammation and relieve pain. New generation Cox-2 inhibitors have shown remarkable results in many cases

– Corticosteroid injections into the outermost of the membranes covering the spinal cord and nerve roots to reduce inflammation and treat acute pain that radiates to the hips or down a leg.

– Physical therapy and/or prescribed exercises to maintain motion of the spine and build endurance to help stabilize the spine

– lumbar brace or corset to provide some support and help the

patient regain mobility


• Surgery– most common surgical solution to spinal

stenosis is a laminectomy – Other procedures include Laminotomy,

Decompressive Laminectomy, Foraminotomy, Medial Facetectomy, Lumbar Discectomy and Fusion

Disc Herniation

• In the lumbar spine, at least 90% of disc herniations occur at the L5–S1 or L4–5 levels. L3–4 herniations make up only 5% of cases, with the remainder occurring at L2–3 and L1–2

• Clinically, a herniated disc at one level usually affects the nerve root that exits at the level below. For instance, a left L4–5 disc herniation usually compresses the left L5 nerve root

Disc HerniationSigns & SX

• Initial complaints are backache, and in most of those affected, there is no history of antecedent trauma

• Prior similar complaints of back pain or sciatica are common complaints

• The patient 's back pain is usually followed by severe pain that radiates into the lower extremities

• Numbness or paresthesias may occur in the same distribution as the pain, and weakness of selected muscle groups can occur

Clinical Findings of Common Lumbar Disc Herniations

Disc Nerve Root

Pain Sensory Change

Motor Deficits

Reflex Loss

L3–4 L4 Anterior thigh, anterior leg, and

medial ankle

Anterior leg Quad Knee jerk

L4–5 L5 Posterior hip and posterolateral thigh

and leg

Medial dorsum of foot and

occasionally medial ankle

Foot and toe

extension

None

L5–S1

S1 Hip, buttock, and posterior thigh and leg

Lateral foot and ankle

Plantar flexion

Ankle jerk

Disc HerniationSigns & SX

• Physical Exam – Paraspinal muscle spasm is frequently present – Radicular pain on flexion of the straight leg at the hip

present

– Complete motor, sensory, and reflex testing should be performed, however variability should be expected due to subtle neuroanatomic differences in patients or to specific characteristics of the actual disc herniation

– Motor, Sensory, and reflex findings may be present individually or in combination

Disc HerniationDiagnostic Findings

Disc HerniationTreatment – Non Surgical

• The mainstay of therapy for herniated lumbar disc is conservative treatment due to the majority of patients the symptoms resolving or subsiding to a level allowing normal activity within 4-6 weeks.

• Analgesics or muscle relaxants often help to relieve pain. • The most commonly prescribed drug therapy involves NSAIDS

reducing inflammation that may be the causative factor underlying nerve root pain.

• Physical Therapy has also become a mainstay in treating patients with HNP in order to strengthen the core support musculature

• Patients must be advised that continued home exercise is a must in order to prevent recurrent pain

• The vast majority of patients are treated with nonoperative techniques.

Disc HerniationTreatment – Surgical

• Indications for surgery include radicular pain that does not improve with conservative measures, recurrent episodes of incapacitating pain, disc herniations associated with significant weakness in the appropriate muscle groups, or massive midline herniations with signs of cauda equina compression

• EVIDENCE OF FOOT DROP OR INCONTINENCE IS A NEUROSURGICAL EMERGENCY. Pressure must be taken off the nerve root within 24hrs, or damage may become permanent

Disc HerniationTreatment – Surgical

The standard treatment of these disorders uses a midline incision over the affected interspace followed by a hemilaminectomy to expose the dural sac and nerve root. Gentle medial retraction of these structures exposes the herniated disc fragments, which are removed along with any loose disc material identified within the disc space. The nerve root is then explored thoroughly along its course to ensure that it is adequately decompressed. In cases of large disc herniations or in those cases with a free, extruded disc fragment, a complete laminectomy at the appropriate level may be necessary (microdiscectomy)

Spondylolisthesis

• Spondylolisthesis is the anterior displacement of one vertebral body over another

• The severity of the slippage in spondylolisthesis is classified according to the migration of the cephalad vertebrae over the caudad. Grade I represents 0% to 25% slippage; grade II, 25% to 50% slippage; grade III, 50% to 75% slippage; and grade IV, 75% to 100% slippage

SpondylolisthesisSigns & SX

• The patient usually complains of gradual onset of low back pain.

• Pain is characterized as deep and aching and is localized to the affected levels.

• Patients may also complain of pain in the buttock or iliac crest.

• Movement makes the pain worse, as do Valsalva maneuvers

• Radicular type symptoms exist most often due to nerve root irritation

SpondylolisthesisDiagnostic Findings

• Most all diagnostic imaging modalities can pick up a Spondy, however dynamic studies are the most telling

SpondylolisthesisTreatment Non-Surgical

• If the spondylolisthesis is non-progressive, no treatment except observation is required. Symptoms often abate once precipitating activities cease. Conservative treatment includes, restriction of activities causing stress to the lumbar spine (e.g. heavy lifting, stooping), physical therapy, anti-inflammatory and pain reducing medications, and/or a corset or brace.

SpondylolisthesisTreatment Surgery

Future Trends

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low back pain: diagnosis to treatment!

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