1

Diagnosing Low Diagnosing Low Back PainBack Pain

Eden Wheeler, M.D.Eden Wheeler, M.D. Physical Medicine and RehabilitationPhysical Medicine and Rehabilitation

Rockhill Orthopaedics, P.C.Rockhill Orthopaedics, P.C.

2

I. History:I. History:

3

• Mechanism of injuryMechanism of injury

• Associated symptoms: Associated symptoms: • Bladder / bowel function

• Fevers / chills

• Sleep disturbance

• Numbness / tingling

• Prior injuries, treatment and outcomesPrior injuries, treatment and outcomes

• MedicationsMedications

• Family historyFamily history

• Social history:Social history:• Vocational

• Education

• Tobacco / ETOH / Illicit drugs

• Function: ADLs & Mobility

• Litigation Litigation

4

Pain Specifics:Pain Specifics:• Quality:Quality: sharp, dull, shooting, burning, etc.

• Location / Distribution:Location / Distribution: • Radicular: Dermatomal distribution, dysesthesias

• Radiating: Nondermatomal

• Onset:Onset:• Gradual: DDD

• Acute: Disc abnormality, strain, compression fractures

• Severity / IntensitySeverity / Intensity• Frequency:Frequency: Constant vs. Intermittent

• DurationDuration• Exacerbating and Alleviating FactorsExacerbating and Alleviating Factors• Time of Day: Time of Day: If nocturnal, consider malignancy

5

Red Flags:Red Flags:• Significant trauma history, or minor in older adultsSignificant trauma history, or minor in older adults

• Nocturnal pain in supine position with history of cancerNocturnal pain in supine position with history of cancer

• Bladder or bowel incontinence or dysfunctionBladder or bowel incontinence or dysfunction

• Constitutional symptoms:Constitutional symptoms:• Fever / chills

• Weight loss

• Lymph node enlargement

• Risk factors for spinal infectionRisk factors for spinal infection• Recent infection

• IV drug use

• Immunosuppression

• Major motor weaknessMajor motor weakness

6

II. Examination:II. Examination:

7

A. Physical:A. Physical:• Posture:Posture:

• Splinting

• Body language

• Gait:Gait:• Antalgia

• Heel / Toe pattern

• Trendelenberg

• Musculoskeletal:Musculoskeletal:• ROM

• Leg length

• Vascular

• Atrophy

8

• Abdomen:Abdomen:• Presence of masses

• Back:Back:• Inspection

• Palpation

• ROM

• Scoliosis

• Neurological:Neurological:• Sensation

• Motor

• DTRs

• Rectal if indicated:Rectal if indicated:• Evaluation of sphincter tone

9

B. Symptom Magnification B. Symptom Magnification Examination:Examination:

• Waddell signs:Waddell signs: Presence of nonorganic signs suggesting symptom magnification and psychological distress– Superficial or nonanatomic distribution of tenderness

– Nonanatomic or regional disturbance of motor or sensory impairment

– Inconsistency on positional SLR

– Inappropriate/excessive verbalization of pain or gesturing

– Pain with axial loading or rotation of spine

• Give-away weakness:Give-away weakness: Inconsistent effort on manual motor testing with “ratcheting” rather than smooth resistance

10

C. Pathological Examination:C. Pathological Examination:• Spurling’s maneuver:Spurling’s maneuver: Lateral rotation and extension of spine resulting

in neuroforaminal narrowing and nerve root encroachment, clinically reproducing extremity pain, usually in dermatomal

distribution

• Straight-leg raise (SLR):Straight-leg raise (SLR): Elevation of lower extremity, seated or standing, resulting in neural tension at S1 nerve root with

extremity pain

• Patrick’s maneuver:Patrick’s maneuver: Crossed leg with unilateral pain indicative of sacro-iliac (SI) joint dysfunction

• Femoral stretch:Femoral stretch: Hip extension stretch with heel pushed to buttock in lateral supine or prone position resulting in anterior thigh pain

11

III. Low Back Pain:III. Low Back Pain:

12

A. Epidemiology:A. Epidemiology:• Incidence of LBP:Incidence of LBP:

• 60-90 % lifetime incidence

• 5 % annual incidence

• 90 %90 % of cases of LBP resolve without treatment within 6-12 of cases of LBP resolve without treatment within 6-12 weeksweeks

• 40-50 %40-50 % LBP cases resolve without treatment in 1 week LBP cases resolve without treatment in 1 week

• 75 %75 % of cases with nerve root involvement can resolve in 6 of cases with nerve root involvement can resolve in 6 monthsmonths

• LBP and lumbar surgery are:LBP and lumbar surgery are:

• 2nd and 3rd highest reasons for physician visits

• 5th leading cause for hospitalization

• 3rd leading cause for surgery

13

B. Disability:B. Disability:

• Age and LBP:Age and LBP:• Leading cause of disability of adults < 45 years old

• Third cause of disability in those > 45 years old

• Prevalence rate:Prevalence rate:• Increased 140 % from 1970 to 1981 with only

125 % population growth

• Nearly 5 million people in the U.S. are ondisability for LBP

14

C. Lifetime Return to Work:C. Lifetime Return to Work:

• Success of Success of less than 50 %less than 50 % if off work greater if off work greater than 6 monthsthan 6 months

• 25 %25 % success rate if off work greater than 1 year success rate if off work greater than 1 year

• Nearly 0 %Nearly 0 % success if return to work has not success if return to work has not occurred in 2 yearsoccurred in 2 years

15

D. Occupational Risk Factors:D. Occupational Risk Factors:

• Low job satisfactionLow job satisfaction

• Monotonous or repetitious workMonotonous or repetitious work

• Educational levelEducational level

• Adverse employer-employee relationsAdverse employer-employee relations

• Recent employmentRecent employment

• Frequent liftingFrequent lifting• Especially exceeding 25 pounds

• Utilization of poor body mechanics in technique

16

E. Differential Diagnoses:E. Differential Diagnoses:• Lumbar strainLumbar strain

• Disc bulge / protrusion / extrusionDisc bulge / protrusion / extrusion producing radiculopathy producing radiculopathy

• Degenerative disc diseaseDegenerative disc disease

• Spinal stenosisSpinal stenosis

• SpondyloarthropathySpondyloarthropathy

• SpondylosisSpondylosis

• SpondylolisthesisSpondylolisthesis

• Sacro-iliac dysfunctionSacro-iliac dysfunction

17

F. Diagnostic Tools:F. Diagnostic Tools:• 1. Laboratory:1. Laboratory:

• Performed primarily to screen for other disease etiologies• Infection

• Cancer

• Spondyloarthropathies

• No evidence to support value in first 7 weeks unless with red flags

• Specifics:• WBC

• ESR or CRP

• HLA-B27

• Tumor markers: Kidney Breast Lung Thyroid Prostate

18

• 2. Radiographs:2. Radiographs:• Pre-existing DJD is most common diagnosis

• Usually 3 views adequate with obliques only if equivocal findings

• Indications:• History of trauma with continued pain

• Less than 20 years or greater than 55 years with severe or persistent pain

• Noted spinal deformity on exam

• Signs / symptoms suggestive of spondyloarthropathy

• Suspicion for infection or tumor

19

• 3. EMG / NCV ( Electrodiagnostics):3. EMG / NCV ( Electrodiagnostics): • Can demonstrate radiculopathy or peripheral nerve

entrapment, but may not be positive in the extremities for the first 3-6 weeks and paraspinals for the first 2 weeks

• Would not be appropriate in clinically obvious radiculopathy

• 4. Bone scan:4. Bone scan: • Very sensitive but nonspecific

• Useful for:• Malignancy screening

• Detection for early infection

• Detection for early or occult fracture

20

• 5. Myelogram:5. Myelogram:• Procedure of injecting contrast material into the spinal canal

with imaging via plain radiographs versus CT

• In past, considered the gold standard for evaluation of the spinal canal and neurological compression

• With potential complications, as well as advent of MRI and CT, is less utilized:

• More common: Headache, nausea / vomiting

• Less common: Seizure, pain, neurological change, anaphylaxis

• Myelogram alone is rarely indicated

• Hitselberger study 1968 Journal of Neurosurgery:• 24 % of asymptomatic subjects with defects

21

• 6. CT with myelogram:6. CT with myelogram: • Can demonstrate much better anatomical detail than

myelogram alone

• Utilized for:• Demonstrating anatomical detail in multi-level disease in pre-

operative state

• Determining nerve root compression etiology of disc versus osteophyte

• Surgical screening tool if equivocal MRI or CT

22

• 7. CT:7. CT:• Best for bony changes of spinal or foraminal stenosis

• Also best for bony detail to determine:• Fracture

• DJD

• Malignancy

• SW Wiesel study 1984 Spine:• 36 % of asymptomatic subjects had “HNP” at L4-L5

and L5-S1 levels

23

• 8. Discography (Diagnostic disc injection):8. Discography (Diagnostic disc injection):• Less utilized as initial diagnostic tool due to high incidence of

false positives as well as advent of MRI

• Utilizations:• Diagnose internal disc derangement with normal MRI / myelo

• Determine symptomatic level in multi-level disease

• Criteria for response:• Volume of contrast material accepted by the disc, with normals of 0.5 to

1.5 cc

• Resistance of disc to injection

• Production of pain---MOST SIGNIFICANT

• Usually followed by CT to evaluate internal architecture, but also may utilize MRI

• As outcome predictor (Coulhoun study 1988 JBJS):• 89 % of those with pain response received benefit from surgery

• 52 % of those with structural change received surgical benefit

24

• 9. MRI:9. MRI:• Best diagnostic tool for:

• Soft tissue abnormalities:• Infection

• Bone marrow changes

• Spinal canal and neural foraminal contents

• Emergent screening:• Cauda equina syndrome

• Spinal cored injury

• Vascular occlusion

• Radiculopathy

• Benign vs. malignant compression fractures

• Osteomyelitis evaluation

• Evaluation with prior spinal surgery

25

• Has essentially replaced CT and myelograms for initial evaluations

• Boden study 1990 JBJS:

• 20 % of asymptomatic population less than 60 years with “HNP”

• 36 % of asymptomatic population of 60 years

• Jensen study 1995 NEJM:

• 52 % of asymptomatic patients with disc bulge at one or more levels

• 27 % of asymptomatic patients with disc protrusion

• 1 % of asymptomatic patients with disc extrusion

26

• MRI with Gadolinium contrast:MRI with Gadolinium contrast:• Gadolinium is contrast material allowing enhancement of

intrathecal nerve roots

• Utilization:• Assessment of post-operative spine---most frequent use

• Identifying tumors / infection within / surrounding spinal cord

• Diagnosis of radiculitis

• Post-operatively can take 2-6 months for reduction of mass effect on posterior disc and anterior epidural soft tissues which can resemble pre-operative studies

• Only indications in immediate post-operative period: • Hemorrhage

• Disc infection

27

• 10. Psychological tools:10. Psychological tools:• Utilized in case scenarios where psychological or emotional

overlay of pain is suspected• Symptom magnification

• Grossly abnormal pain drawing

• Non-responsive to conservative interventions but with essentially normal diagnostic studies

• Includes:• Pain Assessment Report, which combines:

• McGill Pain Questionnaire

• Mooney Pain Drawing Test

• MMPI

• Middlesex Hospital Questionnaire

• Cornell Medical Index

• Eysenck Personality Inventory

28

MRI Nomenclature:MRI Nomenclature: (PER NASS)

• Anular fissure:Anular fissure: Focal disruption of anular fibers in concentric, radial or transverse distribution

• Disc bulge:Disc bulge: Circumferential, diffuse, symmetric extension of anulus beyond the adjacent vertebral end plates by 3 or more mm, usually due to weakened or lax anular fibers

• Disc protrusion:Disc protrusion: Focal, asymmetric extension of disc segment beyond margin of vertebral end plates into the spinal canal with most of anular fibers intact

• Disc extrusion:Disc extrusion: Focal, asymmetric extension of disc segment and / or nucleus pulposis through the anular containment into the epidural space

• Disc sequestration:Disc sequestration: Extruded disc segment that is detached from original with migration into the canal

• Disc degeneration:Disc degeneration: Irreversible structural and histiological changes in nucleus seen on MRI T2WI images (commonly associated with bulge)

29

Specificity / SensitivitySpecificity / Sensitivity

Diagnosis Test Sensitivity Specificity

CT 0.90 0.70

MRI 0.90 0.70

Disc“Herniation”

CT Myelo 0.90 0.70

CT 0.90 0.80-0.95

MRI 0.90 0.75-0.95

SpinalStenosis

Myelogram 0.77 0.70

30

G. TreatmentG. Treatment• MedicationsMedications

• NSAIDS

• Membrane stabilizers• TCA / Neurontin

• re-establish sleep pain

• reduce radicular dysesthesias

• Muscle relaxers:• re-establish sleep patterns

• more useful in myofascial/muscular pain

• Narcotics: rarely indicated

• Steroids: more useful for radiculitis

• Non-narcotic analgesics: Ultram

31

• Physical therapyPhysical therapy• Modalities

• electrical stimulation/TENS

• Postural education / body mechanics

• Massage / mobilization / myofascial release

• Stretching / body work

• Exercise / strengthening

• Traction

• Pre-conditioning / work-conditioning

• InjectionsInjections• Epidural blocks

• Facet blocks

• Trigger point

• SNRB

• SI joint

32

• Surgery:Surgery:• Laminectomy

• Fusion

• Discectomy

• Percutaneous Lumbar Discectomy– Success rate variable 50 -85 %

– Low rate of complications:• Infection

• Peripheral nerve injury

– Benefits:• Outpatient procedure

• Minimal to no epidural scarring

• No general anesthesia

• Spine stability preservation

• Decreased cost

33

• ChemonucleolysisChemonucleolysis• IDET: IDET: Intradiscal Electrotherapy or Spine CATH

• Alternative:Alternative:• Chiropractic:

• Clinical studies show benefit only in first 3 weeks of symptoms

• Acupuncture

• Biofeedback

34

IV. Specific Disorder IV. Specific Disorder ConsiderationsConsiderations

35

A. Sacroiliitis:A. Sacroiliitis:• History:History:

• Trauma is very common

• Repetitive LS motion--lumbar rotation or axial loading

• No specific correlation with exacerbating activities

• Commonly have leg length discrepancy or condition contributing

• Biomechanics:Biomechanics:• Movement of the SIJ is involuntary, usually from muscle imbalances

• Can occur at multiple levels: lower extremities, hip, LS spine

• Motion is complex and not single-axis based

36

• Differential Diagnosis:Differential Diagnosis:a. Fracturea. Fracture

• Traumatic• Insufficiency stress fractures: elderly patient with osteoporosis

without history of trauma

• Fatigue stress fractures: usually athletes / soldiers

b. Infectionb. Infection• Hematogenous spread with predisposing history

• Usually unilateral symptoms present

c. Degenerative joint diseasec. Degenerative joint disease

d. Metabolic diseased. Metabolic disease

e. Referred paine. Referred pain

37

f. Seronegative spondyloarthropathiesf. Seronegative spondyloarthropathies• RA--usually not until late in course of disease

• Ankylosing spondylitis

• Psoriatic arthritis

g. Primary SI tumorg. Primary SI tumor• Rare and usually synovial villoadenomas

h. Iatrogenic instabilityh. Iatrogenic instability• Via pelvic tumor resection or bone graft site

i. Osteitis condensans iliii. Osteitis condensans ilii• Prevalence of 2.2 %, primarily in multiparous women

• Usually self-limiting and bilateral

j. Reactive diseasej. Reactive disease as sequellae of PID

38

• Diagnostic Tools:Diagnostic Tools:• X-rays: Up to 25 % of asymptomatic adults over 50 years

can have abnormalities

• MRI / CT: Only if looking for tumor

• Bone scan: Good for fractures but less favorable for inflammation

• Treatment:Treatment:• Medications: NSAIDS

• Physical therapy

• Correct limb discrepancy

• Injection: Fluoroscopy-guided vs. local

• Surgical fusion: Few figures for efficacy

39

B. Cauda Equina Syndrome:B. Cauda Equina Syndrome:• History:History:

• Sudden, partial or complete loss of voluntary bladder function due to massive disc impingement on spinal nerves

• Can include loss of sensation as well as sphincter tone

• Treatment:Treatment:• Urgent decompression is mandatory for prevention of

irreparable / irreversible bladder damage

• 12 hours is the maximum time prior to irreversible changes

40

C. DDD and Spondylosis:C. DDD and Spondylosis:• Clinical:Clinical:

• Up to 75 % of involvement of the spine occurs at 2 levels:L5-S1 and L4-L5

• Possible factors that contribute to development:– Changes with maturation in:

• Nutrition

• Disc chemistry

• Hormones

– Occupational forces

• Progression of disc narrowing leads to degenerative changes of bony structures, especially posterior components, leading

to spondylosis

41

• Treatment:Treatment:• Medications

• Physical therapy

• Lifestyle changes:• Smoking cessation

• Weight loss

• Vocational changes

• Injections: • Less helpful if pain is limited to central low back only

• Surgery:• Laminectomy

• Fusion

42

D. Spinal Stenosis:D. Spinal Stenosis:• Clinical:Clinical:

• Results from narrowing of spinal canal and / or neural foramina (CONGENITAL OR DEGENERATIVE)

• Most common complaint is leg pain limiting walking

• Neurogenic / Pseudoclaudication = pain in lower extremities with gait

• Relief can occur with:– stopping activity

– sitting, stooping or bending forward

• Common are complaints of weakness and numbness of extremities

• Usually becomes symptomatic in 6th decade

43

• Diagnosis:Diagnosis:• CT and MRI may yield false-positive results, therefore EMG /

NCV can be helpful to confirm diagnosis

• Myelography also can be confirmatory and pre-surgicalscreening tool

• Treatment:Treatment:• Medications

• Physical therapy

• TENS

• Epidural injections

• Surgical decompression laminectomy

44

E. “HNP”:E. “HNP”:

• Clinical:Clinical:• Low back pain wit associated leg symptoms

• Positions can induce radicular symptoms

• Posterolateral disc pathology most common:• Area where anular fibers least protected by PLL

• Greatest shear forces occur with forward or lateral bend

• Central disc pathology:• Usually with LBP only without radicular symptoms, unless

a large defect is present

45

• Treatment:Treatment: • Conservative treatment:

– Saul and Saul study 1989 Spine:• > 90 % success rate of symptom resolution with

non-operative management

– Bozzao study 1992 Radiology:• 69 patients with “HNP” studied longitudinally with MRI

• 63 % with >30 % reduction with 48 % > 70 % reductionover time

• Medications

• Physical therapy

• Injections

• Surgery

46

F. Pars Interarticularis Defects:F. Pars Interarticularis Defects:

• Spondylolysis:Spondylolysis:• Anatomic defect in the bony pars interarticularis within the lamina

• May uni- or bilateral

• Can be congenital or induced

• Usually without clinical symptoms with incidental findings on radiographs

47

• SpondylolisthesisSpondylolisthesis• Progression of spondylolysis with separation

• Grades assigned I-IV for level of translation

• Most common levels are L5-S1 (70 %) and L4-L5 (25 %)

• May be asymptomatic, but can result in• Spondylosis

• DDD

• Radiculopathy

• Treatment:Treatment:• Medication

• Physical Therapy

• Injections

• Surgery

48

V. Chronic Pain IssuesV. Chronic Pain Issues

49

A. Pain Reinforcing Factors:A. Pain Reinforcing Factors:• Secondary gain:Secondary gain: Support system allows passive / inactive role for patient via

catering to needs and hence fostering dependency

• Environmental:Environmental: Inadequate opportunity or skills to compete in the professional community

• Physician knowledge deficit:Physician knowledge deficit: In areas of diagnosis and appropriate treatment, can prolong symptoms and validate pain behavior

• Worker’s compensation:Worker’s compensation: Laws have become counterproductive-- financial compensation or open claim may discourage desire for return work and impede recovery

• Litigation:Litigation: Anticipation of large financial settlement can reinforce pain behavior and develop into learned pain behavior

50

B. Risk Factors for Delayed B. Risk Factors for Delayed Recovery:Recovery:

Occupational Psychosocial Medical

Job availability Anger with “system” History of narcotic orsubstance abuse

Patient perception ofwork load

Disabled spouse Poor fitness

Job dissatisfaction Poor English

proficiency History of prior

injury

Time off of work

51

C. Discouraging Chronic Pain:C. Discouraging Chronic Pain:

• Requiring employer to accommodate restrictions to allow Requiring employer to accommodate restrictions to allow continued working during treatment and recoverycontinued working during treatment and recovery

• Rapid abjudication of disability and compensation claimsRapid abjudication of disability and compensation claims

• Physician education re: appropriate treatments and limiting use of Physician education re: appropriate treatments and limiting use of potentially addictive medicationspotentially addictive medications

• Ergonomic work environmentsErgonomic work environments

• Patient education re: disease process and treatment optionsPatient education re: disease process and treatment options

52

D. Considerations ofD. Considerations ofPM & R Treatment:PM & R Treatment:

• Physical therapy is initially usually one of modalities with progression Physical therapy is initially usually one of modalities with progression into more active exerciseinto more active exercise

• Pre-conditioning therapy is more functional with transition into Work Pre-conditioning therapy is more functional with transition into Work Conditioning (Work Hardening) programConditioning (Work Hardening) program

• AlwaysAlways consider return to work, whether modified duty with restrictions consider return to work, whether modified duty with restrictions or limiting hours workedor limiting hours worked

• If patients poorly tolerate standard therapy, consider pool therapy If patients poorly tolerate standard therapy, consider pool therapy intervention which allows elimination of gravity effectsintervention which allows elimination of gravity effects

• Functional Capacity Evaluations utilized if patients are not progressing Functional Capacity Evaluations utilized if patients are not progressing through therapy or if have reached a plateau and abilities as through therapy or if have reached a plateau and abilities as well as restrictions need to be assessedwell as restrictions need to be assessed

• Job site evaluations appropriate if concerns re: ergonomicsJob site evaluations appropriate if concerns re: ergonomics

53

E. Final Thoughts:E. Final Thoughts:

• It is the It is the patientpatient,, not the diagnostic test, not the diagnostic test, that is treatedthat is treated

• 80 %80 % of patients will recover from acute of patients will recover from acute low back pain within 3 days to 3 weeks, low back pain within 3 days to 3 weeks, with or without treatmentwith or without treatment, , with up to with up to 90 %90 % resolved in 6-12 weeksresolved in 6-12 weeks