musculoskeletal pain back pain

Musculoskeletal Pain

Back Pain

Rodrigo Rodrigues, MD

Copyleft by CM Gibson www.wikidoc.org

M/S Pain – Back Pain

• More then 2/3 of adults will have back pain at some time in their lives

• 5th most common reason for visiting an internist and causes the most work-related disability in persons younger than 45yo

• The incidence of LBP is highest in the 3rd decade, and overall prevalence increases with age until the 60-65yo



• Back pain of <6wks is acute, and >3mo is chronic

• Risk factors:

– Smoking, obesity, older age, female gender – Physically strenuous work, sedentary work – Psychologically strenuous work, low educational attainment – Workers' Compensation insurance, job dissatisfaction– Somatization disorder, anxiety, and depression



• Sciatica:

– It’s a symptom, not a diagnosis– Caused by herniated disk, spinal stenosis, degenerative

disc disease, spondylolisthesis, or other abnormalities of vertebrae can all cause pressure on the sciatic nerve.

– Piriformis Sd. usually develops after an injury– Pain or numbness due to sciatica can vary widely and

can be severe enough to cause immobility



• Sciatica:

– Pain may get worse at night, after standing or sitting for long periods of time, when sneezing, coughing, or laughing; or after bending backwards or walking >50 - 100 yards

– Sciatica pain usually goes away within 6 weeks, unless there are serious underlying conditions

– Pain that gets worse with sitting, coughing, sneezing, or straining may indicated a longer recovery



• Herniated disk:

– Common cause of severe back pain and sciatica– Bulge, protrusion or extrusion of the vertebral disk– Pain in the leg may be worse than the back pain– Many people have disks that bulge or protrude and do

not suffer back pain– Extrusion (which is less common than the other two

conditions) is highly associated with back pain



• Herniated disk:

– Abnormalities in the annular ring may be associated with chronic low back pain

– Cauda equina Sd. is the impingement of the cauda equina. It’s a surgical emergency. Symptoms include: dull back pain, weakness or numbness in the buttocks, legs, or feet; may cause stumbling or difficulty in standing; bowel/bladder incontinence; and pain accompanied by fever (can indicate an infection)

– It can cause permanent incontinence if not promptly treated with surgery.



• Spondylosis:

– Osteoarthritis of the joints of the spine, usually as a result of aging, previous back injuries, excessive wear and tear, previously herniated discs, prior surgeries, and fractures

– Results in gradual loss of mobility of the spine, narrowing and degeneration of the spinal discs

– Symptoms may be similar to that of a herniated disc, lumbar strain, or spinal stenosis



• Spinal stenosis:

– Narrowing of the spinal canal and neural foramina resulting in insidious back pain

– Usually associated with aging, arthritis (DDD), infection and birth defects

– Pain or numbness, can occur in both legs, or on just one side, weakness or heaviness in the buttocks or legs

– Symptoms are worse when standing or walking upright and improve when sitting down or leaning forward.



• Spondylolisthesis:

– Anterior displacement of a vertebra on the one beneath it. Usually between L4-L5. More common in >65yo and women

– The most common cause is DDD

– Other causes include stress/traumatic fractures and bone disease

– It can produce increased lordosis



• Spondylolisthesis:

– Symptoms may include: Lower back pain, pain in the thighs and buttocks, stiffness, muscle tightness and/or weakness of the legs

– Pain generally occurs with activity and is better with rest



• Inflammatory disorders:

– Ankylosing spondylitis: chronic inflammation of the spine that may gradually result in a fusion of vertebrae. Insidious symptoms of back discomfort lasting >3mo. The back is usually stiff in the morning and pain improves with movement or exercise. It’s more common in Caucasian males in their mid-20s.

– About 20% of people with inflammatory bowel disease and about 20% of people with psoriasis develop a similar form of arthritis involving the spine



• Osteoporosis:

– The bones become fragile and prone to fractures. It usually does not cause pain unless the vertebrae collapse suddenly, in which case the pain is often severe. More than one vertebra may be affected.



• Compression fractures:

– The bone tissue of the vertebra collapses

– Often responsible for loss of height

– Symptoms depend upon the area of the back that is affected; however, most fractures are stable and do not produce neurological symptoms.



• More than 95% of lumbar disk herniations occur at L5 or S1 n. roots

• A seated or supine straight leg raising test is 80% sensitive but only 40% specific, differently from crossed-straight-leg raising and ankle plantar flexion weakness (more specific).

• Wide-based gait and abnormal Romberg are highly specific for spinal stenosis.



• Diagnosis

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, or 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.”

Copyleft by CM Gibson

American College of Physicians/American Pain Society Low Back Pain Guidelines Panel

www.wikidoc.org


• Diagnosis:

– Description of the pain (P3QR2ST2)

– Red flags (history of trauma or cancer, unintentional wt loss, immunosuppression, use of steroids or IV drugs, osteoporosis, age >50 years, focal neurologic deficit, and progression of symptoms, psychosocial factors)

– Physical exam (Inspection, palpation, ROM, straight leg raising test, neurologic test)

– Imaging



• Imaging

Recommendation 2:

– “Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain”

– Majority of patients with back pain alone improve rapidly

– Gonadal radiation from a two view radiograph of the lumbar spine is equivalent to radiation exposure from a chest x-ray taken daily for more than one year



www.wikidoc.org


• Imaging

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”



www.wikidoc.org


• Indications for early imaging in patients w/ back pain:

Clinical finding Rationale

Major trauma Possible fracture

Corticosteroid use Increased risk of osteoporotic fracture

Age >50yo Increased risk of osteoporotic fracture/malignancy

Hx of Cancer Increased risk of malignancy

Unexplained wt loss Increased risk of malignancy/infection

Fever, immunossupression, IVDU, infection Risk of spinal infection

Saddle anesthesia, bowel/bladder incontinence

Possible cauda equina Sd.

Severe or progressive neurologic deficit Possible cauda equina Sd. or severe n. root compression


• Imaging

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)”



www.wikidoc.org


• Imaging:

– Plain radiographs — If clinical improvement has not occurred after 4 - 6wks

– CT and MRI scanning — More sensitive than plain radiographs for detecting infection and cancer, and can show herniated discs and spinal stenosis

– MRI or CT findings may be incidental and unrelated to the etiology of low back pain

– MRI is preferred over CT scan for better visualization of soft tissue and absence of radiation exposure



www.wikidoc.org


• Treatment:

– Therapy should focus on temporary symptomatic relief, to maximize patient comfort

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”



www.wikidoc.org


• Treatment

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 self-care. 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. For most patients, first-line medication options are acetaminophen or non-steroidal anti-inflammatory drugs.”



www.wikidoc.org


• Treatment

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.”



www.wikidoc.org


• Treatment:

Recommendation 5

LBP Acute Subacute or chronic

Self-care Advice to remain active X X

Books, handouts X X

Application of superficial heat X




• Treatment:

Recommendations 6 and 7


Pharmacologictherapy

Acetaminophen X X

NSAIDs X X

Muscle relaxants X

Antidepressants (TCAs) X

Benzodiazepines X X

Opioids X X



www.wikidoc.org


• Treatment:

Recommendations 6 and 7


Nonpharmacologictherapy

Spinal manipulation X X

Exercise therapy X

Massage X

Acupuncture X

Yoga X

Cognitive behav. therapy X

Progressive relaxation X

Intensive interdisciplinary Rehabilitation

X



www.wikidoc.org


• Indications for referral:

– The cauda equina syndrome (surgical emergency)– Suspected spinal cord compression (requires

emergent evaluation for surgical decompression or radiation therapy)

– Progressive or severe neurologic deficit



• Indications for referral:

– Patients may also be referred to a neurologist or physiatrist if the neuromotor deficit persists after four to six weeks of conservative therapy; OR persistent sciatica, sensory deficit, or reflex loss after four to six weeks in a patient with positive straight leg raising sign, consistent clinical findings, and favorable psychosocial circumstances.



• Prognosis:

– The long-term outcome of low back pain is generally favorable

– Patients who have high expectations for recovery have better outcomes

– Psychosocial variables are stronger predictors of long-term disability than anatomic findings found on imaging studies

– Predictors of disabling chronic low back pain include maladaptive pain coping behaviors, functional impairment, poor general health status, presence of psychiatric comorbidities, or nonorganic signs


Thank you


musculoskeletal pain back pain

Documents

orgms pain

yardssciatica pain

common cause of severe

cause pressure

strenuous work

painherniated disk

spinal stenosiswww

spinal canal