Management of Back

painDr Stuart Armstrong

Sports and Exercise Physician

Hamilton

Introduction

Differential diagnosis

History and examination

Investigation

Management

Prevention

Summary

Differential diagnosis

4 main diagnostic groups

Facet joint

Disc bulge

Sacroiliac joint

Other

Annular tear, spinal stenosis, discitis, rheumatological, paediatric, athlete

History

Back position at onset of pain or injury

Night pain – grade severity

Morning stiffness

Aggravating activities

Back or leg predominate

Cauda Equina or Red Flags

Examination

Volunteer?

Flexion/extension range

Slump

SLR with cross sciatic stretch

Muscle tightness

Tenderness on palpation – adds nothing to diagnosis

Power, sensation, reflexes

SIJ

Core strength

Back to differential – Facet joint pain

Typically hyperextension injury

Pain in back not leg

Worse with extension activity

Can be on return from flexion

Twisting

Only valid examination finding is reproduction of pain on extension

Palpation is useless

Disc bulge

Usually occurs in flexed position

Pain initially in back then down leg and back pain goes

Radicular pain – electric shock in continuous line

Numbness, tingling, weakness

Slump test – improve with cervical extension

SLR and cross sciatic stretch test

Power, Sensation, Reflexes

Red Flags, Cauda Equina

Prev Hx Malignancy

Age <16 >50 with new pain

Unexplained weight loss

Previous steroid use

Recent infection or ongoing infective symptoms

Cauda Equina

Bilateral pain

Urinary retention

Perianal sensory loss

Reduced anal tone

Erectile dysfunction

Sacroiliac

20% of back pain diagnosis

Posterior pelvic pain (below the belt)

Can have neurology down leg

Worse rolling over in bed/impact activity

Tender over SIJ

My examination

Active Straight leg raise

Femoral thrust

Faber test

Other

Annular tear

Nonspecific, muscle tightness, some peripheral neurology

Spinal stenosis

Worse with exercise, claudicant in nature

Rheumatological

Young, morning stiffness, other joints, skin, eye involvement

Paediatric

Incredibly difficult, No clear referral pattern for discs

Discitis

Easily missed, always ask for fevers/sweats

Athlete

Pars interarticularis fractures

Hyperextension sports

Prolonged recovery and time out of sport

High index of suspicion in any athlete with back pain

Classically in cricketers, tennis players, gymnastics

Investigation

90% improve within 4-6 weeks

If 6+ weeks, or any red flags then image with x-ray

AP and lateral consider pelvic

No diagnostic benefit from oblique or coned SIJ and high radiation

MRI should be considered for all with >3 months back pain, progressive

neurological deficit or suspicion cancer

Management - Acute

Reassure and keep active

Avoid aggravating activity

Analgesics – Paracetamol, NSAIDs, muscle relaxants, Opioids if needed

Massage, Chiropractor, Acupuncture, Heat pack, stretches

Physiotherapist for prevention

Little benefit from braces, multiple wallet-ectomy practitioners

Patient education costs little and nearly effective as above

Management - Chronic

As per acute

Add in central acting medications – nortriptylline, gabapentin

Physio has a greater role in strengthening

Further investigation for cause

Referral on for further management

Consider cortisone injection

? Surgical management

Facet pain further management –

What I do

Educate

2 week course of voltaren 75mg BD

Avoid extension activity

Work of strengthening and stretching

If ongoing pain MRI with a view to CT guided cortisone facet joint injection

If temporary benefit refer Muskuloskeletal physician or surgeon

Disc bulge specific management

Educate

McKenzie Extensions

MRI to confirm disc bulge and nerve root compression

Cortisone epidural or nerve sleeve injection

If temporary benefit consider repeat

If no benefit and >6 months symptoms - surgeons

SIJ specific management

Educate

SIJ periarticular steroid injection Vs 2 week voltaren 75mg BD

Strengthening specific core, gluteal and pelvic

If no benefit MRI – expect to be normal

MRI normal or SIJ pathology

Guided cortisone injection

Temporary benefit consider prolotherapy

Alternative therapies

Physiotherapy

Acupuncture

TENS

Chiropractor

Osteopath

Prevention

Exercise, Exercise, Exercise

Movement patterns

Work Station

Frequent Breaks

Special shout out to the core

Front Plank

Side Plank

Supermans

Gluteal Strengthening

Diaphragm

Pelvic floor

Summary

Back pain is normal

Flexion – disc, extension – facet, below belt line– Sacroliac

Rule out serious underlying pathology

Settle pain then physio for strengthening

Consider work and leisure factors

Core is key