NP Outreach Curriculum in RheumatologySt. Joseph’s Health Care, London, ON

Dr. Sherry RohekarNovember 12, 2009

An Important IssueOne of the most common reasons for seeking

medical attention, second only to respiratory issues

84% of adults will have low back pain at some point

Wide variety of approaches for treatmentSuggests that optimal approach is unsure

Most episodes are self-limitedSome suffer from chronic or recurrent courses,

with substantial impact on quality of life

EpidemiologyAlmost any structure in the back can cause

pain, including ligaments, joints, periosteum, musculature, blood vessels, annulus fibrosus and nervesIntervertebral discs and facet joints most

commonly affected85% of those with isolated low back pain do

not have a clear localization Usually called “strain” or “sprain” no

histopathology, no anatomical locationMen and women equally affectedAge of onset 30-50 years

EpidemiologyLeading cause of work disability in those <

45 yearsMost expensive cause of work disability in

terms of worker’s compensationMultiple known risk factors:

Heavy lifting, twisting, vibration, obesity, poor conditioning

Deyo R and Weinstein J. N Engl J Med 2001;344:363-370

Common Pathoanatomical Conditions of the Lumbar Spine

Deyo R and Weinstein J. N Engl J Med 2001;344:363-370

Differential Diagnosis of Low Back Pain

HistoryAny evidence of systemic disease?

Age (especially >50), hx of cancer, unexplained weight loss, IVDU, chronic infection

DurationPresence of nocturnal painResponse to therapyMany patients with infection or malignancy will

not have relief when lying down Note for arthritis patients – young age, nocturnal

pain and worsening with rest are common in AS

HistoryAny evidence of neurologic compromise?

Cauda equina syndrome is a medical emergency Usually due to tumor or massive herniation

compressing the nerves of the cauda equina Urinary retention with overflow, saddle anesthesia,

bilateral sciatica, leg weakness, fecal incontinenceSciatica caused by nerve root irritation

Sharp/burning pain down posterior or lateral leg to foot or ankle; can be associated with numbness/tingling

If due to disc herniation often worsens with cough, sneeze or performing the Valsalva

HistoryAny evidence of neurologic compromise?

Spinal stenosis is caused by narrowing of the spinal canal, nerve root canals, or intervertebral foramina Most commonly due to bony hypertrophic changes in

facet joints and thickening of the ligamentum flavum Disc bulging or spondylolisthesis may also cause Back pain, transient leg tingling, pain in calf and

lower extremity that is triggered by ambulation and improved with rest

Can differentiate from vascular claudication through detection of normal arterial pulses on exam

Physical ExaminationInspection of back and posture (ie. Scoliosis,

kyphosis)Range of motionPalpation of the spine (vertebral tenderness

sensitive for infection)If high suspicion of malignancy, do a

breast/prostate/lymph node examPeripheral pulses to distinguish from

vascular claudication

Physical ExaminationStraight leg raise: for those with sciatica or

spinal stenosis symptomsPatient supine, examiner holds patient’s leg

straightElevation of less than 60 degrees abnormal and

suggests compression or irritation of nerve rootsReproduces sciatica symptoms (NOT just

hamstring)Ipsilateral straight leg raise sensitive but not

specific for herniated diskCrossed straight leg raise (symptoms of sciatica

reproduced when opposite leg is raised) insensitive byt highly specific

Physical examinationNeurologic examination

L5: ankle and great toe dorsiflexion

S1: plantar flexion, ankle reflex

Dermatomal sensory lossL5: numbness medial

foot and web space between 1st and 2nd toes

S1: lateral foot/ankle

ImagingAP and lateral L-spine if no clinical

improvement after 4-6 weeksGuidelines for American College of Physicians

and American Pain Society: “Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain”Do perform x-rays if: fever, unexplained weight

loss, hx of cancer, neurologic deficits, EtOH, IVDU, age <18 or >50, trauma, immunosuppression, prolonged steroid use, skin/urinary infection, indwelling catheter

ImagingCT and MRI

More sensitive for detection of infection and cancer than plain films

Also able to image herniated discs and spinal stenosis, which cannot be appreciated on plain films

Beware: herniated/bulging discs often found in asymptomatic volunteers may lead to overdiagnosis/overtreatment

MRI better than CT for detection of infection, metastases, rare neural tumours

Natural HistoryMost recover rapidly

90% of patients seen within 3 days of symptom onset recovered within 2 weeks

Recurrences are commonMost have chronic disease with intermittent

exacerbationsSpinal stenosis is the exception usually

gets progressively worse with time

TherapyNon-specific low back pain

Few RCTs; methodology of studies generally poor quality

NSAIDs and muscle relaxants good for symptomatic relief Try giving regular rather than prn

Spinal manipulation (ie. chiropractic) of limited utility in studies

Should recommend rapid return to normal activities with neither bed rest nor exercise in the acute period Bed rest found to not improve and may delay recovery

Exercises not useful in acute phase; use in chronic

TherapyNonspecific low back pain

Traction, facet joint injections, TENS ineffective or minimally effective

Systematic reviews of acupunture have shown little benefit

? Massage therapy some promising resultsSurgery only effective for sciatica, spinal

stenosis or spondylolisthesis

TherapyHerniated intervertebral discs

Nonsurgical treatment for at least a month Exceptions: cauda equina syndrome, progressive

neurologic deficitsEarly treatment same as for nonspecific low back

pain, but may need short courses of narcotics for pain control

Bed rest not usefulSome patients benefit from epidural corticosteroid

injectionsIf severe pain, neurologic defecits MRI and

consider surgery

TherapySpinal stenosis

Physiotherapy to reduce risk of fallsAnalgesics, NSAIDs, epidural corticosteroids

(no clinical trials)Decompressive laminecotomySpinal fusion + decompression if there is

additional spondylolisthesisSymptoms often recur, even after successful

surgery

TherapyChronic low back pain

Intensive exercise improves function and reduces pain, but is difficult to adhere to

Anti-depressants: many with chronic low back pain are also depressed ? Maybe for those without depression (tricyclics)

Opiates Small RCT showed better effect on pain and mood

than NSAIDs No improvement in actity Significant side effects: drowsiness, constipation,

nausea

TherapyChronic low back pain

Referral to multidisciplinary pain center Cognitive-behavioural therapy, education, exercise,

selective nerve blocksSurgical procedures rarely helpful

IntroductionSpondyloarthritis

Refers to inflammatory changes involving the spine and the spinal joints. Remember – can sometimes have peripheral arthritis

without spinal symptoms!

Seronegative SpondyloarthritisAbsence of Rheumatoid Factor

Psoriatic Arthritis Ankylosing Spondylitis Reactive Arthritis Enteropathic Arthritis Undifferentiated Spondyloarthropathy

How do you differentiate inflammatory from mechanical back pain?

Inflammatory vs. Mechanical Back PainInflammatoryAge of onset < 40Insidious onset> 3 months duration> 60 min am stiffnessNocturnal painImproves with activityTenderness over SI

jointsLoss of mobility in all

planesDecreased chest

expansionUnlikely to have

neurologic deficits

Mechanical

Any ageAcute onset< 4 weeks duration< 30 min am stiffnessNo nocturnal painWorse with activityNo SI joint tendernessAbnormal flexionNormal chest

expansionPossible neurologic

deficits

Clinical Features

SacroiliitisUsually bilateral and symmetricInitially involves the synovial-lined lower 2/3

of the SI jointEarliest change: erosion on the iliac side of

SI joint (cartilage is thinner)Could cause “pseudowidening” of SI joint

Bony sclerosis, then complete bony ankylosis or fusion

Spinal Involvement

Spinal InvolvementGradual ossification of the outer layers of the

annulus fibrosis (Sharpey’s fibers) form interverterbral bony bridgesCalled syndesmophytes

Fusion of the apophyseal joints and calcification of the spinal ligaments along with bilateral syndesmophyte formation can result in “bamboo spine”

EnthesitisEnthesis: site of insertion of ligament,

tendon or articular capsule into boneEnthesitis: inflammation of enthesis

resulting in new bone formation or fibrosisCommon sites: SI joints, intervertebral

discs, manubriosternal joints, symphysis pubis, iliac crests, trochanters, patellae, clavicles, calcanei (Achille’s or plantar fasciitis)

More Than Just Back Pain . . .“ANK SPOND”A Aortic insufficiency, ascending aortitis,

conduction abnormalities, pericarditisN Neurologic: atlantoaxial subluxation

and cauda equina syndromeK Kidney: amyloidosis, chronic prostatitisS Spine: Cervical fracture, spinal

stenosis, spinal osteoporosis

More Than Just Back Pain . . .P Pulmonary: upper lobe fibrosis,

restrictive changesO Ocular: anterior uveitis (25-30% of

patients)N Nephropathy (IgA)D Discitis or spondylodiscitis

Also: microscopic colitis in terminal ileum and colon (30-60%)

More Than Just Back Pain . . .Remember that patients with AS can also

have a peripheral arthritisUsually an oligoarthritis of the lower

extremitiesOccasionally, patients will present with

peripheral arthritis before they have back complaints

Physical ExamSchober test

Detects limitation in forward flexion of the lumbar spine

Place mark at dimples of Venus (or level of the posterio superior iliac spine) and another 10 cm above, at the midline

Ask patient to maximally forward flex with locked knees

Measure should increase from 10 cm to at least 15 cm

Modified Schober Test

Making The Diagnosis

TreatmentPhysiotherapy for all

Maintains good postureMaintains chest expansionMinimizes deformities

TreatmentNSAIDs

Good for mild symptomsPotentially disease modifyingIndomethacin seems to work the bestBeware of side effects, especially

gastrointestinal disease

TreatmentDMARDs

Sulfasalazine 1000-2000 mg bid Seems to be the most effective for spinal symptoms

Methotrexate 15-25 mg weekly For patients with prominent peripheral arthritis Doesn’t work very well for spinal symptoms

TreatmentSteroids

Not very effective at all in ASLocal injections for enthesitis or peripheral

arthritisAnti-TNFα agents

Remicade (infliximab), Enbrel (etanercept) and Humira (adalimumab) Very useful for treating symptoms, improving ROM,

improving fatigue Hopefully disease-modifying . . .