Evaluation and Management of Acute Low Back Pain

Zafar Iqal Abbasi Shaheed Hospital Karachi

Acute Low Back Pain
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Affects up to 90% of the US population at some point in their life It is second only to URI-s for symptomrelated visits to primary care physicians It is the most common cause of work related disability in persons under the age of 45 and the second most common cause of temporary disability for all ages It costs over 60 billions annually

Acute Low Back Pain
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It is a self-limiting condition that usually resolves in up to six weeks In approximate 80% of the cases no clear etiology is ever determined There is a small subset of patients in whom LBP signals a life-threatening disease or a disorder that require immediate attention

Low Back Pain

Is defined as pain localized between the lower rib cage and the gluteal folds often extending or radiating into the thighs. It can be subclassified as:
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Acute if lasting less than 6 weeks Subacute if lasts between 6 and 12 weeks Chronic if duration of the pain is longer than 12 weeks

Low Back Pain Generators
1.

2. 3.
• •

Osseous: vertebral body, pedicles, lamina, facets, spinous and transverse processes of the vertebras Neuroanatomic (frequent pain generator) Supporting structures:
Intervertebral disc (most frequent pain gen.) Ligaments (ALL, PLL, L. flavum, facet capsules, supraspinous, intraspinous)

Differential Diagnosis
Mechanical Low Back or Leg Pain 97%  Nonmechanical Spinal Conditions 1%  Visceral Diseases

Differential Dx: Mechanical Low Back or Leg Pain (97%)
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Lumbar strain/sprain 70% Degenerative process 10% Herniated discs 4% Spinal stenosis 3% Compression fx 4% Spondylolisthesis 2%

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Traumatic fracture <1% Congenital disease:severe kyphosis or scoliosis, transitional vertebrae <1% Spondylolysis Internal disc disruption Presumed instability

Differential Dx:Nonmechanical Spinal Conditions (1%)

Neoplasia
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0.7%

multiple myeloma mets lymphoma/leukemia spinal cord tumors retroperitoneal tumors primary vert. Tumors

Inflammatory arthritis 0.3%
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ankylosing spondylitis psoriatic spondylitis Reiter’s syndrome Inflammatory bowel disease

Infection
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0.01%

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osteomyelitis septic diskitis paraspinous abscess shingles

Paget’s disease Scheuermann’s disease

Differential Dx: Visceral Disease (2%)

Disease of pelvic organs
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prostatitis endometriosis chronic PID nephrolithiasis pyelonephritis perinephric abscess

Aortic aneurysms Gastrointestinal diseases
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Renal disease
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pancreatitis cholecystitis penetrating ulcer

Red Flags in the History
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Age – less than 18 or more than 50 Trauma – even minor if elderly/steroid rx Cancer Fever, chills, night sweats Weight loss IVDA Recent GI/GU procedures Severe and unremitting pain Severe or progressive neurological deficit

Red Flags in the History
Benign back pain is usually dull, achy pain which is exacerbated by movement but improves with rest  Red flags for tumor or infection is pain that is worsen at night and awakes patient from sleep, not improved by rest or is unrelenting despite appropriate analgesics

Red Flags in the History
Pain that is worsen with prolonged sitting, coughing and Valsalva maneuver often occurs with disk herniation  Patients with benign acute LBP rarely have associated neurological deficits. Any such complaint is a “red flag”

Physical Examination Inspection

Vital signs – fever is a red flag for infection; is present in 27% of TB OM, 50% of pyogenic OM and in 87% of epidural abscesses Patients with benign back pain prefer to remain still. Severe pain should rise concerns for infection, nephrolithiasis or aortic aneurysm Observe patient’s gait and ability to heel walk (testing dorsiflexion-L4 and L5 roots) and toe walk (testing plantar flexion – S1 root)

Physical Examination Inspection
Back should be exposed and observed for spasm, erythema and edema  Patients with anterior problems (degenerated disk) usually have extension preference; those with posterior mechanical problems (spondylosys or spondylolysthesis) have flexion preference

Physical Examination Palpation

Spine and paraspinal structures should be palpated. Point tenderness usually indicates ligamentous disruption or local destruction by tumor or fracture Straight leg test – a positive test reproduces radicular pain below the knee and along the path of a nerve root (L5, S1) at 30- to 70- degree elevation from supine. Is approximate 80% sensitive for disk herniation. Approximately 80-90% of all herniated disks occur at the level of either L4-5 or L5-S1

Physical Examination – Neurological Evaluation
Lower extremity strength and sensation (dermatomal distribution)  Reflexes - Patellar (L3-L4) - Achilles (S1) - Babinski (upper motor)  Associated neurological deficits – urinary and bowel retention or incontinence

Red Flags in the Physical Examination
Fever  Point tenderness on percussion  Anal sphincter laxity  Perianal sensory loss  Motor weakness  Positive straight leg raise test

Diagnostic Testing

When there are no red flags a good history and physical exam should suffice Lab tests - if tumor or infection is suspected a CBC, ESR, CRP should be obtained Radiography – are necessary only if there is concern for fracture (history of trauma), malignancy or rheumatologic disease. AP and Lat views should suffice. If films are negative but concern still exists MRI or CT should be obtained

Diagnostic Testing - MRI

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Is the gold standard test for compressive lesions of the spinal cord or the cauda equina, infections or disk herniation Allows evaluation for disk degeneration and nerve root entrapment Excellent screening for bone marrow replacement processes If only disk herniation is suspected, it can be delayed for 6 weeks

Diagnostic Testing – CT
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Is the modality of choice to visualize bony details especially subarticular region Very useful in setting of trauma to evaluate the stability of the spinal column and integrity of the spinal canal Useful for vertebral OM but can miss epidural abscesses Use of myelography prior to CAT scanning will provide excellent intratechal detail

Diagnostic Testing
Bone Scan – can help identify metastatic cancer, infectious processes and stress fractures  Electromyography/Nerve Conduction Velocity - can be useful to investigate radiculopathy. Have little use in nonradicular pain syndromes

Treatment of Benign Acute LBP
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About 80% of acute LBP sufferers will completely recover in 4 weeks Several studies found that patients who resumed their activity recovered faster than those who stayed in bed for 2 days Active exercise has not been shown to be beneficial during the acute stage of back pain Patients should resume normal daily activities but curtail those that exacerbate the pain

Analgesia
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The mainstays of therapy are NSAIDs, acetaminophen, and opiate analgesics Acetaminophen has proven efficacy comparable with NSAIDs with fewer side effects. Usual dose is 650 to 1000mg Q 6 hrs Most nonsteroidals are equally efficacious. Lowest dose should be tried. If there is concern about GI bleeding can be combined with misoprostol or PPI

Analgesia

COX-2 inhibitors are effective, have fewer side effects than regular NSAIDs but the cost is very high A common approach is a combination of acetaminophen 650 to 1000 mg QID with ibuprofen 800 mg TID or naproxen 500 mg BID Ketorolac has not been shown to be superior to other oral NSAIDs

Analgesia
Opiate analgesics (codeine) should be prescribed for more severe pain in combination with acetaminophen or NSAIDs  Oxycodone and hydrocodone should be avoided because of higher dependency potential  Should be prescribed only for a short period of time

Analgesia

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Muscle relaxants (methocarbamol, cyclobenzaprine, diazepam) are especially indicated in treating LBP associated with spasm Are more effective than placebo in treating LBP but no better than NSAIDs Can produce drowsiness Does not seem to have a synergistic effect with acetaminophen or NSAIDs

Back Manipulation
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Is one of the most controversial treatments for LBP Most studies have found that while it may have some limited short term benefit the lasting results are unproven A recent meta-analysis of 39 RCT-s did not show back manipulation to be more effective than conventional treatment

Other Physical Modalities

Other treatment modalities include traction, ultrasound, cutaneus laser therapy, massage, accupuncture and electrical nerve stimulation. None of these has been shown to improve recovery rate from acute LBP Heat and ice therapy is marginally effective in reducing pain and is very inexpensive

Preventive Measures

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Start a program of regular exercises beginning with low stress aerobic exercises followed in a few weeks by exercises to condition specific trunk muscles Loss of excess of weight Regular walking and swimming Avoidance of high impact exercises for at least several months after the acute LBP

Epidural Compression Syndrome
Includes spinal cord compression, cauda equina syndrome and conus medularis syndrome  Except for the level of the neurological deficit, the presentation of these syndromes is similar  The initial evaluation and management is also similar

Epidural Compression Syndrome
Is a medical emergency because of the catastrophic neurological loss that can develop  Is caused by pressure being exerted on the cord or cauda equina from a space occupying lesion – tumor, abscess, disk herniation or traumatic compression

Epidural Compression Syndrome
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LBP might not be the dominating complaint Leg pain is more frequent Symptoms are usually bilateral and usually a combination of motor, sensory and autonomic dysfunctions Patients can experience constipation or incontinence of the bowel, retention or incontinence of the urinary bladder

Epidural Compression Syndrome
Saddle anesthesia  Major motor or sensory loss is often noted  Patients with these symptoms should be treated emergently and should be assumed they have spinal cord injury until proven otherwise

Epidural Compression Syndrome
10 –100 mg of dexamethasone should be administered iv because it might reduce the progression of deficits and alleviate pain  Emergent MRI of the region according to the level of the neurological deficits  Immediate specialist consultation

Epidural Compression Syndrome
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Outcomes depend on the neurologic deficit at presentation Patients paraplegic at presentation are unlikely to walk again; those who were too weak to walk alone but not paraplegic had a 50% chance of walking again. Those who were ambulatory remained so Of the patients catheterized for denervated bladder 80% did not recover bladder function

Cancer

History
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sensitivity
0.77 0.31 0.31 >0.90 0.50 1.00

specificity
0.71

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Age > 50 previous history 0.98 of cancer failure to improve 0.90 in 1 mo. of therapy no relief -bed rest duration > 1 mo age >50 or cancer hx or unexplained wt loss or failure of conservative tx. Insidious onset constitutional symptoms

0.46 0.81 0.60

Infection
Intravenous drug abuse, UTI, or skin infection in 40%  also,

immune suppression  insidious onset  previous surgery  constitutional symptoms

Compression fracture

History specificity
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sensitivity
0.96 0.06 0.995

age >500.84 0.61 age >70 0.22 trauma 0.30 0.85 corticosteroid use

in elderly trauma can be minor

Herniated Disc

Sciatica
• sensitivity 0.95 specificity 0.88 • aching pain in buttock-- paresthesias radiating into posterior thigh and calf or posterior lateral thigh and lateral foreleg • pain worsened by flexion • aggravated by sneeze, cough, Valsalva

Ankylosing Spondylitis

History specificity
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sensitivity
1.00 0.49 0.59 0.71 0.23 0.54 0.82 0.07

age at onset <40 pain not relieved by supine 0.80 morning back stiffness 0.64 pain duration >3 months 4 of 5 questions above positive also: improved by exercise worse after rest, heat helps

Spinal Stenosis
Pain beyond back to buttock,thigh or lower legs  “Neurogenic claudication”  Worse with extension of LS (stand/walk)  Improves with flexion (sitting)  Average age of surgery-55 (4 yrs of sx’s)

Cauda equina syndrome
Bladder dysfunction  Saddle anesthesia  Major limb motor weakness

Factors predisposing to Repetitive strain injury
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Reaching overhead repetitively standing or working on concrete w/o cushioned shoes repetitive rotating of trunk during prolonged tasks heavy lifting chores lifting inappropriately sleeping on the abdomen beginning weightlifting using a rowing machine driving prolonged periods to work

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Carrying a large wallet in the back pocket leg length discrepancy recent weight gain excessive coughing high risk occupations
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miscellaneous labor garbage collection warehouse work nursing

Predicting Chronic Pain

Clinical factors
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Pain experience
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previous episodes of BP multiple musculoskeletal complaints hypochondriasis etoh, drugs, tobacco rate pain as severe blame others for pain legal issues or compensation

Premorbid factors
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rate job as physically demanding believe they will not be working in 6 months don’t get along with coworkers near to retirement spouse to supportive unmarried or multiple x’s low socioeconomic troubled childhood

LUMBAR SPINE

Range of Motion

Flexion (>60 degrees)

floor to finger measurement

extension (>25 degrees)  lateral bending (>25 degrees)

Dermatomes

L3

L3/L4- quadriceps muscle

sit on table and attempt to straighten bent knee against resistance

sensation - oblique band on anterior thigh-immediately above knee cap

L4
Tibialis anterior-offer resistance to dorsiflexion and inversion of foot  Patellar reflex  sensation - medial leg and foot

L5
Extensor hallucis longus-resist dorsiflexion of great toe or heel walk (foot drop)  Gluteus medius - resist abduction of leg  No reflex  sensation- dorsum of foot  98% L4/5 or L5/S1 herniations-affects L5 and S1 levels

S1
Peroneus longus and brevis-oppose plantar flexion/eversion of foot by pushing on 5th metatarsal with palm of hand  inability to walk on toes  Achilles reflex  sensation-lateral malleolus and lateral/plantar surface of foot

Straight leg raising
Pain in leg, buttock, or back at 60 degrees or less of leg elevation  usually worsened by dorsiflexion of ankle and relieved by flexion of knee and hip  Sensitivity 0.80 Specificity 0.40

Crossed and Reverse Straight Leg Raising

Crossed
pain in contralateral, symptomatic leg when asymptomatic leg raised  sensitivity 0.25 specificity 0.90

Reverse
lies prone or on side and thigh is extended one at a time; pain over involved nerve root  usually L3 or L4 irritation

PE -Lumbar disc herniation

Test sensitivity specificity  ipsilateral SLR 0.80 0.40  crossed SLR 0.25 0.90  impaired ankle reflex 0.50 0.60  ankle plantar flex weak 0.06 0.95  great toe exten weak0.50 0.70  ankle dorsiflex weak 0.35 0.70

Schober’s test

Technique • Patient stands erect with normal posture • Identify level of posterosuperior iliac spine
• Mark midline at 5 cm below iliac spine • Mark midline at 10 cm above iliac spine

• Patient bends at waist to full forward flexion • Measure distance between 2 lines (started 15 cm apart)

Interpretation • Normal: distance between 2 lines increases to >20 cm • Abnormal: distance does not increase to >20 cm
• Suggests decreased Lumbar spine range of motion • May suggest Ankylosing Spondylitis

Other tests
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Milgram test- hold heels 2 in. off table for 30 sec., if can hold intrathecal pathology ruled out FABER test- laying supine, place foot of involved side on opposite knee, press on knee and opposite hip, if pain may be SI joint pathology Pelvic rock- hands on iliac crests and ant sup iliac spines then compress pelvis toward midline, if pain may be sacroiliac pathology Hoover test- for malingering, pt should bear down with opposite heal if making attempt to raise leg

Must do Exam
Straight leg raising test  Dorsiflexion strength of the ankle and the great toe  Light touch sensation of the medial (L4), dorsal (L5), and lateral (S1) aspect of the foot  ankle reflexes

Waddell’s signs
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Overreaction during the exam Simulated testing  positive when pain reported with axial loading or rotation with pelvis/shoulders in same plane Distracted testing  test straight leg raise while distracted when sitting Superficial, nonanatomical or variable tenderness Nonanatomical motor or sensory disturbances

sensory loss does not follow dermatome or entire leg is numb or when “ratchety” giveway on strength testing

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3/5 = likely psychogenic component 2/5 = correlates with poor surgical outcome, not rehab outcome

Summary
Many causes-most common strain/sprain  Know the red flags  Examine the patient  Waddell’s signs

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