LOW BACK PAINLOW BACK PAINChronic Care Lecture Series

Brian Liem, MDSports Medicine FellowUniversity of WashingtonDepartment of Rehabilitation Medicine

About your presentery p

Hometown: Seattle, WA Hometown: Seattle, WA College: University of Washington Med School: NYU School of Medicine Med School: NYU School of Medicine Residency: Northwestern University

I Biki Hiki R i Interests: Biking, Hiking, Running Favorite quote: “Don’t ever think that you are useless. You can always be usedas a bad example.”

Outline

Epidemiology Epidemiology Anatomy Review Pain Generators Pain Generators History

Ph i l E Physical Exam Differential Work Up Cases and Treatment

Epidemiologyp gy

LBP is the 2nd most common reason for physician LBP is the 2 most common reason for physician visits (cold is #1)

50% of population has experienced LBP by age 20 50% of population has experienced LBP by age 20 Up to 1/3 of pts with back pain report continued

moderate intensity pain for up to 1 year after acute moderate intensity pain for up to 1 year after acute event

5% of the people with back pain disability are 5% of the people with back pain disability are estimated to account for 75% of the LBP Costs.

Outline

Epidemiology Epidemiology Anatomy Review Pain Generators Pain Generators History

Ph i l E Physical Exam Differential Work Up Cases and Treatment

Anatomy: Superficial Musclesy p

Trapezius

Latissimus DorsiLatissimus Dorsi

Glut max

Thoracolumbar fascia

Glut max

Anatomy: Deep Musclesy p

Paraspinals-Erector Spinae

Quadratus lumborum

p-Multifidi

Anatomy: Psoasy

Iliopsoas

Anatomy: Spine Overviewy p

7 i i l V b7 cerivical Vertebrae

12 Thoracic Vertebrae

5 L mbar Vertebrae5 Lumbar Vertebrae

5 Sacral Vertebrae

3-4coccyx

Anatomy: Bony Landmarksy y

Anatomy: Bony Landmarks 2y y

Transverse Process

Spinous Process

Superior Articulating Process (SAP)

Pedicle

Lamina Inferior Articulating Process (IAP)

Anatomy: Ligamentsy g

Why is it called the LigamentumFlavum?

It’s Yellow in colorIt s Yellow in color

Anatomy: Disc and Nervesy

Anatomy: Disc and Nervesy

Things you should knowg y

What vetebral level does the spinal cord end? What vetebral level does the spinal cord end? A: L1. Why is this important? A: When you do a lumbar tap or any spinal procedure A: When you do a lumbar tap or any spinal procedure

if you know you are below the cord, there is little risk to SCI

What vetebral level is at the same level as your iliac crests? A: L4. Why is this important? A: This helps you know which level you are at for both

h i l di i b ff di physical exam, diagnosis about offending nerve roots, and for procedures

Outline

Epidemiology Epidemiology Anatomy Review Pain Generators Pain Generators History

Ph i l E Physical Exam Differential Work Up Cases and Treatment

Pain Generators

Muscle (Myofascial) Muscle (Myofascial) Bone (Fracture, compression fracture, spondylolysis) Ligaments (interpsinous) Ligaments (interpsinous) Joints (Facets, Endplates)

Di Disc Annular Fissure (Tear), Degenerative disc

N (R d l ) Nerves (Radiculitis) Supratentorial (ie: Chronic Pain)

Outline

Epidemiology Epidemiology Anatomy Review Pain Generators Pain Generators History

Ph i l E Physical Exam Differential Work Up Cases and Treatment

History: Basicsy

Time course 2 weeks ago? 1 month? 6 months? 10 years! Acute vs. Chronic

Trauma history Trauma history Especially for old ladies who fall!

Where specifically H ti t i t t E tl h it h t Have patient point to Exactly where it hurts

Radicular Symptoms Does the pain TRAVEL down the legs or just stays in the back?

Positions that WORSEN symptoms Bending, Twisting, Walking, Lying Flat, Climbing Stairs

Positions that ALLEVIATE symptoms Positions that ALLEVIATE symptoms

History: Red Flagsy g

Numbness?N Weakness?– Sign of nerve damage

Clarify Pain vs. True Weaknessy Fevers, Chills, Nightsweats? (Constitutional Symptom)

What you’re after is do they have an epidural abcess(infection), osteomyelitis, or malignancy (primary or metastatic)

Bowel or Bladder Symptoms? Bowel or Bladder Symptoms? Primarily: Incontinence of bowel or bladder Tells you if this is involving the Cauda Equina (sacral y g q (

regions)

History: Functiony

How bad is the pain? 0-10 How bad is the pain? 0 10 This helps you get a baseline and later after some

treatment you can compare

What are they functionally NOT able to do?y y You want to see how much this is affecting their life. If

they are going to work, still doing everyday tasks then they are relatively high functioning

History: Prior Work upy p

What other medical history? What other medical history? Cancer, Hx of Neurologic problems, Family hx of

Rheum disorders?

Prior work up X-raysy MRIsOften pts have already had an MRI before even trying any

therapy

EMGs/NCS

History: Treatmentsy

Medications (type, duration, frequency) Other treatments

Injections? (ESI, Myofascial Trigger points) Chiropractic Care? Chiropractic Care? Massage? Surgery? ICE/Heat ICE/Heat TENS

Have the had Physical Therapy? H h? How much?

How many sessions? What did the therapist actually do? Passive vs. Active

History: Secondary Gainy y

What’s their motivation? What s their motivation? Do they have a lawsuit Do they even want to get better? Do they even want to get better?

History of psych issues? Depression and Anxiety affect pain perception. Depression and Anxiety affect pain perception.

Outline

Epidemiology Epidemiology Anatomy Review Pain Generators Pain Generators History

Ph i l E Physical Exam Differential Work Up Cases and Treatment

The Rotisserie

Physical Exam: Gaity

Gait Gait Weakness on one side Antalgic Gait (Limping) Antalgic Gait (Limping) Trendelenberg GaitWeakness of Glut Medius

Physical Exam: Standingy g

Posture Posture Look for asymmetry, Any lean to one side (lateral shift)? Increased thoracic kyphosis (hunch back), loss of lumbar Increased thoracic kyphosis (hunch back), loss of lumbar

lordosis (flat lower back)?, increased lumbar lordosis

ROM in standing (Flexion, Extension, Lateral Side g ( , ,Bending)

Percussion/Palpation/ p Balance

Single Leg Squats: Tests hip abductor strengthg g q p g

Physical Exam: Sittingy g

Strength of Lower Extremities (HF/HE, KF/KE, Strength of Lower Extremities (HF/HE, KF/KE, DF/PF/EHL)

Sensation L2-S2 Dermatomes Sensation L2 S2 Dermatomes Reflexes (Patellar L4, Medial Hamstring L5,

Achielles S1)Achielles S1) Seated SLUMP

Strength testingg g

Sensation Testing g

Physical Exam: Supiney p

Passive SLR Passive SLR Hip ROM

Helps to rule out Hip as source of pain Helps to rule out Hip as source of pain

FABER = Flexion, ABduction, External Rotation (aka: Patrick’s)(aka: Patrick s) Helps rule out SI joint vs. Intrarticular Hip as sources of

painp

Physical Exam: Side Lyingy y g

Testing hip abductor strength mainly Testing hip abductor strength mainly

Physical Exam: Proney

Palpation for tenderness– spine, buttox, SI jt Palpation for tenderness spine, buttox, SI jt Prone instability– a test of lumbar core

Outline

Epidemiology Epidemiology Anatomy Review Pain Generators Pain Generators History

Ph i l E Physical Exam Differential Work Up Cases and Treatment

Differential

Basically after you combine the history and physical Basically after you combine the history and physical exam you can generate a list of possible etiologies (causes) for the pain.( ) p

Think back to the “Pain Generators” Muscle? Bone? Ligaments?g Nerves? Chronic Pain?

Outline

Epidemiology Epidemiology Anatomy Review Pain Generators Pain Generators History

Ph i l E Physical Exam Differential Work Up Cases and Treatment

Work Upp

80% diagnoses can be made with H&P alone When do you get imaging?

Any history of trauma or red flags Indicated if no improvement in symptoms after 6 weeks Indicated if no improvement in symptoms after 6 weeks

X-ray L-spine AP and Lateral Tells you about Alignment, Arthritis (spondylosis), Fractures

MRI Helps to evaluate canal narrowing, soft tissues, discs, and

nervesnerves Order this if pain continues despite conservative treatment has already had negative X rays has already had negative X-rays weakness is present Red flags present

X-rays (Plain Films): AP and Lateraly ( )

MRI: Sagital and Axialg

Outline

Epidemiology Epidemiology Anatomy Review Pain Generators Pain Generators History

Ph i l E Physical Exam Differential Work Up Cases and Treatment

Case 1

30 y/o man presents with 3 day history of LBP 30 y/o man presents with 3 day history of LBP after helping his friend move into his new apartment.p Key History: No radiation of back pain down legs. Just

stays in back.

Worse: Bending forward, Transitional Movements Better: Bending backwards Physical Exam: Pain with forward flexion, nl

strength, reflexes and sensation. Work Up: None needed

Case 1 cont

Diagnosis: Acute Discogenic Low Back Pain Diagnosis: Acute Discogenic Low Back Pain Pain generator: Disc herniation or annular fissure (tear) Muscles tense up to help “stabilize” the back in Muscles tense up to help stabilize the back in

response to pain.

Treatment: Reassurance! Key is that most back pain y presolves on own. 40-50% of acute LBP resolves in 2 weeks. 90% get better w/o physician intervention

NSAIDS prn. Other modailties: Heat/TENS

Case 2

78 y/o woman presents with low back pain x 6 78 y/o woman presents with low back pain x 6 months with buttock and right leg pain

Worse: Leaning back, Walking down hills. Pain Worse: Leaning back, Walking down hills. Pain makes her legs feel tired

Better: Leaning forward, “leaning on a shopping Better: Leaning forward, leaning on a shopping cart.”

Physical Exam: Stooped posture. Pain with lumbar Physical Exam: Stooped posture. Pain with lumbar extension

Work Up: X-ray and MRI Work Up: X ray and MRI

MRI Case 2

Central t istenosis

L4-L5

Wide open L5-S1 level

Case 2 cont

Diagnosis: Spinal Stenosis and Neurogenic Diagnosis: Spinal Stenosis and NeurogenicClaudication Pain generators: arthritic bony spine, degenerative discs g y p , g

and compression of nerves because of narrowing of spinal canal and foramen

Treatment: Physical Therapy– goal improve pain free ROM,

/strengthen/stabilize the core musculature Lumbar Epidural Steroid Injection during Flare

S D i Surgery--Decompression

Case 3

46 y/o W with LBP and pain going down his Right 46 y/o W with LBP and pain going down his Right legs. He tells you he thinks he has “sciatica.”

Worse: Bending forward Worse: Bending forward Better: Not moving. Extending the back. Physical Exam: Radiating pain reproduced with Physical Exam: Radiating pain reproduced with

lumbar flexion. Slight weakness with ankle dorsiflexion, Numbness over dorsal foot. +Seated dorsiflexion, Numbness over dorsal foot. Seated slump

Work Up: X-ray and MRI or EMG/NCS Work Up: X ray and MRI or EMG/NCS

MRI

Case 3 cont

Diagnosis: Radiculopathy from Herniated Nucleus Pulposis (HNP) Pain generator is a posteriroly herniated disc compressing

on a nerve root or chemomechanically irritating the nerve y groot

Most common level is L4-L5 and L5-S1 disc impinging on L5 and S1 nerve roots

Treatment: Physical Therapy w/ Extension base, NSAIDS, Steroid dose

pack pack Epidural Steroid Injection, Disectomy if fail conservative tx.

Education: Educate the patient that “sciatica” isn’t the t il b th i ti i t proper term necessarily because the sciatic nerve is not

what is affected, but rather a nerve root.

Case 4

80 y/o woman with hx of osteoporosis presents with 80 y/o woman with hx of osteoporosis presents with pain in her low back after a fall

Worse: Any movement. Sleeping. Worse: Any movement. Sleeping. Better: Sitting very very very still Physical Exam: Pain with percussion over lumbar Physical Exam: Pain with percussion over lumbar

spine Work Up: X ray and MRI Work Up: X-ray and MRI

X-Rayy

Case 4 Cont

Diagnosis: Lumbar Compression Fracture Diagnosis: Lumbar Compression Fracture Pain Generator: Bone

Treatment Treatment Lumbar Corset Opioids for pain managment Opioids for pain managment Vetebralplasty or Kyphoplasty

Case 5

14 y/o gymnast presents with back pain x 2 months 14 y/o gymnast presents with back pain x 2 months Worse: Doing a back bend Better: Staying in flexion Better: Staying in flexion Physical Exam: Tender to palpation over spinous

process Pain with one legged extensionprocess. Pain with one-legged extension Work up: X-ray, CT scan, Bone scan

X-rayy

Case 5 cont

Diagnosis Diagnosis Spondylolysis Fracture of the pars interarticularisp

Pain generator: Fractured bone Mechanism: Repetitive extension

Treatment Rest x 3 months– no sportp NSAIDs PT once pain free ROM

Other common LBP diagnosesg

55 y/o man with low back pain. He has also noted 55 y/o man with low back pain. He has also noted some easy brusing. Diagnosis: Multiple Myelomag p y

75 y/o man with hx of prostate cancer and low back painp Diagosis: Mestatsitc Prostate Cancer

61 y/o woman w/ hx of breast cancer and low y/ /back pain Diagnosis: Metastatic Breast Cancer

Other LBP Diagnosesg

Anklylosing Spondylitis Anklylosing Spondylitis Tarlov Cysts

LBP Pearls

Take a good HISTORY and PHYSICAL Take a good HISTORY and PHYSICAL Most acute LBP back pain resolves on its own. Don’t go by results of MRI Go by how the patient Don t go by results of MRI. Go by how the patient

feels and functions. In other words, don’t treat an image, treat the patientimage, treat the patient

Watch out for Red Flags Don’t use “sciatica” to explain radicular pain Be Don t use sciatica to explain radicular pain. Be

more specific!