How to approach a patient with low back pain

DONE BY: Al-Yaqdhan Al-AtbiSenior clerckship student

SQUH

• History• Physical examination• Investigations• Management

Case …

Mr. B is a relatively healthy 37 years old male. While working in his yard, he experienced intense lower back pain that prevented him from doing any more work. He used some ibuprofen for pain relief and spent the remainder of the day resting. The next morning he had increased muscle stiffness and was not feeling any better, so he come to see you.

What do you want to ask Mr.B?

• Personal data

• Present complain

Present complain

• Onset & how it start :• acute or chronic• What were you doing just before the pain began? • Did you have a particular injury or accident?

• Character:

Sharp, dull, throbbing or burning ??

• Location & radiation:• lumber strain .. Paraspinous muscles- buttock• Herniated disc .. Below the knee

• Duration• < 6wk Acute• 6-12 wk Subacute • > 12 wk Chronic

• Intensity• How it effects daily activity?• Interfere with sleeping, walking or driving ?

• Associated symptoms• stiffness, urinary or abdominal symptoms ??

Present complain

• Aggravating factors• Valsalva maneuvers• Sitting• Walking down-staires

• Relieving factors• Medication• Non-pharmacologic measures ( massage, stretching,

heat or ice)• Certain position.

Present complain

MR. B

He describe the pain as dull and burning. There is some radiation into the left buttock. Prolong sitting or moderate activity aggravate the pain. He can get relief when he lies down. He has never had back pain like this.

• Fever ??• Appetite/ wt loss?• Abdominal pain?• Cough/ sputum? • Bowel habits?• Dysuria, Hematuria?• Menestural history?

Systemic review

• Medical & surgical history:– Previous trauma– Kidney diseases– Previous back pain, therapy– Malignancy– Disc prolepses—surgery– Female---obstrict diseases

• medication?? • Corticosteroids , immunosuppressant

past medical history

Family history

• Cancers • Back pain • Spondylarthropathie

s

Social history• Current stresses• Occupation:

• Work, job tasks.• Activity level of the job

• Perception of the pain ,impact on life

In Evaluating Patient With Low Back pain Should Remember :

• Determine that the pain is intrinsic to the back and not referred from problem elsewhere.

• Rule out progressive and Life- threatening disease.

• Determine whether nerve root compromise is present or not.

Red flags

General•Failure to improve after 4-6wk of conservative therapy•Unrelenting night pain or pain at rest•Progress motor or sensory deficit

Cancer•Age > 50 •History of cancer or current cancer•Unexplained weight loss

Infection•Fever or chills•Recent infection .. UTI or skin•Immunosuppression• IV drug use

Fracture•Age > 50 •History of osteoporosis•Significant trauma•Chronic oral steroid use

Red flags

Cauda Equina S.

•Urinary incontinence or retention•Saddle anesthesia •Decrease anal tone or fecal incontinence•Lower extremities weakness

AAA•Age > 60 •Abdominal pulsating mass •Pain at rest

Red flags

Physical examination

• General appearance• Vital sings• Back examination• Systemic examination

• GENERAL APPERANCE :• Comfortable or not ?• Sitting, standing or leaning on something?

• Vital sing • Record vital sings• High Temp. ???

Back examination• look• Feel• Move• Special tests

Look:• From side:

• evaluate spinal curvatures.• From behind:

• Note any scars, swelling, erythema.• Shape of the spine.

Feel:• The spinous processes of each vertebra.

– Tenderness .. Fracture, dislocation , infection or arthritis• Any step-offs

– in spondylolisthesis or forword slipping of one vertebra, which may compress the spinal cord.

• Muscle spasm or tenderness– degenerative or inflammatory process , prolong contraction from

abnormal posture or anxiety.• Sacroiliac joint

– tenderness indicate sacroiliitis or ankylosing sponylitis

MOVE

Flexion Extension

Rotation Lateral bending

Special Tests

• Scobar’s test: – measure forward flexion of the spine

Straight leg raising Test

• How: • Ask the patient to lie down on their back. • Have the patient completely relax the affected leg. • Cup the heel of their foot and gently raise the leg .

• Positive test:– Sciatic pain at 30-70 degree– Aggravation of pain dorsiflexion of

the foot– Relief of pain by knee flexion

• The straight leg raising test.• if positive indicates lumber nerve root compromise.

• The crossed straight leg raising test.(pain radiate into opposite leg)

• if positive indicates disc herniation.

Examination of the lower limb

• Muscle strength:• Hip:

» Flexion (L2, 3,4 )» Adduction (L2, 3,4 )» Abduction ( L4, L5, S1 )» Extension (SI)

• Knee» Extension at the knee (L2,L3,L4)» Flexion at the knee (L4,L5,S1,S2 )

• Dorsiflexion ( mainly L4,L5) • planter flexion (mainly S1).

• Deep tendon reflexes:– The knee reflex (L2,L3,L4)

The Ankle reflex (S1) The planter response(L5,S1)

• Gaite• Walk on heel ( L5)• Walk on toe (S1)

Examination of the lower limb

• Uncomfortable, prefer to stand.• Has full ROM excep for limited forward

flexion• Tenderness on paraspinous muscles.• SLR & crossed SLR test are negetive.• Lower limb:

– Normal reflexes, strength and sensation.

MR. B

• What investigations you will order for MR.B ??

• MOST PATIENTS WITH LOW BACK PAIN DO NOT NEED INVESTIGATIONS

-Majority not due to a serious underlying condition

-Most are self-limited

70% to 90% of acute Low Back Pain cases will Resolve in 1 month

Investigations

• Radiological imaging

1. X-ray

2. MRI

3. CT

4. Radionuclide (bone scan)

• Laboratory tests

Plain X-ray

Are very commonly used for low back pain

Do not X-ray routinely

Required only if the pain is associated with red flag signs, which indicate a high risk of more serious

underlying problems

Do not X-ray routinely

• EXCEPTIONS:

1. Young(<25) X-ray sacroiliac joint to exclude ankylosing spondylitis

2. Elderly: to exclude vertebral collapse/malignancy; history of trauma; ‘red flag’ signs

Plain X-ray

• Useful to identify: 1. Trauma

2. Compression fractures

3. Dislocation

4. Degenerative changes

5. Check spinal curvatures

6. End stages of malignancies

Plain X-ray

• AP & lateral view of lumbosacral spine

• Not highly sensitive or specific• Not rule out serious illness• Not good at identifying muscles and ligaments

MRI• Provide more detailed images of soft tissues (disc & Nerve roots)

1. Spinal stenosis2. Disc bulge3. Spinal tumors4. Infections5. Compressive lesions6. Cauda equina

Note : -If red flags are present , MRI should be undertaken even if X-ray is normal.-MRI is preferable to CT scanning when neurological signs and symptoms are present

CT-scan

• Most of boney spinal pathology1. Trauma 2. Osteomylitis 3. Infection4. Tumors 5. Cases where MRI is contraindicated (e.g. pacemaker or metallic clips)• More radiation exposure

Radionuclide (bone scan)

• Useful when radiographs of the spine are normal

but the clinical findings are suspected 1. Osteomyelitis

2. Bony neoplasm

3. Occult fracture

• Unlikely to demonstrate bone changes when radiographs and ESR are normal

Radionuclide (bone scan)

• More sensitive than radiography

in detecting :

1. Metastasis

2. Paget’s disease (metabolic, bone turnover)

3. ankylosing spondylitis (Inflammatory

condition)

4. Trauma

5. Certain tumors (osteiod osteoma= benign)

Laboratory tests

• Indications:

1. Red flag signs

2. Malignancies or Infections

3. Metabolic causes

Laboratory tests

• FBC• ESR/CRP• Others( HLA B27 Ag),(Ca2+,PO4,Alkaline

phosphatase)

• HLA B27 is a protein in WBCs– If positive, possible ankylosing spondylitis (AS)– HLA B27 positive without having AS– 95% of AS sufferers are HLA B27 positive

Laboratory tests

Diagnosis Test’s resultInflammation or malignancy Raised CRP or ESR

Metastatic carcinoma of the prostate

Raised acid phosphatase or prostate specific antigen

Other bone metastases and Paget’s disease

Raised alkaline phosphatase

Myeloma Monoclonal band on serum immunoelectrophoresis and presence of urine light chains

• How to treat MR.B ??

Treatment

Symptomatic treatment

• Aims to:1. Relive pain

2. Improve quality of life

3. Treat underlying cause

Non-pharmacological

• Explanation• Reassurance• Advice on exercise

• Simple analgesics

Pharmacological

• Regular analgesia and/or non-steroidal anti-inflammatory drugs (NSAIDs) may be required to:

1. Improve mobility

2. Facilitate exercise

Pharmacological

• Opiates can be used for severe pain (single dose)• Tricyclic antidepressant drugs (analgesics+sleep &

mood)

Would you advice bed rest?

• Bed rest should not be advised • Returning to normal activities as soon as possible

(reduce chance of chronic pain)

Complementary and alternative medicine

• Acupuncture• Spinal manipulation• Massage therapy• Physical therapy

• Exercise

Knee to Chest

Pelvic Tilt

Hip Rolling

Pelvic Lift

Curl Ups

Hip Extension

Lying Prone In Extension

Back Extension

Arm Lifts

Hip Extension

Push Up

When to refer?

• No significant improvement in symptoms after 4-6 wks of treatment (reassess the treatment plan).

• To avoid misdiagnosis and unnecessary or inappropriate treatments

Referral to spine specialist

• Cauda equina syndrome• Intractable pain• Serious spinal pathology is suspected• Progressive neurological deficits

Risk factors

• Prior history of back pain• Heavy lifting• Frequent bending• Twisting and lifting• Repetitive work with exposure to vibration

• Psychosocial issues

Prevention • Limited number of studies• Overall , effective strategies for preventing initial or

recurrent low back pain are lacking• Education:

1. Instruction on proper lifting technique (not seem to be helpful)

2. Coping with back pain and encourages activity (small benefit)

Prevention

3. Back belt and lumbar support (not effective in workers)

4. Most effective prevention strategy seems to be physical exercise

Differential diagnosiscompliant Diagnosis

1- 42 yrs male, alcoholic has abdominal pain radiated to the back.

Referred pain

2- 70 yrs old female known to have osteoporosis has h/o trauma.

fracture

3- 50 yrs male has Fever, back pain unrelieved by bed rest or remaining motionless.

Infection

4- 22 yrs male has Pain unrelieved by remaining motionless and morning stiffness relieved by exercise

AS

5- 54 yrs old female k/c/o breast Cancer on chemotherapy. Spinal ca.

6- Acute onset of urinary retention or fecal incontenence,loss of anal sphincter tone ,saddle anasthesia,global/progressive lower extremity weakness

Cauda equinasyndrome

References

• Philip D. Sloane, Lisa M. Slatt, Mark H. Ebell, Louis B. Jacques, Mindy A. Smith. Essentials of Family Medicine. Fifth edition

• Robin C. Fraser. Clinical Method .A general practice approach. Third edition

• Davidson’s. principles & practice of medicine. Twentieth edition

• Oxford handbook of general practice. Third edition• Oxford handbook of clinical medicine. Seventh

edition