Back Pain Made Ez! Dr Ammar March 2nd
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Transcript of Back Pain Made Ez! Dr Ammar March 2nd
Ammar Al-Kashmiri, MDAmmar Al-Kashmiri, MDEmergency PhysicianEmergency PhysicianKhoula HospitalKhoula Hospital
Back Pain Made EZ!
Primary Health Care Physicians Workshop
Epidemiology
Definitions/Classifiication
RED FLAGS +Interpretation
How to examine?
Testing
Specific conditions
Management
Overview
Epidemiology
Affects up to 90% of population at some point in their lives
4% of emergency department visits
Highest economic burden after heart disease & stroke
85% have no definite etiology
90% with nonspecific back pain symptoms resolve within 1 month
Risk Factors
Increasing ageHeavy physical work (long periods of static work
postures, heavy lifting, twisting, and vibration)Psychosocial factors (including work
dissatisfaction and monotonous work)DepressionObesity (BMI > 30)SmokingDrug abuseHistory of headache
Definitions
Acute LBP = < 6 weeks
Subacute LBP = 6-12 weeks
Chronic LBP = > 12 weeks
Nonspecific back pain (majority) = localized
Back pain + radiculopathy/sciatica = radiating
Back pain associated with another specific cause
= referred
Classification
Clinical Presentation
Ranges : mild (muscle spasm) severe/unrelenting (epidural
abscess)
NOT important recognize a particular classic presentation for various diseases
IMPORTANT evaluate for the red flags
Identification of red flags will direct whether further evaluation is required
Very Serious Pathology
Vascular AAA, Aortic Dissection (AD)
Malignancy Mets: breast, prostate, lung, kidney, thyroid Bone or spinal epidural metastasis (SEM)
Infectious Process Vertebral osteomyelitis ,Spinal epidural abscess
(SEA)
Spinal cord compressive syndromes (SCCS) Spinal epidural mets (SEM), central disc
herniation, SEA, spinal epidural hematoma
Less Serious Pathology
Spinal fractures
Spinal stenosis
Spondylolysis / spondylolisthesis
Regular disc herniations usually lateral and compress nerves on one side
and not the cord / cauda
Red FlagsHistory
Age <18,>50>6 weeks*Systemic complaints:
fever/chills/night sweatsundesired weight lossmalaise
Trauma (minor in OP, elderly)Cancer (0.7% 9%)ImmunocompromiseIVDU
Red Flags
Red FlagsHistoryThink outside the box!
Resp- e.g. Pneumonia
GI- e.g. Pancreatitis
GU- e.g. Pyelonephritis
AAA
Historical Red Flags? What do they mean?
Gradual onset of back pain Malignancy or infection usually progress over weeks to
months
Age <18 Congenital, spondylolysis/spondylolisthesis
Age >50 AAA, malignancy, compression fracture
Thoracic back pain Aortic dissection, SEA, Vertebral osteomyelitis, malignancy
Most common site of malignant spine lesions is thoracic spines (accounts for 60% of cases)
History
History
Pain > 6 weeks Malignancy, infection, spinal stenosis,
spondylolysisHx of trauma
Fracture MVA in normal, fall in elderly/osteoporotic
Fever/chills/night sweats, weight loss Malignancy or infection
Pain worse when supine Malignancy or infection
History
Pain worse at night Malignancy or infection
Pain despite good analgesics Malignancy or infection
Hx of malignancy Hello? Can you guess?
Hx of immunosup (corticosteroids) Infection, osteoporosis
History
Recent procedure causing bacteremia Infection GU or GI procedures
Hx of IV drug abuse Infection
Bowel or bladder incontinence SCCS
Saddle numbness Cauda compression
Red FlagsExamination
General appearanceo lies still Vs writhes in pain
Vital signso BP : ,, R to L differenceo Fever
Pulsatile abdominal massSpinal process tendernessNeurological deficits
Physical Exam Red Flags? What do they mean?
Examination
Fever Infection BUT fever may not always be present
(especially vertebral osteomyelitis)
Hypotension Ruptured AAA
Extreme hypertension AD, especially if thoracic back pain
Pulsatile abdominal mass AAA
Examination
BP difference > 20 mm Hg in arms AD, but: BP difference > 20mm Hg in arms only
found in 40% of aortic dissections- 20% of normals have this difference
Spinal process tenderness Fracture, osteomylelitis, SEA, malignancy
Focal neuro signs SCCS
Examination
Acute urinary incontinence SCCS / Cauda compression Actually is overflow incontinence Check for urinary residual > 150cc post void
Perianal numbness, loss of rectal tone SCCS / Cauda compression
Neurological Examination of the Back
Straight Leg Raise (SLR) TestMotor
L3-S1Sensory
L3-S1Rectal tonePerianal sensation
Urinary retention
SLR
SLR
+ SLR 80% sensitive for herniated disk at L4-L5/L5-S1 (95% of DH)
Leg passively elevated up to 7o
+ test = new/worsening pain below knee along path of a nerve root between 30-70 of elevation
Reproduction of back pain or pain in the hamstring is NOT a + test
+ test can be verified by:Ankle dorsiflexionInternal rotationHead flexionCrossed SLR
SLR
Knee extension Foot inversion Foot inversion 1st toe extension Foot eversion
A Word about S1
S1 radiculopathy cause weakness of plantar flexion, but is difficult to detect until quite advanced
To illicit have the patient raise up on tip-toe three times in a row, on one foot alone and then the other
Waddell Signs
≥3/5 signs more likely to have non-organic disease
Excessive Tenderness Superficial: Widespread sensitivity to light touch
of the skin over a wide area of the lumbar skin Nonanatomic: felt over a wide area, not localized
to one structure, and often extends to the thoracic spine, sacrum, or pelvis
Stimulation Axial loading: LBP with light pressure on skull
while standing Rotation: LBP with passive rotation of shoulders
and pelvis in same plane, in standing position
Distraction Inconsistent findings when patient is distracted,
most commonly seen when testing sitting versus supine SLR
Regional Disturbance Motor: Generalized giving way or cogwheel
resistance in manual muscle Sensory: Glove or stocking, nondermatomal loss of
sensation Overreaction
Disproportionate verbalization or facial expression with movement
Assisted movement Rigid or slow movement Collapsing
Waddell Signs
Caution! use in conjunction with entire presentation and not as sole basis of discounting a patient’s symptoms
Waddell Signs
Diagnostic Studies
When is a diagnostic work-up required?
When there are no red flags, a good history and physical examination suffice
When red flags are elucidated, further evaluation is warranted
Laboratory Tests
Complete blood count (CBC)
Erythrocyte sedimentation rate (ESR)
Plain Radiography
There is a sense among many patients that they should receive x-rays as part of their evaluation!
Plain radiographs rarely add helpful information in establishing the diagnosis
X-ray early in the course of LBP do not improve outcomes or reduce costs of care
They add cost, time and unnecessary radiation
Normal plain films do not exclude malignancy or infection in patients with a suspicious history
Radiation Risks
Gonadal radiation from a two view x-ray of the lumbar spine = radiation exposure from a CXR taken daily for > 1 year!!
Oblique views substantially increase risks of radiation and add little diagnostic information
Indications for Back X-rays
Age ≤18 years or ≥50 yearsConstitutional symptoms Pain > 6 weeksHistory of traumatic onsetHistory of malignancyOsteoporosisInfectious risk (e.g. IVDU,
immunosuppression, indwelling urinary catheter, steroids, skin infection or UTI, recent procedures)
Progressive focal neurologic deficit
MRI
Gold standard for evaluation for epidural compression
syndromes spinal infection
(osteomyelitis and epidural abscess)
spinal cord injury intervertebral disk herniation
(may be delayed 4-6 weeks)*MRI evaluation to provide reassurance does not lead to better prognosis
Management
Nonspecific back pain (radiculopathy/ red flags) important to educate patients that they will
respond to conservative management over 4-6 weeks (many respond well after several days)
Approach to treatment is focused: analgesic medications (combination
therapy) activity modification physical modalities
Analgesics
ParacetamolExcellent analgesic Proven efficacy comparable to NSAIDsinexpensive Small side effect profile in comparison
to NSAIDsRecommended in the treatment for all
patients
NSAIDsMost are equally efficaciousLowest dose needed to reach pain reduction
should be attemptedCOX-2 inhibitors should be used sparingly
and only after discussion with the patient about the risks
Analgesics
The most common recommended approach is to use a combination of Paracetamol and NSAIDs
One suggested regimen = Paracetamol 500-1000 mg QID
+/- Ibuprofen 400-800 mg TID
or Naproxen 250-500 mg BID
Analgesics
Analgesics
OpiatesLiberal use recommended for patients with
moderate-severe painAllows patients to break pain cycle Gives stronger option when exacerbations of
pain occur Only for short period (7-10 days) to
development of dependenceWarn patients of problems of driving
Muscle Relaxantse.g. DiazepamCause sedation + addiction with chronic useMay be useful if patient demonstrates
significant muscle spasm of the paraspinal musculature
Exert benefit only in first 4 days when muscular spasm is at its peak (rarely a significant component of symptoms after 1st week of injury)
Analgesics
Activity Modification/Physical Modalities
Continue routine activities as tolerated + use pain as guide for activity modification
Bed rest has no benefit and may ultimately be harmful in the recovery (not even 2 days!)
Active exercise/back strengthening exercises not beneficial during acute crisis
Moderate stretching and strengthening of abdominal muscles and back muscles beneficial when acute pain subsides
Thermal and ice therapy ?marginally effective
Other Modalities
None of the following treatments has shown significant improvement in the recovery rate from acute LBP:
Traction Diathermy Cutaneous laser therapy Ultrasound Corsets & Lumbar braces
Homeopathy Acupuncture Massage TENS
Management directed at restoring function and supporting adaptive techniques:
Exercise Reduction in body weight Improving cardiovascular fitness Smoking cessation Massage- beneficial when combined with
exerciseAcupuncture-may be beneficialTENS-no benefitSpinal manipulation-no benefit
Subacute/Chronic LBP
Subacute/Chronic LBP
Activity Modification
MedicationsParacetamol/NSAIDAvoid opiates & muscle relaxantsAntidepressants- cyclic antidepressants
Subacute/Chronic LBP
LBP with Sciatica
1% -4% of individuals with LBPYoung = herniated disc, Older = spinal
stenosisHerniated disk
50% recover in 6 weeks5-10% ultimately require surgery
Surgery beneficial only in first 2 years No difference in symptoms at 4 and 10
years post operatively
Management similar to patient with uncomplicated LBP
Analgesics- Paracetamol, NSAIDs, short-term opiates
Activity- routine, use pain as limiting factorEpidural steroid injection- mild-moderate pain
reduction Must be diligent to detect progressive neurological
functionPatient should be educated to return earlier if the
symptoms are worsening
LBP with Sciatica
Indications for Referral
Cauda equina syndrome – bowel and bladder dysfunction, saddle anesthesia, bilateral leg weakness and numbness = surgical emergency
Suspected spinal cord compression – acute neurologic deficits in a patient with cancer and risk of spinal metastases
Progressive or severe neurologic deficit
Neuromotor deficit that persists after 4-6 weeks of conservative therapy
Persistent sciatica, sensory deficit, or reflex loss after 4-6 weeks in a patient with positive SLR , consistent clinical findings
Fractures
Conclusions
Back pain is a costly and common problem
Evaluation done best by categorizing into 3 categories: nonspecific back pain/back pain with radiculopathy/back pain with specific cause
Systematic approach is key. Know your red flags well!
Remember radiation risk and x-ray only when indicated
Chronic back pain is complex and needs comprehensive approach
Thank You!