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LOW BACK PAINChronic Care Lecture Series

Brian Liem, MDSports Medicine FellowUniversity of WashingtonDepartment of Rehabilitation Medicine

About your presenter

Hometown: Seattle, WA

College: University of Washington

Med School: NYU School of Medicine

R id N th t U i it Residency: Northwestern University

Interests: Biking, Hiking, Running

Favorite quote: “Don’t ever think that

you are useless. You can always be used

as a bad example.”

Outline

Epidemiology

Anatomy Review

Pain Generators

Hi t History

Physical Exam

Differential

Work Up

Cases and Treatment

Epidemiology

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

50% of population has experienced LBP by age 20

Up to 1/3 of pts with back pain report continued Up to 1/3 of pts with back pain report continued moderate intensity pain for up to 1 year after acute event

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

Outline

Epidemiology

Anatomy Review

Pain Generators

Hi t History

Physical Exam

Differential

Work Up

Cases and Treatment

Anatomy: Superficial Muscles

Trapezius

Thoracolumbar fascia

Latissimus Dorsi

Glut max

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Anatomy: Deep Muscles

Paraspinals-Erector Spinae-Multifidi

Quadratus lumborum

Anatomy: Psoas

Iliopsoas

Anatomy: Spine Overview

7 cerivical Vertebrae

12 Thoracic Vertebrae

5 Lumbar Vertebrae

5 Sacral Vertebrae

3-4coccyx

Anatomy: Bony Landmarks

Anatomy: Bony Landmarks 2

Spinous Process

Superior

Transverse Process

Pedicle

Lamina Inferior Articulating Process (IAP)

Articulating Process (SAP)

Anatomy: Ligaments

Why is it called the LigamentumFlavum?

It’s Yellow in color

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Anatomy: Disc and Nerves Anatomy: Disc and Nerves

Things you should know

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 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 physical exam, diagnosis about offending nerve roots, and for procedures

Outline

Epidemiology

Anatomy Review

Pain Generators

Hi t History

Physical Exam

Differential

Work Up

Cases and Treatment

Pain Generators

Muscle (Myofascial)

Bone (Fracture, compression fracture, spondylolysis)

Ligaments (interpsinous)

J i t (F t E d l t ) Joints (Facets, Endplates)

Disc Annular Fissure (Tear), Degenerative disc

Nerves (Radiculitis)

Supratentorial (ie: Chronic Pain)

Outline

Epidemiology

Anatomy Review

Pain Generators

Hi t History

Physical Exam

Differential

Work Up

Cases and Treatment

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History: Basics

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

Trauma history Especially for old ladies who fall!

Where specifically 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

History: Red Flags

Numbness? Weakness?– Sign of nerve damage

Clarify Pain vs. True Weakness

Fevers, Chills, Nightsweats? (Constitutional Symptom)g ( y p ) What you’re after is do they have an epidural abcess

(infection), osteomyelitis, or malignancy (primary or metastatic)

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

regions)

History: Function

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? 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 up

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

Rheum disorders?

Prior work upp X-rays

MRIsOften pts have already had an MRI before even trying any

therapy

EMGs/NCS

History: Treatments

Medications (type, duration, frequency) Other treatments

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

Have the had Physical Therapy? How much? How many sessions? What did the therapist actually do? Passive vs. Active

History: Secondary Gain

What’s their motivation? Do they have a lawsuit

Do they even want to get better?

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

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Outline

Epidemiology

Anatomy Review

Pain Generators

Hi t History

Physical Exam

Differential

Work Up

Cases and Treatment

The Rotisserie

Physical Exam: Gait

Gait Weakness on one side

Antalgic Gait (Limping)

Trendelenberg Gaitg GWeakness of Glut Medius

Physical Exam: Standing

Posture Look for asymmetry, Any lean to one side (lateral shift)?

Increased thoracic kyphosis (hunch back), loss of lumbar lordosis (flat lower back)?, increased lumbar lordosis

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

Percussion/Palpation

Balance Single Leg Squats: Tests hip abductor strength

Physical Exam: Sitting

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

Sensation L2-S2 Dermatomes

Reflexes (Patellar L4 Medial Hamstring L5 Reflexes (Patellar L4, Medial Hamstring L5, Achielles S1)

Seated SLUMP

Strength testing

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Sensation Testing Physical Exam: Supine

Passive SLR

Hip ROM Helps to rule out Hip as source of pain

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

pain

Physical Exam: Side Lying

Testing hip abductor strength mainly

Physical Exam: Prone

Palpation for tenderness– spine, buttox, SI jt

Prone instability– a test of lumbar core

Outline

Epidemiology

Anatomy Review

Pain Generators

Hi t History

Physical Exam

Differential

Work Up

Cases and Treatment

Differential

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

Think back to the “Pain Generators” Muscle?

Bone?

Ligaments?

Nerves?

Chronic Pain?

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Outline

Epidemiology

Anatomy Review

Pain Generators

Hi t History

Physical Exam

Differential

Work Up

Cases and Treatment

Work Up

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

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

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

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

X-rays (Plain Films): AP and Lateral MRI: Sagital and Axial

Outline

Epidemiology

Anatomy Review

Pain Generators

Hi t History

Physical Exam

Differential

Work Up

Cases and Treatment

Case 1

30 y/o man presents with 3 day history of LBP after helping his friend move into his new apartment. 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, nlstrength, reflexes and sensation.

Work Up: None needed

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Case 1 cont

Diagnosis: Acute Discogenic Low Back Pain Pain generator: Disc herniation or annular fissure (tear)

Muscles tense up to help “stabilize” the back in response to pain.

Treatment: Reassurance! Key is that most back pain resolves 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 months with buttock and right leg pain

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

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

Physical Exam: Stooped posture. Pain with lumbar extension

Work Up: X-ray and MRI

MRI Case 2

Central stenosisL4-L5

Wide open L5-S1 level

Case 2 cont

Diagnosis: Spinal Stenosis and NeurogenicClaudication Pain generators: arthritic bony spine, degenerative discs

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

Surgery--Decompression

Case 3

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

Worse: Bending forward

Better: Not moving Extending the back Better: Not moving. Extending the back.

Physical Exam: Radiating pain reproduced with lumbar flexion. Slight weakness with ankle dorsiflexion, Numbness over dorsal foot. +Seated slump

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

MRI

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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 root

M t l l i L4 L5 d L5 S1 di i i i L5 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 Epidural Steroid Injection, Disectomy if fail conservative tx.

Education: Educate the patient that “sciatica” isn’t the 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 pain in her low back after a fall

Worse: Any movement. Sleeping.

Better: Sitting very very very still Better: Sitting very very very still

Physical Exam: Pain with percussion over lumbar spine

Work Up: X-ray and MRI

X-Ray Case 4 Cont

Diagnosis: Lumbar Compression Fracture Pain Generator: Bone

Treatment Lumbar Corset Lumbar Corset

Opioids for pain managment

Vetebralplasty or Kyphoplasty

Case 5

14 y/o gymnast presents with back pain x 2 months

Worse: Doing a back bend

Better: Staying in flexion

Ph i l E T d t l ti i Physical Exam: Tender to palpation over spinousprocess. Pain with one-legged extension

Work up: X-ray, CT scan, Bone scan

X-ray

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Case 5 cont

Diagnosis Spondylolysis Fracture of the pars interarticularis

Pain generator: Fractured bone

Mechanism: Repetitive extension

Treatment Rest x 3 months– no sport

NSAIDs

PT once pain free ROM

Other common LBP diagnoses

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

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

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

Other LBP Diagnoses

Anklylosing Spondylitis

Tarlov Cysts

LBP Pearls

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

Watch out for Red Flags

Don’t use “sciatica” to explain radicular pain. Be more specific!