Lower Back Pain Lower Back Pain

MS3 Sports Medicine Workshop

Objectives Objectives Review the functional anatomy of lumbo-sacral spine List essential components of a LBP history, including

RED FLAGS Describe common causes of LBP Review proper indications for imaging and referral Review Physical Examination of LS spine Correlate pathology with pertinent physical findings

““Red FlagsRed Flags” in back pain” in back pain Age < 15 or > 50 Fever, chills, UTI Significant trauma Unrelenting night pain; pain at rest Progressive sensory deficit Neurologic deficits

– Saddle-area anesthesia

– Urinary and/or fecal incontinence

– Major motor weakness Unexplained weight loss Hx or suspicion of Cancer Hx of Osteoporosis Hx of IV drug use, steroid use, immunosuppression Failure to improve after 6 weeks conservative tx

Epidemiology of back painEpidemiology of back pain

Fifth most common reason for all physician visits in US

Second only to common cold as cause of lost work time

25% of US adults have LBP x1d in last 3 mos The most common cause of disability in persons

under the age of 45

Your patient with LBP has paresthesias in the lateral foot, decreased toe-raise strength, diminished sensation lateral foot,

and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

1. L4

2. L5

3. S1

4. S2

Better anatomy knowledgeBetter anatomy knowledge==

Better diagnoses and treatmentsBetter diagnoses and treatments

Vertebra

– Body, anteriorlyFunctions to support weight

– Vertebral arch, posteriorlyFormed by two pedicles and two laminaeFunctions to protect neural structures

LigamentsLigaments

Anterior longitudinal ligament Posterior longitudinal ligament Ligamentum flavum Interspinous ligament Supraspinous ligament

Anterior longitudinal ligament

Ligamentous

MusclesMuscles Spinalis Longissimus Iliocostalis Quadratus lumborum

– Ilium to lumbar TPs Intertransversalis Interspinals Multifidus Erector spinae

Sciatica is defined as…

Pain radiating up th

e back

Pain radiating to

the th

igh

Pain radiating below th

e knee

Pain in th

e butt

25% 25%25%25%1. Pain radiating up the back

2. Pain radiating to the thigh

3. Pain radiating below the knee

4. Pain in the butt

Neuro-anatomyNeuro-anatomy

•L4•L5•S1

PATIENT HISTORY PATIENT HISTORY “OPQRSTU”“OPQRSTU”

Onset Palliative/Provocative factors Quality Radiation Severity/Setting in which it occurs Timing of pain during day Understanding - how it affects the patient

Which one is NOT considered a “red flag” of LBP?

Hist

ory of c

ancer

Age over 50

Fever o

r chills

Sciatica

25% 25%25%25%1. History/suspicion of cancer

2. Age over 50

3. Fever or chills

4. Sciatica

““Red FlagsRed Flags” in back pain” in back pain Age < 15 or > 50 Fever, chills, UTI Significant trauma Unrelenting night pain; pain at rest Progressive sensory deficit Neurologic deficits

– Saddle-area anesthesia

– Urinary and/or fecal incontinence

– Major motor weakness Unexplained weight loss Hx or suspicion of Cancer Hx of Osteoporosis Hx of IV drug use, steroid use, immunosuppression Failure to improve after 6 weeks conservative tx

OnsetOnset Acute - Lift/twist, fall, MVA Subacute - inactivity,

occupational (sitting, driving, flying)

?Pending litigation Pain effect on:

– work/occupation– sport/activity (during or after)– ADL’s

Other HistoryOther History

Prior h/o back pain Prior treatments and response Exercise habits Occupation/recreational

activities Cough/valsalva exacerbation

Diagnoses & Diagnoses & Red FlagsRed Flags Cancer

– Age > 50– History of Cancer– Weight loss– Unrelenting night pain– Failure to improve

Infection– IVDU– Steroid use– Fever– Unrelenting night pain– Failure to improve

Fracture– Age >50– Trauma – Steroid use– Osteoporosis

Cauda Equina Syndrome– Saddle anesthesia– Bowel/bladder dysfunction– Loss of sphincter control– Major motor weakness

Physical ExaminationPhysical ExaminationMsk Big-6Msk Big-6

Inspection Palpation Range of motion Strength testing Neurologic examination Special tests

Approach to LBPApproach to LBP

History & physical exam Classify into 1 of 4:

– BAD: LBP from other serious causesCancer, infection, cauda equina, fracture

– LBP from radiculopathy or spinal stenosis– Non-specific LBP– Non-back LBP

Workup or treatment

BAD low back pain (examples)BAD low back pain (examples)

What to do aboutWhat to do about

Possible BAD Low Back PainPossible BAD Low Back Pain Cauda Equina:

– MRI STAT Neurosurgery consult Fracture: x-rays

– MRI/CT if still suspect Cancer: x-rays + CRP, ESR, CBC (+/- PSA)

– MRI if still suspect Infection: x-rays; CRP, ESR, CBC, +/- UA

Radiculopathy, Spinal StenosisRadiculopathy, Spinal Stenosis

Sciatica (pain below knee) May have abnl neuro exam

Radiates to leg Pain worse walking,

better sitting (pseudo-claudication)

What to do aboutWhat to do about

Suspected Radiculopathy or Suspected Radiculopathy or Spinal StenosisSpinal Stenosis

Refer to Physical Therapy Follow in 2-4 weeks for progress If no improvement by 6-12 weeks

– Plain films, MRI, +/- EMG/NCV

– Refer for interventionsEpidural steroid injections for radiculopathy

Causes of “Non-specific LBP”Causes of “Non-specific LBP”

Spondylosis (Osteoarthritis of facet/disk)

Spondylolysis/-listhesis Kyphosis/scoliosis

Acute lumbar strain Facet pain Discogenic pain Ligamentous pain

Management of an acute low back muscle strain should consist of all the

following EXCEPT:1. X-rays to rule out a

fracture

2. Educate the patient on generally good prognosis

3. Non-opiate analgesics

4. Remain active

What to do aboutWhat to do about

Non-specific Low Back PainNon-specific Low Back Pain Educate patient about expected good prognosis Advise to remain active as tolerated Provide analgesics and self-care directions FU in 2-4 weeks; adjust tx as needed Don’t do x-rays unless it becomes chronic WU if no improvement

““Think Outside the Back”Think Outside the Back”

Renal dz (pyelo, stones, abscess) Pelvic dz (PID, endometriosis,

prostate) Gastrointestinal dz (cholecystitis,

ulcer, cancer) Retroperitoneal dz Aortic aneurysm Zoster Diabetic radiculopathy

Rheumatologic disorders– Reiters– Ankylosing Spondylitis– Inflammatory bowel dz– Psoriatic spondylitis

Neoplasia (multiple myeloma, metastatic CA, lymphoma, leukemia, spinal cord tumors, vertebral tumors)

What to do aboutWhat to do about

Non-back LBPNon-back LBP

WU and tx as appropriate for suspected diagnoses

Diagnostic StudiesDiagnostic Studies Radiographs

– Early if RED FLAGS– Symptoms present > 6

weeks despite tx

Diagnostic StudiesDiagnostic StudiesMRI indications

– Possible cancer, infection, cauda equina synd

– >6-12 weeks of pain– Pre-surgery or invasive therapy

Disadvantages– False-positives; may not be

causing pain– More costly, increased time to

scan, problem with claustrophobic patients

Diagnostic StudiesDiagnostic Studies

Bone Scan indications– Adolescent LBP (r/o spondy)

SPECT scan Cost ~$300

Diagnostic StudiesDiagnostic Studies

EMG/NCV– r/o peripheral neuropathy– localize nerve injury– correlate with radiographic

changes– order after 6-12 weeks of

symptoms– Pre-surgical or invasive therapy

Lab StudiesLab Studies

Indications– Chronic LBP– Suspected systemic disease

CBC, CRP, ESR, +/- UA, SPEP, UPEP Avoid RF, ANA or others unless indicated

Issues specific to CHRONIC LBPIssues specific to CHRONIC LBP(>6 weeks and/or non-responsive)(>6 weeks and/or non-responsive) Evaluation

– X-rays, labs

– Evaluate for “YELLOW FLAGS” Management

– Medication selection

– Interventions

YELLOW FLAGS YELLOW FLAGS in Chronic LBPin Chronic LBP

Affect: anxiety, depression; feeling useless; irritability

Behavior: adverse coping, impaired sleep, treatment passivity, activity withdrawal

Social: h/o abuse, lack of support, older age Work: believe pain will be worse at work; pending

litigation; workers comp problems; poor job satisfaction; unsupportive work env’t

Medications in Chronic LBPMedications in Chronic LBP

FIRST: Acetaminophen Second: NSAIDs

– If one fails, change classesMeloxicam naproxen COX2’s

Third: tramadol Fourth: tri-cyclic antidepressants

– Radiculopathy: gabapentin LOATHE: narcotics

Non-pharmacologic treatmentsNon-pharmacologic treatments

EFFECTIVE Acupuncture Exercise therapy Behavior therapy Massage TENS Spinal manipulation Multidisciplinary rehab program

NOT EFFECTIVE/

CONFLICTING EVIDENCE

BACK SCHOOLS LOW-LEVEL LASER LUMBAR SUPPORTS PROLOTHERAPY SHORT WAVE DIATHERMY TRACTION ULTRASOUND

Epidural Steroid InjectionsEpidural Steroid Injections

Indicated for radiculopathy not responding to conservative mgmt

– Conflicting evidence

– Small improvement up to 3 months

– Less effective in spinal stenosis

Surgery for Chronic LBPSurgery for Chronic LBP

Most do NOT benefit from surgery Should have ANATOMIC LESION C/W PAIN

DISTRIBUTION Significant functional disability, unrelenting pain

– Several months despite conservative tx Procedures: spinal fusion, spinal decompression,

nerve root decompression, disc arthroplasty, intradiscal electrothermal therapy

Break for Break for Physical Examination Hands-on Physical Examination Hands-on

SessionSession

InspectionInspection

Observe for areas of erythema– Infection– Long-term use of heating element

Unusual skin markings– Café-au-lait spots

Neurofibromatosis– Hairy patches, lipomata

Tethered cord– Dimples, nevi (spina bifida)

Inspection (cont.)Inspection (cont.)

Posture

– Shoulders and pelvis should be level

– Bony and soft-tissue structures should appear symmetrical

Normal lumbar lordosis

– Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall

Posture

– Shoulders and pelvis should be level

– Bony and soft-tissue structures should appear symmetrical Normal lumbar lordosis

– Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall

Bone PalpationBone Palpation

Palpate L4/L5 junction (level of iliac crests) Palpate spinous processes superiorly and inferiorly

– S2 spinous process at level of posterior superior iliac spine

Absence of any sacral and/or lumbar processes suggests spina bifida

Visible or palpable step-off indicative of spondylolisthesis

Soft Tissue PalpationSoft Tissue Palpation

4 clinical zones

– Midline raphe

– Paraspinal muscles

– Gluteal muscles

– Sciatic area

– Anterior abdominal wall and inguinal area

ANTERIOR PALPATION

Flexion - 80º

Extension - 35º

Side bending - 40º each side

Twisting - 3-18º

Range of Motion

Neurologic ExaminaionNeurologic Examinaion

Includes an exam of entire lower extremity, as lumbar spine pathology is frequently manifested in extremity as altered reflexes, sensation and muscle strength

Describes the clinical relationship between various muscles, reflexes, and sensory areas in the lower extremity and their particular cord levels

Neurologic ExaminationNeurologic Examination(T12, L1, L2, L3 level)(T12, L1, L2, L3 level)

Motor

– Iliopsoas - main flexor of hip

– With pt in sitting position, raise thigh against resistance

Reflexes - none Sensory

– Anterior thigh

Neurologic ExaminationNeurologic Examination(L2, L3, L4 level)(L2, L3, L4 level)

Motor

– Quadriceps - L2, L3, L4, Femoral Nerve

– Hip adductor group - L2, L3, L4, Obturator N. Reflexes

– Patellar - supplied by L2, L3, and L4, although essentially an L4 reflex and is tested as such

L2, L3, L4 testing

Neurologic ExaminationNeurologic Examination(L4 level)(L4 level)

Motor

– Tibialis AnteriorResisted inversion of ankle

Reflexes

– Patellar Reflex (L2, L3, L4) Sensory

– Medial side of leg

Neurologic ExaminationNeurologic Examination(L5 level)(L5 level)

Motor

– Extensor Hallicus Longus

– Resisted dorsiflexion of great toe Reflexes - none Sensory

– Dorsum of foot in midline

Neurologic ExaminationNeurologic Examination(S1 level)(S1 level)

Motor

– Peroneus Longus and Brevis

– Resisted eversion of foot Reflexes

– Achilles Sensory

– Lateral side of foot

Special TestsSpecial Tests

Tests to stretch spinal cord or sciatic nerve

Tests to increase intrathecal pressureTests to stress the sacroiliac joint

Tests to Stretch the Spinal Cord Tests to Stretch the Spinal Cord or Sciatic Nerveor Sciatic Nerve

Straight Leg RaiseCross Leg SLRKernig Test

Test to increase intrathecal Test to increase intrathecal pressurepressure

Valsalva Maneuver

–Reproduction of pain suggestive of lesion pressing on thecal sac

Kernig SignKernig Sign

Pain present Pain relieved

Tests to stress the Sacroiliac JointTests to stress the Sacroiliac Joint

FABER TestGaenslen sign

FABER test:FlexionA-BductionExternalRotation

Gaenslen signGaenslen sign

Waddell, et al. Spine 5(2):117-125, 1980.

Non-organic Physical SignsNon-organic Physical Signs(“Waddell’s signs”)(“Waddell’s signs”)

Non-anatomic superficial tenderness Non-anatomic weakness or sensory loss Simulation tests with axial loading and en bloc

rotation producing pain Distraction test or flip test in which pt has no pain

with full extension of knee while seated, but the supine SLR is markedly positive

Over-reaction verbally or exaggerated body language

Hoover TestHoover Test

Helps to determine whether pt is malingering Should be performed in conjunction with SLR When pt is genuinely attempting to raise leg, he

exerts pressure on opposite calcaneus to gain leverage

OtherOther

Rectal tone Anal wink Cremasteric reflex

Questions?Questions?