•Low back pain is a symptom - Amazon...
Transcript of •Low back pain is a symptom - Amazon...
EVALUATION AND MANAGEMENT OF LOW BACK PAINGregory M Yoshida MD
LOW BACK PAIN
•Low back pain is a symptom
LOW BACK PAIN• 90% of Americans will experience at some
time• Leading cause of disability in persons
under age 45• 1-2% is operative• Cost is in the billions• Only a problem in industrialized nations• Cocktail medicine
LOW BACK PAIN
• Self-limiting• Resolution▫ 40% @ 1 mo▫ 60% @ 2 mo▫ 75% @ 3 mo
• Remaining 25% accounts for 85% of the cost
PEARL
LOW BACK PAIN
• Non-orthopedic causes▫ Pyelonephritis▫ AAA▫ Pancreatitis/pancreatic CA
LOW BACK PAIN – RED FLAGS
• Pain radiating past the knee• Pain radiating out the front• Fevers/chills• Weakness/numbness in the LE’s• Bowel/bladder incontinence or retention
PATIENT EVALUATION
• History• PMH• PE• Diagnostic tests
HISTORY
•“OLD CARTS”
ONSET
• Sudden vs gradual• Mechanism• Body position▫ Flexion▫ Rotation
LOCATION
• Midline• Paraspinous• Hip/buttocks• Flank
PEARL
LOCATION
• Greater trochantericbursitis
• Iliotibial band syndrome
DURATION
• Total duration• Time of each episode
CHARACTERISTICS
• Open-ended question• Sharp, dull, stabbing, throbbing, aching, electrical, burning, etc.• Get a “feel” of the pt’s pain
AGGRAVATING AND ALLEVIATING FACTORS
• Posture▫ Sit/stand/supine▫ Flexion/extension
• Activity• Lifting• Valsalva• Medications
RADIATION
• Dermatomal• Sclerotomal• Past the knee• Out the front
TEMPORAL RELATIONS
• AM vs PM• Time after aggravating or alleviating factor• Night pain
ASSOCIATED Sx
• Weight loss• Fever/chills• Numbness/weakness• Bowel/bladder problems
PAST MEDICAL Hx
• Previous back surgery• Malignancy• Foreign travel
PHYSICAL EXAM
•Confirm your hypothesis
INSPECTION• Pt posture and attitude• Scoliosis• Pt’s behavior during interview
GAIT ANALYSIS
• Antalgic▫ Weak gastroc
• Drop foot▫ Toe stub▫ Circumduction▫ High step
• Back knee• Gluteal lurch
PE - STANDING• Palpation▫ Midline▫ Paraspinous▫ Spasm▫ Buttocks▫ Sciatic notch
• ROM▫ Flexion/extension▫ Rotation▫ Lateral bend
• Fluidity• Reversal of lordosis
PE - SITTING
•Sitting straight leg raise (SLR)•Neurologic exam
NEUROLOGIC EXAMMOTOR SENSORY
• Manual muscle test (MMT)▫ 0 – nothing▫ 1 – fasciculation▫ 2 – full ROM, no gravity▫ 3 – full ROM, against gravity▫ 4 – between 3 and 5▫ 5 - normal
• Test pin prick and light touch▫ 0 – absent▫ 1 – impaired▫ 2 - normal
NEUROLOGIC EXAMMOTOR SENSORY
• L1 – none• L2 – psoas• L3 – quads• L4 – Tibialis anterior• L5 – ext hallicis longus• S1 – gastroc, peroneals• S2 – medial hamstrings• S3 – anal sphincter• S4 – anal sphincter
• Inguinal crease• Anterolateral thigh• Patella• Medial malleolus• 1st dorsal webspace• Sole of foot• Posteromedial thigh• Scrotum/labia majora• Glans/clitoris
NEUROLOGIC EXAM
•Reflexes▫PatellaL3,L4▫AchillesS1,S2
•Look for asymmetry
PEARL
PE - SUPINE
• SLR• Must recreate radicular pain past the knee• Less than 40 degrees is non-physiologic
RELIABILITY TEST
• Hold both heels off table
• Ask pt to quickly lift one leg up
• Downward pressure should be exerted by the other leg
DIAGNOSTIC TESTS
•Patient dependent
•Diagnosis dependent
BACK PAIN
• Lumbar sprain/strain• Lumbosacral strain• Lumbago• Mechanical back pain• Most common Dx
LS STRAIN
• Antecedent event▫ MVA, lifting, slip and fall, etc.
• Isolated back pain• No red flags
PEARL
LS STRAIN
• Hip DJD can be confused with back pain
• Pain typically in the groin• Reproduce Sx with int
rotation of the hip
TREATMENT• Initial▫ One day bed rest▫ Medrol dose pack
• One week F/U▫ NSAID▫ PT▫ +/- antispasmodics
• One month F/U▫ 40% improved
• Not improved▫ X-rays▫ PT▫ Meds
TREATMENT
• Three month F/U▫ 75% improved
• Not improved▫ LS MRI▫ Refer
HERNIATED DISC (HNP)
• Pain radiating down LE in a dermatomal distribution
• Flexion and rotation• Standing more comfortable• Increased pain with
valsalva
HNP
• PE▫ Pain with forward flexion▫ + SLR▫ Cross SLR Raise uninvolved LE – create
pain in involved LE
▫ +/- neuro findings
HNP
• Affects the traversing nerve root▫ L5-S1 gets S1▫ L4-5 gets L5
PEARL
HNP
• 76% will resolve on their own within 3-4 mo
SPORT STUDY
• Spine Patient Outcomes Research Trial▫ 90-95% good and excellent results at 8 years▫ Surgery had slightly better results Level dependent L2-3, L3-4 surgery most beneficial L4-5 equivocal L5-S1 surgery less indicated
TREATMENT• Without a deficit▫ Medrol
• If improved▫ Rx like a strain▫ PT
• If not improved▫ ESI
• With a deficit▫ Medrol▫ LS MRI
• Follow previous algorithm
SURGICAL REFERAL
• Patients failing conservative treatment • L2-3 or L3-4 level• Increasing neurological deficit• Bowel/bladder problems▫ EMERGENCY
SPONDYLOLISTHESIS
• Forward slippage of a vertebra on the one below
• Six types▫ Isthmic▫ Degenerative
SPONDYLOLISTHESIS• Isthmic▫ Stress fracture of the pars interarticularis▫ Repetitive hyperextension▫ Age 6 to 16▫ L5-S1 most common
• Degenerative▫ Incompetence of the facets▫ Women > men▫ L4-5 most common
ISTHMIC SPONDY
• Pain with extension• Tight hamstrings• Hx of extension activities▫ Gymnastics▫ Football interior linemen
• Oblique X-rays▫ Scotty dog
ISTHMIC SPONDY
ISTHMIC SPONDY
ISTHMIC SPONDY
ISTHMIC SPONDY
• Any child with back pain > 3 mo with normal X-rays requires a bone/spect scan
DEGEN SPONDY
• Results from incompetence of the facets
• Presents like stenosis
SPONDYLOLISTHESIS
• Any patient with spondylolisthesis should be referred
STENOSIS
• Narrowing of the spinal canal from degeneration
STENOSIS
• Neurogenic claudication• Pain radiating down LE
with standing or walking• Sleep in fetal position
STENOSIS
• Differentiate from vascular claudication▫ Riding a seated exercise bike▫ Walking uphill
• LS MRI• refer
SPORT
• PT and ESI provide temporary relief at best• ESI not recommended• Surgery provided 85-90% good and excellent results up to 6 years• By 8 years op and non op groups converged
ANKYLOSING SPONDYLITIS
• Young adults• Male > female• AM stiffness, improves as day progresses• Primarily hips/buttocks
ANKYLOSING SPONDYLITIS
• PE▫ Decreased lumbar and
chest excursion
• AP Pelvis• CBC, ESR, CRP, HLA-B27
ANKYLOSING SPONDYLITIS
COMPRESSION FRACTURE
• Osteoporosis• Minimal trauma• Pain centered • X-ray all elderly patients
with back pain
COMPRESSION FRACTURE
• Must r/o pathologic fracture
• CBC, Chem-20, SPEP, UPEP
• Hx of wt loss• Night pain
PATHOLOGIC FRACTURE
•Most common tumor of the spine is metastatic disease
•Most common primary tumor of the spine is multiple myeloma/plasmacytoma
PEARL
PATHOLOGIC FRACTURE
• Tumors most likely to metastasize to bone• P. T. Barnum Loves Little Kids▫ Prostate▫ Thyroid▫ Breast▫ Lung▫ Lymphoma▫ Kidney
• Refer
COMPRESSION FRACTURE
• Brace• Kyphoplasty▫ Acute▫ Thoracic
DEGENERATIVE DISC DISEASE
• Dx of exclusion• Spondylosis• Discogenic pain• Retrolisthesis• Facet syndrome
DEGENERATIVE DISC DISEASE
• Conservative care• PT• NSAIDs• Pain management• Surgery is 65% successful
at best
THE FUTURE
• Disc regeneration therapy• Improve minimally
invasive surgery• Robotics
CONCLUSION
• Back pain is common• The majority of pts can be treated successfully conservatively• Differentiate from extremity problems• Some pts require early referral
THANK YOU