Low Back Pain

What is low back pain?

Pain in the low back

Epidemiology

80% of the population will have at least one episode of LBP in their lifetime

Annually $20 million in direct cost and $50 million when indirect cost is added

3% of workers’ comp case but account 30% of the cost and receive 75% of the payment

Common causes of LBP? Nonspecific – ligamentous or articular

structures, strain, myofascial disorders, psychosocial factors

Arthritis Spondylolisthesis Disc herniation - >95% L4-5, L5-S1 Spinal stenosis Fracture Tumor

History? Characterize the pain

Diffuse, tight, gradual onset, worse after sitting or with cold, relieved with warmth, associated stiffness – myofascial disorder

Brief, shooting, worse with coughing, standing or sitting, relieved when lying down, radiating down the leg – nerve root, sciatica

Persistent, burning, tingling, worse when lying down at night – peripheral nerve or lumbosacral plexus

Radiating to buttock, thighs, legs, worse with back extension, relieved with sitting – spinal stenosis

Associated with horse saddle – cauda equina syndrome

History – rule out “red flags” symptoms?

Trauma Fever Weight loss Neurologic deficits – numbness,

bowel/bladder incontinence History of IVDA, cancer, steroid use Last longer than one month Associated with abdominal pain

Physical exam?

Gait Muscle weakness – atrophy, pelvic tilt Knee flexion – guard against root traction

ROM Palpation – tenderness, step off

Physical exam

Motor strength Heel – L5 Tiptoe – S1

Sensation – dermatomes L4 – big toe L5 – middorsum of foot S1 – lateral foot

Physical exam

Reflex Knee – L3, L4 Ankle – S1

Straight leg raise Crossed straight leg raise - >

specificity than straight leg raise Rectal exam

Inconsistent examinations

Axial loading Whole body rotation at the hip Straight leg raise in sitting position

Tests for patients without “red flags” symptoms?

None 90% resolve spontaneously in 4

weeks

Tests with “red flags” symptoms?

CBC and ESR X-ray CT scan – fracture, fact joint

Tests with “red flags” symptoms?

MRI Infection, cancer, disc herniation Age >50, asymptomatic, disc bulging 75-

80% and 30% disc protrusion Bone scan – cancer EMG

Nerve root involvement after multiple back surgeries

Fastitious weakness

Treatments – acute LBP?

Activity versus bed rest Without radiculopathy, activity as

tolerated With radiculopathy, may consider bed

rest < 3 days

Treatments – acute LBP?

Medications Acute – around the clock rather than prn Analgesics: acetaminophen, NSAID, cox-

2 inhibitor, narcotics Muscle relaxants – short term Subacute/chronic: TCA, SSRI, phenytoin,

tramadol, gabapentin

Treatments – acute LBP

Soft tissue injection – controversial Back exercise

Limited benefit Not during acute attack

Treatments – acute LBP

Disc herniation Multiple conservative modalities - >90%

resolved Discectomy

Sciatica Conservative treatment initially for 1-3

months - 80% resolved spontaneously 73% recurred at least once

Treatment – chronic LBP? Back exercise Antidepressants – mixed result,

confounding depression Steroid injection in

Epidural space – may help in some patients, conflicting reports

Facets – limited data, one small study showed relief at 6 months but not month 1-3

Spinal stenosis – laminectomy Minimally invasive procedures Spinal fusion – multiple laminectomy,

unstable

Treatment – chronic LBP

Lumbar disc replacement Behavior therapy Spinal manipulation – mildly effective

in some patients but no better than other routine modalities

TENS – no benefits