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Low Back Pain: Case Based Evaluation and Management

Low Back Pain: Case Based Evaluation and Management. Patrick Kortebein, M.D. Departments of PM&R and Geriatrics University of Arkansas for Medical Sciences 5/31/09 Slides: www.uams.edu/pmr. Objectives. Understand the evaluation and management of common sources of low back and related pain

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Low Back Pain: Case Based Evaluation and Management

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  1. Low Back Pain:Case Based Evaluation and Management Patrick Kortebein, M.D. Departments of PM&R and Geriatrics University of Arkansas for Medical Sciences 5/31/09 Slides: www.uams.edu/pmr

  2. Objectives • Understand the evaluation and management of common sources of low back and related pain • Understand the significance of abnormal findings on lumbar spine MRI in individuals with low back and related pain. • Understand the evaluation and management of chronic low back pain.

  3. Low Back Pain • Common; 2nd primary care visits • 5-15% per year • 60-80% lifetime • Acute episodes • 75-90% recover w/in 3 months • 25-75% will have recurrence w/in 6 months

  4. LBP: Anatomy • Bone / Vertebrae • Disc • Annulus • Nucleus Pulposus • Muscles / Ligaments • Spinal Nerve Roots

  5. LBP • Facet joint • Zygopophyseal joint • Synovial

  6. LBP • Sacroiliac Joint • Tight, Synovial • Ligaments • “SI Dysfunction”

  7. Case #1 28 yo M presents with CC: LBP • Started 4 days ago while bending over to pick up his 14 mo old child • PMHX: L knee arthroscopy • Meds: Acetaminophen • NKDA • Social Hx: Married, insurance salesman What other information is important?

  8. Acute LBP: History • Location • Axial or Radiating (Sciatica) ? • Onset: Traumatic, Insidious • Duration: • Acute: < 12 weeks • Chronic: > 12 weeks • Character/Quality: Ache, Burning, etc • Exacerbating / Alleviating Factors

  9. Acute LBP: History “Red Flags” (AHCPR 1994) • Fracture: • Major/minor trauma • Age > 70 yrs (~50 yrs) • Chronic corticosteroids • Cauda Equina • B/B dysfunction • Saddle Anesthesia • LE weakness

  10. Acute LBP: History “Red Flags” (AHCPR 1994) • Infection • Fever • Steroids / Immunosuppression / IV Drug Use • UTI / Systemic Infection • Cancer • Hx of Cancer • Unintentional Weight Loss • Supine/Night Pain • Age > 50

  11. “Red Flag” Evaluation

  12. Acute LBP: Physical Exam • Lumbar Spine: • Inspection • Palpation • ROM: Flexion / Extension • +/- LE Neurologic Exam

  13. Acute LBP: Imaging • When? • What imaging?

  14. Acute LBP: Imaging When? • Minimum 6 weeks • + “Red Flags” What? • X-ray 3-view: • AP / Lat / L5 Spot Obliques: • Limited information • Radiation exposure

  15. Acute LBP: Imaging • Lumbar MRI

  16. Acute LBP: Imaging Abnormal findings • “Degenerative disc disease” • “Bulging disc” • “Herniated disc”

  17. LBP: Imaging MRI Abnormalities in Normals / No LBP • Boden et al (N=67) JBJS 1990 • HNP: 21-36% • Bulging Disc: 50-80% • Degenerative Disc Changes: 34-93% • Jensen et al (N= 98) NEJM 1994 • Bulging Disc: 52% (28-100%) • Disc Protrusion: 27% (21-30%)

  18. Case #1 History • Onset: 4 days ago, constant • Location: R lumbosacral junction • No radiation / neurological symptoms • No clear exacerbating / alleviating factors Physical Exam • Mild tenderness R low lumbar region • Increased pain with flexion • Normal LExt neuro exam

  19. Case # 1 • Diagnosis ? • Management ?

  20. LBP: Differential Diagnosis Deyo NEJM 2001

  21. Case # 1Diagnosis: “Mechanical” LBP • Education / Activity Modification • Bedrest: ~ 2 days (Deyo NEJM 1986) • Analgesics: • Acetaminophen • NSAID’s • Tramadol • Muscle Relaxants • Cyclobenzaprine

  22. “Mechanical” LBP • Physical Therapy • Exercise • Modalities • Lumbar Support • Chiropractic • Acupuncture Back Heat

  23. LBP: Zygapophyseal (Facet) joint • History/Examination • Axial LBP +/- post thigh • No neuro sxs • Worse w/ static posture • Lumbar Extension • Stand / Walk • Neuro exam normal

  24. LBP: Zygapophyseal (Facet) joint Management • Analgesics • Tylenol, NSAID • Physical Therapy • Injections • Diagnostic • Therapeutic

  25. LBP: Sacroiliac (SI) Joint • History • Atraumatic > Traumatic • Axial; Lumbosacral • Uni- > Bilateral • No radiation / neuro sxs • Physical Exam • ~ Normal • Tender SI region

  26. LBP- SI Joint • Diagnosis / Treatment • Physical Therapy • Injection

  27. LBP: Discogenic History / Exam • Axial LBP • No radiation / neuro sxs • Aggravating: • Static posture- Sitting or Sit to stand • Normal neurological exam

  28. LBP: Discogenic Management • Physical Therapy • Core Strength • Surgery: • Fusion • Artificial Disc • Not yet

  29. Case # 2 • 38 yo with left LE radicular pain > LBP for ~6 weeks. Also left foot tingling and weakness. • PMHx: HTN, Hyperlipidemia • Meds: HCTZ, Atorvastatin • Allergies: Sulfa • Social Hx: Divorced, Landscaper

  30. Case # 2 Physical Exam • L-spine: Non-tender • Left LExt: + SLR / Crossed SLR • Neuro • Motor: 5/5 except Plantar Flexion • Reflex: KJ +2/+2, AJ +2 / 0 • Sensory: Dec to LT lateral heel

  31. Case # 2 • Diagnosis ?

  32. LBP: Radiculopathy Diagnosis • Physical Exam • MRI • EMG • CT Myelogram * Correlate anatomy w/ sxs and exam

  33. LBP: Radiculopathy Neurological Exam: MotorReflexSensory L2/3: Hip Flex/Add Knee Med Thigh /Knee L4: Knee Ext/DFlex Knee Med Ankle L5: Great toe/EHL Int. HS Dorsum Foot S1: Plantarflex Ankle Lat Heel Functional: Squat, Heel / Toe Walk, Heel Raise

  34. LBP: Evaluation • SLR / Dural Tension

  35. Case # 2 • MRI: Left L5-S1 disc herniation impinging on S1 nerve root Management?

  36. LBP: Radiculopathy Management • Medications • NSAID’s • Acetaminophen • Tramadol • Neuropathic • Steroids; • Oral (? dose) vs epidural

  37. LBP: Radiculopathy Management • Physical Therapy • McKenzie Extension therapy • TENS ~ No benefit

  38. LBP: Radiculopathy • Injections Epidural Selective

  39. LBP: Radiculopathy Surgery • Indications • Cauda equina • Progressive neuro deficits • No relief w/ conservative treatment • SPORT trial • JAMA 2006

  40. LBP: Spinal Stenosis • History (Neurogenic claudication) • Prox LE Pain +/- Neuro sxs • Walk / Stand • Uphill > Downhill • Grocery Cart • Physical Exam • ~ Normal • Stand / Walk

  41. LBP: Spinal Stenosis • Diagnosis • MRI • EMG • Management • Medications • Neuropathic • PT • Epidural Injection • Surgery: (SPORT trial)

  42. Case # 3 • 51 yo M truck driver injured at work 2 years ago lifting a 30# box, and applying for disability • Continued axial LBP and “numb” R LE • No “Red Flags” • Treatments to date: • Medications: NSAIDs, Tramadol, Hydrocodone • Physical Therapy: 24 sessions • Work restrictions; not working • Injections: Epidural / Facet / Sacroiliac

  43. Case # 3 Physical Examination • Lumbar: Diffuse tenderness to light palpation • Exaggerated pain behavior w/ trunk rotation • Lower Extremity Neurologic • 50% decreased sensation entire LExt • Normal strength / reflexes • Supine SLR: LBP; Seated SLR: No pain

  44. Case # 3 • Lumbar MRI: • Mild DD changes with diffuse disc bulge at L4-5 and L5-S1 • Diagnosis? • Treatment?

  45. Chronic LBP • Duration • > 12 weeks • Poor Correlation • Symptoms • Objectives Finding

  46. Chronic LBP • Strong Association • Depression • Anxiety • Poor Coping Skills “My back hurts, but I’m here because I can’t cope with this episode, as well as the turmoil at home (or work)”- N Hadler “Last Well Person”

  47. Chronic LBP

  48. Chronic LBP **Goal** • Improve Function • Minimize focus on treating pain itself • Biopsychosocial Model of Pain • Maladaptive Behavior • Neuroplasticity

  49. Chronic LBP

  50. Case # 3 Multidisciplinary Pain Management • Education • Medications • Chronic Opioids ? • PT • Functional Restoration • Psychology • Pain Management

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