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Diagnosing Low Back Pain

Diagnosing Low Back Pain. FARIS HAZIM ALHAFID ORTHOPAEDIC SURGEON. I. History:. Mechanism of injury Associated symptoms: Bladder / bowel function Fevers / chills Sleep disturbance Numbness / tingling Prior injuries, treatment and outcomes Medications Family history Social history:

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Diagnosing Low Back Pain

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  1. Diagnosing Low Back Pain FARIS HAZIM ALHAFID ORTHOPAEDIC SURGEON

  2. I. History:

  3. Mechanism of injury • Associated symptoms: • Bladder / bowel function • Fevers / chills • Sleep disturbance • Numbness / tingling • Prior injuries, treatment and outcomes • Medications • Family history • Social history: • Vocational • Education • Tobacco / ETOH / Illicit drugs • Function: ADLs & Mobility • Litigation

  4. Pain Specifics: • Quality:sharp, dull, shooting, burning, etc. • Location / Distribution: • Radicular:Dermatomal distribution, dysesthesias • Radiating: Nondermatomal • Onset: • Gradual: DDD • Acute: Disc abnormality, strain, compression fractures • Severity / Intensity • Frequency:Constant vs. Intermittent • Duration • Exacerbating and Alleviating Factors • Time of Day: If nocturnal, consider malignancy

  5. Red Flags: • Significant trauma history, or minor in older adults • Nocturnal pain in supine position with history of cancer • Bladder or bowel incontinence or dysfunction • Constitutional symptoms: • Fever / chills • Weight loss • Lymph node enlargement • Risk factors for spinal infection • Recent infection • IV drug use • Immunosuppression • Major motor weakness

  6. II. Examination:

  7. A. Physical: • Posture: • Splinting • Body language • Gait: • Antalgia • Heel / Toe pattern • Trendelenberg • Musculoskeletal: • ROM • Leg length • Vascular • Atrophy

  8. Abdomen: • Presence of masses • Back: • Inspection • Palpation • ROM • Scoliosis • Neurological: • Sensation • Motor • DTRs • Rectal if indicated: • Evaluation of sphincter tone

  9. B. Symptom Magnification Examination: • Waddell signs: Presence of nonorganic signs suggesting symptom magnification and psychological distress • Superficial or nonanatomic distribution of tenderness • Nonanatomic or regional disturbance of motor or sensory impairment • Inconsistency on positional SLR • Inappropriate/excessive verbalization of pain or gesturing • Pain with axial loading or rotation of spine • Give-away weakness: Inconsistent effort on manual motor testing with “ratcheting” rather than smooth resistance

  10. C. Pathological Examination: • Spurling’s maneuver:Lateral rotation and extension of spine resulting in neuroforaminal narrowing and nerve root encroachment, clinically reproducing extremity pain, usually in dermatomal distribution • Straight-leg raise (SLR):Elevation of lower extremity, seated or standing, resulting in neural tension at S1 nerve root with extremity pain • Patrick’s maneuver:Crossed leg with unilateral pain indicative of sacro-iliac (SI) joint dysfunction • Femoral stretch:Hip extension stretch with heel pushed to buttock in lateral supine or prone position resulting in anterior thigh pain

  11. III. Low Back Pain:

  12. A. Epidemiology: • Incidence of LBP: • 60-90 % lifetime incidence • 5 % annual incidence • 90 % of cases of LBP resolve without treatment within 6-12 weeks • 40-50 % LBP cases resolve without treatment in 1 week • 75 % of cases with nerve root involvement can resolve in 6 months • LBP and lumbar surgery are: • 2ndand 3rd highest reasons for physician visits • 5th leading cause for hospitalization • 3rd leading cause for surgery

  13. B. Disability: • Age and LBP: • Leading cause of disability of adults < 45 years old • Third cause of disability in those > 45 years old • Prevalence rate: • Increased 140 % from 1970 to 1981 with only125 % population growth • Nearly 5 million people in the U.S. are ondisability for LBP

  14. C. Lifetime Return to Work: • Success of less than 50 % if off work greater than 6 months • 25 % success rate if off work greater than 1 year • Nearly 0 % success if return to work has not occurred in 2 years

  15. D. Occupational Risk Factors: • Low job satisfaction • Monotonous or repetitious work • Educational level • Adverse employer-employee relations • Recent employment • Frequent lifting • Especially exceeding 25 pounds • Utilization of poor body mechanics in technique

  16. E. Differential Diagnoses: • Lumbar strain • Disc bulge / protrusion / extrusion producing radiculopathy • Degenerative disc disease • Spinal stenosis • Spondyloarthropathy • Spondylosis • Spondylolisthesis • Sacro-iliac dysfunction

  17. F. Diagnostic Tools: • 1. Laboratory: • Performed primarily to screen for other disease etiologies • Infection • Cancer • Spondyloarthropathies • No evidence to support value in first 7 weeks unless with red flags • Specifics: • WBC • ESR or CRP • HLA-B27 • Tumor markers: Kidney Breast Lung Thyroid Prostate

  18. 2. Radiographs: • Pre-existing DJD is most common diagnosis • Usually 3 views adequate with obliques only if equivocal findings • Indications: • History of trauma with continued pain • Less than 20 years or greater than 55 years with severe or persistent pain • Noted spinal deformity on exam • Signs / symptoms suggestive of spondyloarthropathy • Suspicion for infection or tumor

  19. 3. EMG / NCV ( Electrodiagnostics): • Can demonstrate radiculopathy or peripheral nerve entrapment, but may not be positive in the extremities for the first 3-6 weeks and paraspinals for the first 2 weeks • Would not be appropriate in clinically obvious radiculopathy • 4. Bone scan: • Very sensitive but nonspecific • Useful for: • Malignancy screening • Detection for early infection • Detection for early or occult fracture

  20. 5. Myelogram: • Procedure of injecting contrast material into the spinal canal with imaging via plain radiographs versus CT • In past, considered the gold standard for evaluation of the spinal canal and neurological compression • With potential complications, as well as advent of MRI and CT, is less utilized: • More common:Headache, nausea / vomiting • Less common:Seizure, pain, neurological change, anaphylaxis • Myelogram alone is rarely indicated • Hitselberger study 1968 Journal of Neurosurgery: • 24 % of asymptomatic subjects with defects

  21. 6. CT with myelogram: • Can demonstrate much better anatomical detail than myelogram alone • Utilized for: • Demonstrating anatomical detail in multi-level disease in pre- operative state • Determining nerve root compression etiology of disc versus osteophyte • Surgical screening tool if equivocal MRI or CT

  22. 7. CT: • Best for bony changes of spinal or foraminal stenosis • Also best for bony detail to determine: • Fracture • DJD • Malignancy • SW Wiesel study 1984 Spine: • 36 % of asymptomatic subjects had “HNP” at L4-L5and L5-S1 levels

  23. 8. Discography (Diagnostic disc injection): • Less utilized as initial diagnostic tool due to high incidence of false positives as well as advent of MRI • Utilizations: • Diagnose internal disc derangement with normal MRI / myelo • Determine symptomatic level in multi-level disease • Criteria for response: • Volume of contrast material accepted by the disc, with normals of 0.5 to 1.5 cc • Resistance of disc to injection • Production of pain---MOST SIGNIFICANT • Usually followed by CT to evaluate internal architecture, but also may utilize MRI • As outcome predictor (Coulhoun study 1988 JBJS): • 89 % of those with pain response received benefit from surgery • 52 % of those with structural change received surgical benefit

  24. 9. MRI: • Bestdiagnostic tool for: • Soft tissue abnormalities: • Infection • Bone marrow changes • Spinal canal and neural foraminal contents • Emergent screening: • Cauda equina syndrome • Spinal cored injury • Vascular occlusion • Radiculopathy • Benign vs. malignant compression fractures • Osteomyelitis evaluation • Evaluation with prior spinal surgery

  25. Has essentially replaced CT and myelograms for initial evaluations • Boden study 1990 JBJS: • 20 % of asymptomatic population less than 60 years with “HNP” • 36 % of asymptomatic population of 60 years • Jensen study 1995 NEJM: • 52 % of asymptomatic patients with disc bulge at one or more levels • 27 % of asymptomatic patients with disc protrusion • 1 % of asymptomatic patients with disc extrusion

  26. MRI with Gadolinium contrast: • Gadolinium is contrast material allowing enhancement of intrathecal nerve roots • Utilization: • Assessment of post-operative spine---most frequent use • Identifying tumors / infection within / surrounding spinal cord • Diagnosis of radiculitis • Post-operatively can take 2-6 months for reduction of mass effect on posterior disc and anterior epidural soft tissues which can resemble pre-operative studies • Only indications in immediate post-operative period: • Hemorrhage • Disc infection

  27. 10. Psychological tools: • Utilized in case scenarios where psychological or emotional overlay of pain is suspected • Symptom magnification • Grossly abnormal pain drawing • Non-responsive to conservative interventions but with essentially normal diagnostic studies • Includes: • Pain Assessment Report, which combines: • McGill Pain Questionnaire • Mooney Pain Drawing Test • MMPI • Middlesex Hospital Questionnaire • Cornell Medical Index • Eysenck Personality Inventory

  28. MRI Nomenclature:(PER NASS) • Anular fissure: Focal disruption of anular fibers in concentric, radial or transverse distribution • Disc bulge:Circumferential, diffuse, symmetric extension of anulus beyond the adjacent vertebral end plates by 3 or more mm, usually due to weakened or lax anular fibers • Disc protrusion:Focal, asymmetric extension of disc segment beyond margin of vertebral end plates into the spinal canal with most of anular fibers intact • Disc extrusion:Focal, asymmetric extension of disc segment and / or nucleus pulposis through the anular containment into the epidural space • Disc sequestration:Extruded disc segment that is detached from original with migration into the canal • Disc degeneration:Irreversible structural and histiological changes in nucleus seen on MRI T2WI images (commonly associated with bulge)

  29. Specificity / Sensitivity

  30. G. Treatment • Medications • NSAIDS • Membrane stabilizers • TCA / Neurontin • re-establish sleep pain • reduce radicular dysesthesias • Muscle relaxers: • re-establish sleep patterns • more useful in myofascial/muscular pain • Narcotics: rarely indicated • Steroids: more useful for radiculitis • Non-narcotic analgesics: Ultram

  31. Physical therapy • Modalities • electrical stimulation/TENS • Postural education / body mechanics • Massage / mobilization / myofascial release • Stretching / body work • Exercise / strengthening • Traction • Pre-conditioning / work-conditioning • Injections • Epidural blocks • Facet blocks • Trigger point • SNRB • SI joint

  32. Surgery: • Laminectomy • Fusion • Discectomy • Percutaneous Lumbar Discectomy • Success rate variable 50 -85 % • Low rate of complications: • Infection • Peripheral nerve injury • Benefits: • Outpatient procedure • Minimal to no epidural scarring • No general anesthesia • Spine stability preservation • Decreased cost

  33. Chemonucleolysis • IDET: Intradiscal Electrotherapy or Spine CATH • Alternative: • Chiropractic: • Clinical studies show benefit only in first 3 weeks of symptoms • Acupuncture • Biofeedback

  34. IV. Specific Disorder Considerations

  35. A. Sacroiliitis: • History: • Trauma is very common • Repetitive LS motion--lumbar rotation or axial loading • No specific correlation with exacerbating activities • Commonly have leg length discrepancy or condition contributing • Biomechanics: • Movement of the SIJ is involuntary, usually from muscle imbalances • Can occur at multiple levels: lower extremities, hip, LS spine • Motion is complex and not single-axis based

  36. Differential Diagnosis: a. Fracture • Traumatic • Insufficiency stress fractures: elderly patient with osteoporosis without history of trauma • Fatigue stress fractures: usually athletes / soldiers b. Infection • Hematogenous spread with predisposing history • Usually unilateral symptoms present c. Degenerative joint disease d. Metabolic disease e. Referred pain

  37. f. Seronegative spondyloarthropathies • RA--usually not until late in course of disease • Ankylosing spondylitis • Psoriatic arthritis g. Primary SI tumor • Rare and usually synovial villoadenomas h. Iatrogenic instability • Via pelvic tumor resection or bone graft site i. Osteitis condensans ilii • Prevalence of 2.2 %, primarily in multiparous women • Usually self-limiting and bilateral j. Reactive diseaseas sequellae of PID

  38. Diagnostic Tools: • X-rays:Up to 25 % of asymptomatic adults over 50 years can have abnormalities • MRI / CT:Only if looking for tumor • Bone scan:Good for fractures but less favorable for inflammation • Treatment: • Medications:NSAIDS • Physical therapy • Correct limb discrepancy • Injection:Fluoroscopy-guided vs. local • Surgical fusion:Few figures for efficacy

  39. B. Cauda Equina Syndrome: • History: • Sudden, partial or complete loss of voluntary bladder function due to massive disc impingement on spinal nerves • Can include loss of sensation as well as sphincter tone • Treatment: • Urgent decompression is mandatory for prevention of irreparable / irreversible bladder damage • 12 hours is the maximum time prior to irreversible changes

  40. C. DDD and Spondylosis: • Clinical: • Up to 75 % of involvement of the spine occurs at 2 levels: L5-S1 and L4-L5 • Possible factors that contribute to development: • Changes with maturation in: • Nutrition • Disc chemistry • Hormones • Occupational forces • Progression of disc narrowing leads to degenerative changes of bony structures, especially posterior components, leading to spondylosis

  41. Treatment: • Medications • Physical therapy • Lifestyle changes: • Smoking cessation • Weight loss • Vocational changes • Injections: • Less helpful if pain is limited to central low back only • Surgery: • Laminectomy • Fusion

  42. D. Spinal Stenosis: • Clinical: • Results from narrowing of spinal canal and / or neural foramina (CONGENITAL OR DEGENERATIVE) • Most common complaint is leg pain limiting walking • Neurogenic / Pseudoclaudication = pain in lower extremities with gait • Relief can occur with: • stopping activity • sitting, stooping or bending forward • Common are complaints of weakness and numbness of extremities • Usually becomes symptomatic in 6th decade

  43. Diagnosis: • CT and MRI may yield false-positive results, therefore EMG / NCV can be helpful to confirm diagnosis • Myelography also can be confirmatory and pre-surgical screening tool • Treatment: • Medications • Physical therapy • TENS • Epidural injections • Surgical decompression laminectomy

  44. E. “HNP”: • Clinical: • Low back pain wit associated leg symptoms • Positions can induce radicular symptoms • Posterolateral disc pathology most common: • Area where anular fibers least protected by PLL • Greatest shear forces occur with forward or lateral bend • Central disc pathology: • Usually with LBP only without radicular symptoms, unlessa large defect is present

  45. Treatment: • Conservative treatment: • Saul and Saul study 1989 Spine: • > 90 % success rate of symptom resolution withnon-operative management • Bozzao study 1992 Radiology: • 69 patients with “HNP” studied longitudinally with MRI • 63 % with >30 % reduction with 48 % > 70 % reductionover time • Medications • Physical therapy • Injections • Surgery

  46. F. Pars Interarticularis Defects: • Spondylolysis: • Anatomic defect in the bony pars interarticularis within the lamina • May uni- or bilateral • Can be congenital or induced • Usually without clinical symptoms with incidental findings on radiographs

  47. Spondylolisthesis • Progression of spondylolysis with separation • Grades assigned I-IV for level of translation • Most common levels are L5-S1 (70 %) and L4-L5 (25 %) • May be asymptomatic, but can result in • Spondylosis • DDD • Radiculopathy • Treatment: • Medication • Physical Therapy • Injections • Surgery

  48. V. Chronic Pain Issues

  49. A. Pain Reinforcing Factors: • Secondary gain:Support system allows passive / inactive role for patient via catering to needs and hence fostering dependency • Environmental:Inadequate opportunity or skills to compete in the professional community • Physician knowledge deficit:In areas of diagnosis and appropriate treatment, can prolong symptoms and validate pain behavior • Worker’s compensation:Laws have become counterproductive-- financial compensation or open claim may discourage desire for return work and impede recovery • Litigation:Anticipation of large financial settlement can reinforce pain behavior and develop into learned pain behavior

  50. B. Risk Factors for Delayed Recovery:

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