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Comprehensive Evaluation and Management of Low Back Pain: Insights and Case Studies

This presentation by Dr. Patrick Kortebein focuses on the evaluation and management of low back pain (LBP), a common ailment that accounts for a significant number of primary care visits. It highlights the importance of understanding the anatomy and sources of LBP, recognizing red flag symptoms, and utilizing imaging techniques such as MRI for accurate diagnosis. Case studies illustrate common LBP presentations and management strategies, emphasizing the role of education, activity modification, and physical therapy in treatment.

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Comprehensive Evaluation and Management of Low Back Pain: Insights and Case Studies

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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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