Low Back Pain Dr.Kishore Nallapu

Goals To recognize red flags To recognize yellow flags To recognize disability from simple low back pain To relieve pain To improve ability to function and alleviate disability To prevent recurrence and the development of chronicity

To recognize red flags

To recognize yellow flags

To recognize disability from simple low back pain

To relieve pain

To improve ability to function and alleviate disability

To prevent recurrence and the development of chronicity

How Common? 4% of GP consultations. £1632 million (1998). 800,000 in-patient bed-days. 52 million lost working days each year in Britain. Lifetime prevalence is. -- >80% in adults. -- >40% in adolescents. Men and women are equally affected. Aged 30 to 50.

4% of GP consultations.

£1632 million (1998).

800,000 in-patient bed-days.

52 million lost working days each year in Britain.

Lifetime prevalence is.

-- >80% in adults.

-- >40% in adolescents.

Men and women are equally affected.

Aged 30 to 50.

How Common Are Serious Causes ? <5% have true nerve root pain <1% have serious disease such as spinal tumour or infection <1% have inflammatory disease such as ankylosing spondylitis

<5% have true nerve root pain

<1% have serious disease such as spinal tumour or infection

<1% have inflammatory disease such as ankylosing spondylitis

Anatomy

Anatomy

Risk factors Heavy physical work Lifting and handling of loads Awkward postures and movements Whole body vibration (truck driving) Trauma

Heavy physical work

Lifting and handling of loads

Awkward postures and movements

Whole body vibration (truck driving)

Trauma

Causes Mostly unknown (simple low back pain) Traumatic Referred pain Degenerative Inflammatory Infective Neoplastic Metabolic etc

Mostly unknown (simple low back pain)

Traumatic

Referred pain

Degenerative

Inflammatory

Infective

Neoplastic

Metabolic

etc

Referred pain Abdomen: aortic aneurysm Kidney: pyelonephritis, hydronephrosis, calculi, tumour, perinephric abscess Ovary: cysts, cancer Pelvis: endometriosis, period pain, pelvic inflammatory disease Bladder: infections

Abdomen: aortic aneurysm

Kidney: pyelonephritis, hydronephrosis, calculi, tumour, perinephric abscess

Ovary: cysts, cancer

Pelvis: endometriosis, period pain, pelvic inflammatory disease

Bladder: infections

Degenerative and Structural Spondylosis Spondylolisthesis Gross scoliosis and/or kyphosis

Spondylosis

Spondylolisthesis

Gross scoliosis and/or kyphosis

Inflammatory Conditions Ankylosing spondylitis Polymyalgia rheumatica Rheumatoid arthritis (rarely) Coccydynia

Ankylosing spondylitis

Polymyalgia rheumatica

Rheumatoid arthritis (rarely)

Coccydynia

Infections Shingles Discitis Osteomyelitis Epidural abscess

Shingles

Discitis

Osteomyelitis

Epidural abscess

Metabolic Bone Disease Osteoporosis Osteomalacia Paget's disease

Osteoporosis

Osteomalacia

Paget's disease

Neoplasm Secondaries Myeloma , etc

Secondaries

Myeloma , etc

Red flags Spine fracture Cancer or Infection Cauda equina syndrome

Spine fracture

Cancer or Infection

Cauda equina syndrome

Red flags for spine fracture Major trauma Minor trauma, or even just strenuous lifting, in people with osteoporosis Suspicion of secondaries

Major trauma

Minor trauma, or even just strenuous lifting, in people with osteoporosis

Suspicion of secondaries

Rx –suspected spinal # X-ray Refer if #, if not follow up in 10 days On follow-up -if fracture still suspected, or -multiple sites of pain, consider bone scan and referral

X-ray

Refer if #, if not follow up in 10 days

On follow-up

-if fracture still suspected, or

-multiple sites of pain,

consider bone scan and referral

Red flags for cancer or infection Age > 50 years and new back pain, or age <20 years History of cancer Constitutional symptoms (fever, unexplained wt. loss) Recent bacterial infection (e.g. UTI) IVDU Immune suppression Pain that worsens when supine; severe night-time pain; thoracic pain Structural deformity

Age > 50 years and new back pain, or age <20 years

History of cancer

Constitutional symptoms (fever, unexplained wt. loss)

Recent bacterial infection (e.g. UTI)

IVDU

Immune suppression

Pain that worsens when supine; severe night-time pain; thoracic pain

Structural deformity

Rx –suspected cancer or infection Check FBC,ESR, Urine analysis If still concerned, consider -referral - bone scan, X-ray, etc. Note that a negative X-ray alone does not rule out disease.

Check FBC,ESR, Urine analysis

If still concerned, consider

-referral

- bone scan, X-ray, etc.

Note that a negative X-ray alone does not rule out disease.

Red flags for cauda equina syn. Perianal/perineal sensory loss (Saddle anaes.) Bladder dysfunction (e.g. urine retention, increased frequency, overflow incontinence) Faecal incontinence Neurological deficit in the lower extremities Unexpected laxity of the anal sphincter

Perianal/perineal sensory loss (Saddle anaes.)

Bladder dysfunction (e.g. urine retention, increased frequency, overflow incontinence)

Faecal incontinence

Neurological deficit in the lower extremities

Unexpected laxity of the anal sphincter

Rx-suspected Cauda equina syn. Refer immediately

Refer immediately

Yellow Flags Belief that pain and activity are harmful Sickness behaviours (extended rest) Social withdrawal Emotional problems Problems and/or dissatisfaction at work Problems with claims or compensation or time off work Overprotective family; Lack of support Inappropriate expectations of treatment

Belief that pain and activity are harmful

Sickness behaviours (extended rest)

Social withdrawal

Emotional problems

Problems and/or dissatisfaction at work

Problems with claims or compensation or time off work

Overprotective family; Lack of support

Inappropriate expectations of treatment

How do I know my patient has simple low back pain? Thorough history + brief examination Red & yellow flags Distinguish referred pain from nerve root pain Consider diagnostic imaging only if red flags

Thorough history + brief examination

Red & yellow flags

Distinguish referred pain from nerve root pain

Consider diagnostic imaging only if red flags

Chronicity Acute :< 6 weeks Sub-acute : 6-12 weeks Chronic >12 weeks

Acute :< 6 weeks

Sub-acute : 6-12 weeks

Chronic >12 weeks

Complications Chronicity Depression Disability and loss of employment Cauda equina syndrome

Chronicity

Depression

Disability and loss of employment

Cauda equina syndrome

Table 1 . Questions for disability assessment. Dress: help required with footwear Dressing? Sexual activity reduced or curtailed Sex life? Sleep disturbed by pain at least twice a week Sleeping? Miss or curtail social activities (excluding sport) Socializing? Travel less than 30 minutes Travelling ? Walk less than 30 minutes or 1-2 miles Walking? Stand in one place: less than 30 minutes Standing? Sit in an ordinary chair: less than 30 minutes Sitting? Lift 15-20 kg, heavy suitcase, 3- to 4-year-old Bending, lifting? Standard limits Does back pain limit you in:

Rx of Simple Low Back Pain Educational advice Symptom control Rapid return to usual activities (incl. work) Consider referral to -physiotherapists -osteopaths -chiropractors Address any psycho-social risk factors. Assess response to treatment after about 4 weeks.

Educational advice

Symptom control

Rapid return to usual activities (incl. work)

Consider referral to

-physiotherapists

-osteopaths

-chiropractors

Address any psycho-social risk factors.

Assess response to treatment after about 4 weeks.

Drug treatment Paracetamol – 1 st choice If it is unsuitable/ineffective -NSAID s’ if suitable -Combination : e.g. paracetamol, an NSAID, or codeine Muscle relaxant (diazepam-1 st choice)

Paracetamol – 1 st choice

If it is unsuitable/ineffective

-NSAID s’ if suitable

-Combination : e.g. paracetamol, an NSAID, or codeine

Muscle relaxant (diazepam-1 st choice)

Traction Electrotherapy Ultrasound Interferential therapy Laser treatments TENS - not to be confused with PENS Not recommended Rx

Traction

Electrotherapy

Ultrasound

Interferential therapy

Laser treatments

TENS - not to be confused with PENS

What do I do if it remains after 4-6 weeks? Reassess Address concerns Adjust analgesia to control pain -Pcm ,NSAIDs’ ,Diazepam , -Antidepressants, Gabapentin, Amitriptyline, Opioids

Reassess

Address concerns

Adjust analgesia to control pain

-Pcm ,NSAIDs’ ,Diazepam ,

-Antidepressants, Gabapentin,

Amitriptyline, Opioids

not responding to analgesia ? Referral Multi-disciplinary (bio-psycho-social) assessment Cognitive behavioural therapy Spinal manipulation therapy (SMT) Exercise therapy Back school

Referral

Multi-disciplinary (bio-psycho-social) assessment

Cognitive behavioural therapy

Spinal manipulation therapy (SMT)

Exercise therapy

Back school

Evidence based medicine Routine physiotherapy was no more effective for chronic low back pain than one session of assessment and advice from a physiotherapist [Frost et al, ‘04]

Routine physiotherapy was no more effective for chronic low back pain than one session of assessment and advice from a physiotherapist [Frost et al, ‘04]

Evidence …. Exercise and spinal manipulation therapy (SMT) provide at best only modest clinical benefits acupuncture is more effective than no treatment acupuncture compared with other active treatments is inconclusive.

Exercise and spinal manipulation therapy (SMT) provide at best only modest clinical benefits

acupuncture is more effective than no treatment

acupuncture compared with other active treatments is inconclusive.

Summary Red & Yellow flags Analgesia Disability Support

Red & Yellow flags

Analgesia

Disability

Support

NICE Referral guidelines Cauda equina - immediately Serious spinal pathology – in 1 wk Progressive neurological deficit –in 1 wk Nerve root pain that is not resolving after 6 weeks –in 3 wks Inflammatory disorder -soon Yellow flags not resolved in 3 mon-soon

Cauda equina - immediately

Serious spinal pathology – in 1 wk

Progressive neurological deficit –in 1 wk

Nerve root pain that is not resolving after 6 weeks –in 3 wks

Inflammatory disorder -soon

Yellow flags not resolved in 3 mon-soon