How to approach a patient
with low back pain

DONE BY: Al-Yaqdhan Al-Atbi
Senior clerckship student
SQUH
•
•
•
•

History
Physical examination
Investigations
Management
Case …
Mr. B is a relatively healthy 37
years old male. While working in
his yard, he experienced intense
lower back pain ...
What do you want to ask Mr.B?
• Personal data
• Present complain
Present complain
•

Onset & how it start :
•
•
•

•

acute or chronic
What were you doing just before the pain began?
Did ...
Present complain
• Duration
• < 6wk  Acute
• 6-12 wk Subacute
• > 12 wk  Chronic

• Intensity
• How it effects daily ac...
Present complain
• Aggravating factors
• Valsalva maneuvers
• Sitting
• Walking down-staires

• Relieving factors
• Medica...
MR. B
He describe the pain as dull and
burning. There is some radiation
into the left buttock. Prolong sitting
or moderate...
Systemic review
•
•
•
•
•
•
•

Fever ??
Appetite/ wt loss?
Abdominal pain?
Cough/ sputum?
Bowel habits?
Dysuria, Hematuria...
past medical history
• Medical & surgical history:
–
–
–
–
–
–

Previous trauma
Kidney diseases
Previous back pain, therap...
Family history
• Cancers
• Back pain
• Spondylarthropathies

Social history
• Current stresses
• Occupation:
• Work, job t...
In Evaluating Patient With Low Back pain Should
Remember :
• Determine that the pain is intrinsic to the back and not refe...
Red flags
General
•Failure to improve after 4-6wk of
conservative therapy
•Unrelenting night pain or pain at rest
•Progres...
Red flags
Infection
•Fever or chills
•Recent infection .. UTI or skin
•Immunosuppression

• IV drug use
Fracture
•Age > 50...
Red flags
Cauda
Equina S.
•Urinary incontinence or retention
•Saddle anesthesia
•Decrease anal tone or fecal
incontinence
...
Physical examination
•
•
•
•

General appearance
Vital sings
Back examination
Systemic examination
• GENERAL APPERANCE :
• Comfortable or not ?
• Sitting, standing or leaning on
something?

• Vital sing
• Record vital sin...
Back examination
•
•
•
•

look
Feel
Move
Special tests
Look:
• From side:
• evaluate spinal curvatures.
• From behind:
• Note any scars, swelling, erythema.
• Shape of the spine...
Flexion

Rotation

Extension

MOVE

Lateral bending
Special Tests
• Scobar’s test:
– measure forward flexion of the spine
Straight leg raising Test
• How:
• Ask the patient to lie down on their back.
• Have the patient completely relax the affe...
• The straight leg raising test.
• if positive indicates lumber nerve root compromise.

• The crossed straight leg raising...
Examination of the lower limb
• Muscle strength:
• Hip:
» Flexion (L2, 3,4 )
» Adduction (L2, 3,4 )
» Abduction ( L4, L5, ...
Examination of the lower limb

• Deep tendon reflexes:
– The knee reflex (L2,L3,L4)
The Ankle reflex (S1)
The planter resp...
MR. B
•
•
•
•
•

Uncomfortable, prefer to stand.
Has full ROM excep for limited forward flexion
Tenderness on paraspinous ...
• What investigations you will order
for MR.B ??
• MOST PATIENTS WITH LOW BACK PAIN DO
NOT NEED INVESTIGATIONS
-Majority not due to a serious underlying condition
-Most ar...
Investigations
•
1.
2.
3.
4.

Radiological imaging
X-ray
MRI
CT
Radionuclide (bone scan)

•

Laboratory tests
Plain X-ray

Are very commonly used for low back pain
Do not X-ray routinely
Required only if the pain is associated with red flag
signs, which indicate a high risk of more ser...
Do not X-ray routinely
• EXCEPTIONS:
1. Young(<25) X-ray sacroiliac joint to exclude
ankylosing spondylitis
2. Elderly: to...
Plain X-ray
•

Useful to identify:

1.
2.
3.
4.
5.
6.

Trauma
Compression fractures
Dislocation
Degenerative changes
Check...
Plain X-ray
• AP & lateral view of lumbosacral spine
• Not highly sensitive or specific
• Not rule out serious illness
• N...
MRI
•

Provide more detailed images of soft tissues (disc & Nerve roots)

1.
2.
3.
4.
5.
6.

Spinal stenosis
Disc bulge
Sp...
CT-scan
•
1.
2.
3.
4.
5.
•

Most of boney spinal pathology
Trauma
Osteomylitis
Infection
Tumors
Cases where MRI is contrai...
Radionuclide (bone scan)
•

Useful when radiographs of the spine are normal
but the clinical findings are suspected

1. Os...
Radionuclide (bone scan)
• More sensitive than radiography
in detecting :
1. Metastasis
2. Paget’s disease (metabolic, bon...
Laboratory tests
•
1.
2.
3.

Indications:
Red flag signs
Malignancies or Infections
Metabolic causes
Laboratory tests
• FBC
• ESR/CRP
• Others( HLA B27 Ag),(Ca2+,PO4,Alkaline
phosphatase)
• HLA B27 is a protein in WBCs
– If...
Laboratory tests
Test’s result

Diagnosis

Raised CRP or ESR

Inflammation or malignancy

Raised acid phosphatase or
prost...
• How to treat MR.B ??
Treatment
Symptomatic treatment

• Aims to:
1. Relive pain
2. Improve quality of life
3. Treat underlying cause
Non-pharmacological
• Explanation
• Reassurance
• Advice on exercise

• Simple analgesics
Pharmacological
•

Regular analgesia and/or non-steroidal antiinflammatory drugs (NSAIDs) may be required
to:

1. Improve ...
Pharmacological
• Opiates can be used for severe pain (single dose)
• Tricyclic antidepressant drugs (analgesics+sleep &
m...
Would you advice bed rest?
• Bed rest should not be advised
• Returning to normal activities as soon as possible
(reduce c...
Complementary and alternative medicine
•
•
•
•

Acupuncture
Spinal manipulation
Massage therapy
Physical therapy

• Exerci...
Knee to Chest
Hip Extension

Arm Lifts

Pelvic Tilt

Hip Rolling

Pelvic Lift

Back Extension

Hip Extension
Curl Ups

Lyi...
When to refer?
• No significant improvement in symptoms after 4-6
wks of treatment (reassess the treatment plan).

• To av...
Referral to spine specialist
•
•
•
•

Cauda equina syndrome
Intractable pain
Serious spinal pathology is suspected
Progres...
Risk factors
•
•
•
•
•

Prior history of back pain
Heavy lifting
Frequent bending
Twisting and lifting
Repetitive work wit...
Prevention
•
•

Limited number of studies
Overall , effective strategies for preventing initial or
recurrent low back pain...
Prevention
3. Back belt and lumbar support (not effective in
workers)
4. Most effective prevention strategy seems to be
ph...
compliant

Diagnosis

Differential diagnosis Referred pain

1- 42 yrs male, alcoholic has abdominal pain radiated to
the b...
References
• Philip D. Sloane, Lisa M. Slatt, Mark H. Ebell, Louis B.
Jacques, Mindy A. Smith. Essentials of Family
Medici...
approach a patient with low back pain
approach a patient with low back pain
approach a patient with low back pain
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approach a patient with low back pain

  1. 1. How to approach a patient with low back pain DONE BY: Al-Yaqdhan Al-Atbi Senior clerckship student SQUH
  2. 2. • • • • History Physical examination Investigations Management
  3. 3. Case … Mr. B is a relatively healthy 37 years old male. While working in his yard, he experienced intense lower back pain that prevented him from doing any more work. He used some ibuprofen for pain relief and spent the remainder of the day resting. The next morning he had increased muscle stiffness and was not feeling any better, so he come to see you.
  4. 4. What do you want to ask Mr.B?
  5. 5. • Personal data • Present complain
  6. 6. Present complain • Onset & how it start : • • • • acute or chronic What were you doing just before the pain began? Did you have a particular injury or accident? Character: Sharp, dull, throbbing or burning ?? • Location & radiation: • • lumber strain .. Paraspinous muscles- buttock Herniated disc .. Below the knee
  7. 7. Present complain • Duration • < 6wk  Acute • 6-12 wk Subacute • > 12 wk  Chronic • Intensity • How it effects daily activity? • Interfere with sleeping, walking or driving ? • Associated symptoms • stiffness, urinary or abdominal symptoms ??
  8. 8. Present complain • Aggravating factors • Valsalva maneuvers • Sitting • Walking down-staires • Relieving factors • Medication • Non-pharmacologic measures ( massage, stretching, heat or ice) • Certain position.
  9. 9. MR. B He describe the pain as dull and burning. There is some radiation into the left buttock. Prolong sitting or moderate activity aggravate the pain. He can get relief when he lies down. He has never had back pain like this.
  10. 10. Systemic review • • • • • • • Fever ?? Appetite/ wt loss? Abdominal pain? Cough/ sputum? Bowel habits? Dysuria, Hematuria? Menestural history?
  11. 11. past medical history • Medical & surgical history: – – – – – – Previous trauma Kidney diseases Previous back pain, therapy Malignancy Disc prolepses—surgery Female---obstrict diseases • medication?? • Corticosteroids , immunosuppressant
  12. 12. Family history • Cancers • Back pain • Spondylarthropathies Social history • Current stresses • Occupation: • Work, job tasks. • Activity level of the job • Perception of the pain ,impact on life
  13. 13. In Evaluating Patient With Low Back pain Should Remember : • Determine that the pain is intrinsic to the back and not referred from problem elsewhere. • Rule out progressive and Life- threatening disease. • Determine whether nerve root compromise is present or not.
  14. 14. Red flags General •Failure to improve after 4-6wk of conservative therapy •Unrelenting night pain or pain at rest •Progress motor or sensory deficit Cancer •Age > 50 •History of cancer or current cancer •Unexplained weight loss
  15. 15. Red flags Infection •Fever or chills •Recent infection .. UTI or skin •Immunosuppression • IV drug use Fracture •Age > 50 •History of osteoporosis •Significant trauma •Chronic oral steroid use
  16. 16. Red flags Cauda Equina S. •Urinary incontinence or retention •Saddle anesthesia •Decrease anal tone or fecal incontinence •Lower extremities weakness AAA •Age > 60 •Abdominal pulsating mass •Pain at rest
  17. 17. Physical examination • • • • General appearance Vital sings Back examination Systemic examination
  18. 18. • GENERAL APPERANCE : • Comfortable or not ? • Sitting, standing or leaning on something? • Vital sing • Record vital sings • High Temp. ???
  19. 19. Back examination • • • • look Feel Move Special tests
  20. 20. Look: • From side: • evaluate spinal curvatures. • From behind: • Note any scars, swelling, erythema. • Shape of the spine. Feel: • The spinous processes of each vertebra. – Tenderness .. Fracture, dislocation , infection or arthritis • Any step-offs – in spondylolisthesis or forword slipping of one vertebra, which may compress the spinal cord. • Muscle spasm or tenderness – degenerative or inflammatory process , prolong contraction from abnormal posture or anxiety. • Sacroiliac joint – tenderness indicate sacroiliitis or ankylosing sponylitis
  21. 21. Flexion Rotation Extension MOVE Lateral bending
  22. 22. Special Tests • Scobar’s test: – measure forward flexion of the spine
  23. 23. Straight leg raising Test • How: • Ask the patient to lie down on their back. • Have the patient completely relax the affected leg. • Cup the heel of their foot and gently raise the leg . • Positive test: – Sciatic pain at 30-70 degree – Aggravation of pain dorsiflexion of the foot – Relief of pain by knee flexion
  24. 24. • The straight leg raising test. • if positive indicates lumber nerve root compromise. • The crossed straight leg raising test. (pain radiate into opposite leg) • if positive indicates disc herniation.
  25. 25. Examination of the lower limb • Muscle strength: • Hip: » Flexion (L2, 3,4 ) » Adduction (L2, 3,4 ) » Abduction ( L4, L5, S1 ) » Extension (SI) • Knee » Extension at the knee (L2,L3,L4) » Flexion at the knee (L4,L5,S1,S2 ) • Dorsiflexion ( mainly L4,L5) • planter flexion (mainly S1).
  26. 26. Examination of the lower limb • Deep tendon reflexes: – The knee reflex (L2,L3,L4) The Ankle reflex (S1) The planter response(L5,S1) • Gaite • Walk on heel ( L5) • Walk on toe (S1)
  27. 27. MR. B • • • • • Uncomfortable, prefer to stand. Has full ROM excep for limited forward flexion Tenderness on paraspinous muscles. SLR & crossed SLR test are negetive. Lower limb: – Normal reflexes, strength and sensation.
  28. 28. • What investigations you will order for MR.B ??
  29. 29. • MOST PATIENTS WITH LOW BACK PAIN DO NOT NEED INVESTIGATIONS -Majority not due to a serious underlying condition -Most are self-limited 70% to 90% of acute Low Back Pain cases will Resolve in 1 month
  30. 30. Investigations • 1. 2. 3. 4. Radiological imaging X-ray MRI CT Radionuclide (bone scan) • Laboratory tests
  31. 31. Plain X-ray Are very commonly used for low back pain
  32. 32. Do not X-ray routinely Required only if the pain is associated with red flag signs, which indicate a high risk of more serious underlying problems
  33. 33. Do not X-ray routinely • EXCEPTIONS: 1. Young(<25) X-ray sacroiliac joint to exclude ankylosing spondylitis 2. Elderly: to exclude vertebral collapse/malignancy; history of trauma; ‘red flag’ signs
  34. 34. Plain X-ray • Useful to identify: 1. 2. 3. 4. 5. 6. Trauma Compression fractures Dislocation Degenerative changes Check spinal curvatures End stages of malignancies
  35. 35. Plain X-ray • AP & lateral view of lumbosacral spine • Not highly sensitive or specific • Not rule out serious illness • Not good at identifying muscles and ligaments
  36. 36. MRI • Provide more detailed images of soft tissues (disc & Nerve roots) 1. 2. 3. 4. 5. 6. Spinal stenosis Disc bulge Spinal tumors Infections Compressive lesions Cauda equina Note : -If red flags are present , MRI should be undertaken even if X-ray is normal. -MRI is preferable to CT scanning when neurological signs and symptoms are present
  37. 37. CT-scan • 1. 2. 3. 4. 5. • Most of boney spinal pathology Trauma Osteomylitis Infection Tumors Cases where MRI is contraindicated (e.g. pacemaker or metallic clips) More radiation exposure
  38. 38. Radionuclide (bone scan) • Useful when radiographs of the spine are normal but the clinical findings are suspected 1. Osteomyelitis 2. Bony neoplasm 3. Occult fracture • Unlikely to demonstrate bone changes when radiographs and ESR are normal
  39. 39. Radionuclide (bone scan) • More sensitive than radiography in detecting : 1. Metastasis 2. Paget’s disease (metabolic, bone turnover) 3. ankylosing spondylitis (Inflammatory condition) 1. Trauma 2. Certain tumors (osteiod osteoma= benign)
  40. 40. Laboratory tests • 1. 2. 3. Indications: Red flag signs Malignancies or Infections Metabolic causes
  41. 41. Laboratory tests • FBC • ESR/CRP • Others( HLA B27 Ag),(Ca2+,PO4,Alkaline phosphatase) • HLA B27 is a protein in WBCs – If positive, possible ankylosing spondylitis (AS) – HLA B27 positive without having AS – 95% of AS sufferers are HLA B27 positive
  42. 42. Laboratory tests Test’s result Diagnosis Raised CRP or ESR Inflammation or malignancy Raised acid phosphatase or prostate specific antigen Metastatic carcinoma of the prostate Raised alkaline phosphatase Other bone metastases and Paget’s disease Myeloma Monoclonal band on serum immunoelectrophoresis and presence of urine light chains
  43. 43. • How to treat MR.B ??
  44. 44. Treatment Symptomatic treatment • Aims to: 1. Relive pain 2. Improve quality of life 3. Treat underlying cause
  45. 45. Non-pharmacological • Explanation • Reassurance • Advice on exercise • Simple analgesics
  46. 46. Pharmacological • Regular analgesia and/or non-steroidal antiinflammatory drugs (NSAIDs) may be required to: 1. Improve mobility 2. Facilitate exercise
  47. 47. Pharmacological • Opiates can be used for severe pain (single dose) • Tricyclic antidepressant drugs (analgesics+sleep & mood)
  48. 48. Would you advice bed rest? • Bed rest should not be advised • Returning to normal activities as soon as possible (reduce chance of chronic pain)
  49. 49. Complementary and alternative medicine • • • • Acupuncture Spinal manipulation Massage therapy Physical therapy • Exercise
  50. 50. Knee to Chest Hip Extension Arm Lifts Pelvic Tilt Hip Rolling Pelvic Lift Back Extension Hip Extension Curl Ups Lying Prone In Extension Push Up
  51. 51. When to refer? • No significant improvement in symptoms after 4-6 wks of treatment (reassess the treatment plan). • To avoid misdiagnosis and unnecessary or inappropriate treatments
  52. 52. Referral to spine specialist • • • • Cauda equina syndrome Intractable pain Serious spinal pathology is suspected Progressive neurological deficits
  53. 53. Risk factors • • • • • Prior history of back pain Heavy lifting Frequent bending Twisting and lifting Repetitive work with exposure to vibration • Psychosocial issues
  54. 54. Prevention • • Limited number of studies Overall , effective strategies for preventing initial or recurrent low back pain are lacking • Education: 1. Instruction on proper lifting technique (not seem to be helpful) 2. Coping with back pain and encourages activity (small benefit)
  55. 55. Prevention 3. Back belt and lumbar support (not effective in workers) 4. Most effective prevention strategy seems to be physical exercise
  56. 56. compliant Diagnosis Differential diagnosis Referred pain 1- 42 yrs male, alcoholic has abdominal pain radiated to the back. 2- 70 yrs old female known to have osteoporosis has h/o trauma. fracture 3- 50 yrs male has Fever, back pain unrelieved by bed rest or remaining motionless. Infection 4- 22 yrs male has Pain unrelieved by remaining motionless and morning stiffness relieved by exercise 5- 54 yrs old female k/c/o breast Cancer on chemotherapy. 6- Acute onset of urinary retention or fecal incontenence,loss of anal sphincter tone ,saddle anasthesia,global/progressive lower extremity weakness AS Spinal ca. Cauda equina syndrome
  57. 57. References • Philip D. Sloane, Lisa M. Slatt, Mark H. Ebell, Louis B. Jacques, Mindy A. Smith. Essentials of Family Medicine. Fifth edition • Robin C. Fraser. Clinical Method .A general practice approach. Third edition • Davidson’s. principles & practice of medicine. Twentieth edition • Oxford handbook of general practice. Third edition • Oxford handbook of clinical medicine. Seventh edition
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