Low Back Pain: ppt Overview (2)
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Low Back Pain: ppt Overview (2)

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  • Very nice slide for education
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  • Good LBP overview, with good summary of MRI disc findings (slide 50 something)
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Low Back Pain: ppt Overview (2) Low Back Pain: ppt Overview (2) Presentation Transcript

  • Diagnosing Low Back Pain
    • Eden Wheeler, M.D.
    • Physical Medicine and Rehabilitation
    • Rockhill Orthopaedics, P.C.
  • 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:
            • Vocational
            • Education
            • Tobacco / ETOH / Illicit drugs
            • Function: ADLs & Mobility
        • Litigation
  • 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
  • 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
  • II. Examination:
  • A. Physical:
        • Posture:
            • Splinting
            • Body language
        • Gait:
            • Antalgia
            • Heel / Toe pattern
            • Trendelenberg
        • Musculoskeletal:
            • ROM
            • Leg length
            • Vascular
            • Atrophy
        • Abdomen:
            • Presence of masses
        • Back:
            • Inspection
            • Palpation
            • ROM
            • Scoliosis
        • Neurological:
            • Sensation
            • Motor
            • DTRs
        • Rectal if indicated:
            • Evaluation of sphincter tone
  • 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
  • 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
  • III. Low Back Pain:
  • 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:
        • 2nd and 3rd highest reasons for physician visits
        • 5th leading cause for hospitalization
        • 3rd leading cause for surgery
  • 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 only 125 % population growth
        • Nearly 5 million people in the U.S. are on disability for LBP
  • 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
  • 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
  • E. Differential Diagnoses:
    • Lumbar strain
    • Disc bulge / protrusion / extrusion producing radiculopathy
    • Degenerative disc disease
    • Spinal stenosis
    • Spondyloarthropathy
    • Spondylosis
    • Spondylolisthesis
    • Sacro-iliac dysfunction
  • 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
    • 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
    • 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
    • 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
    • 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
    • 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-L5 and L5-S1 levels
    • 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
    • 9. MRI:
      • Best diagnostic 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
    • 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
    • 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
    • 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
  • 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)
  • Specificity / Sensitivity
  • 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
    • 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
    • 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
    • Chemonucleolysis
    • IDET: Intradiscal Electrotherapy or Spine CATH
    • Alternative:
        • Chiropractic:
            • Clinical studies show benefit only in first 3 weeks of symptoms
        • Acupuncture
        • Biofeedback
  • IV. Specific Disorder Considerations
  • 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
    • 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
      • 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 disease as sequellae of PID
    • 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
  • 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
  • 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
    • 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
  • 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
    • 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
  • 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, unless a large defect is present
    • Treatment:
        • Conservative treatment:
          • Saul and Saul study 1989 Spine :
            • > 90 % success rate of symptom resolution with non-operative management
          • Bozzao study 1992 Radiology :
            • 69 patients with “HNP” studied longitudinally with MRI
            • 63 % with >30 % reduction with 48 % > 70 % reduction over time
        • Medications
        • Physical therapy
        • Injections
        • Surgery
  • 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
    • 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
  • V. Chronic Pain Issues
  • 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
  • B. Risk Factors for Delayed Recovery:
  • C. Discouraging Chronic Pain:
    • Requiring employer to accommodate restrictions to allow continued working during treatment and recovery
    • Rapid abjudication of disability and compensation claims
    • Physician education re: appropriate treatments and limiting use of potentially addictive medications
    • Ergonomic work environments
    • Patient education re: disease process and treatment options
    • D. Considerations of PM & R Treatment:
      • Physical therapy is initially usually one of modalities with progression into more active exercise
      • Pre-conditioning therapy is more functional with transition into Work Conditioning (Work Hardening) program
      • Always consider return to work, whether modified duty with restrictions or limiting hours worked
      • If patients poorly tolerate standard therapy, consider pool therapy intervention which allows elimination of gravity effects
      • Functional Capacity Evaluations utilized if patients are not progressing through therapy or if have reached a plateau and abilities as well as restrictions need to be assessed
      • Job site evaluations appropriate if concerns re: ergonomics
  • E. Final Thoughts:
    • It is the patient , not the diagnostic test, that is treated
    • 80 % of patients will recover from acute low back pain within 3 days to 3 weeks, with or without treatment , with up to 90 % resolved in 6-12 weeks