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Ammar Al-Kashmiri, MDAmmar Al-Kashmiri, MD
Emergency PhysicianEmergency Physician
Khoula HospitalKhoula Hospital
Back Pain...
Epidemiology
Definitions/Classifiication
RED FLAGS +Interpretation
How to examine?
Testing
Specific conditions
Mana...
Epidemiology
Affects up to 90% of population at some point in
their lives
∼ 4% of emergency department visits
Highest e...
Risk Factors
Increasing age
Heavy physical work (long periods of static work
postures, heavy lifting, twisting, and vibr...
Definitions
Acute LBP = < 6 weeks
Subacute LBP = 6-12 weeks
Chronic LBP = > 12 weeks
 Nonspecific back pain (majority)
= localized
 Back pain + radiculopathy/sciatica
= radiating
 Back pain associated wit...
Clinical Presentation
Ranges :
 mild (muscle spasm) → severe/unrelenting (epidural abscess)
NOT important → recognize a...
Very Serious Pathology
Vascular
 AAA, Aortic Dissection (AD)
Malignancy
 Mets: breast, prostate, lung, kidney, thyroid...
Less Serious Pathology
Spinal fractures
Spinal stenosis
Spondylolysis / spondylolisthesis
Regular disc herniations
 u...
Red Flags
History
Age <18,>50
>6 weeks
*Systemic complaints:
 fever/chills/night sweats
 undesired weight loss
 mala...
Red Flags
Red Flags
History
Think outside the box!
Resp- e.g. Pneumonia
GI- e.g. Pancreatitis
GU- e.g. Pyelonephritis
AAA
Historical Red Flags? What do
they mean?
Gradual onset of back pain
 Malignancy or infection usually progress over weeks to months
Age <18
 Congenital, spondyl...
History
Pain > 6 weeks
 Malignancy, infection, spinal stenosis, spondylolysis
Hx of trauma
 Fracture
 MVA in normal, ...
History
Pain worse at night
 Malignancy or infection
Pain despite good analgesics
 Malignancy or infection
Hx of mali...
History
Recent procedure causing bacteremia
 Infection
 GU or GI procedures
Hx of IV drug abuse
 Infection
Bowel or ...
Red Flags
Examination
General appearance
o lies still Vs writhes in pain
Vital signs
o BP : ↑,↓, R to L difference
o Fev...
Physical Exam Red Flags? What
do they mean?
Examination
Fever
 Infection BUT fever may not always be present
(especially vertebral osteomyelitis)
Hypotension
 Rup...
Examination
BP difference > 20 mm Hg in arms
 AD, but: BP difference > 20mm Hg in arms only
found in 40% of aortic disse...
Examination
Acute urinary incontinence
 SCCS / Cauda compression
 Actually is overflow incontinence
 Check for urinary...
Neurological Examination of the Back
Straight Leg Raise (SLR) Test
Motor
 L3-S1
Sensory
 L3-S1
 Rectal tone
 Perian...
SLR
SLR
+ SLR ∼ 80% sensitive for herniated
disk at L4-L5/L5-S1 (95% of DH)
Leg passively elevated up to 7o°
+ test = new/w...
+ test can be verified by:
Ankle dorsiflexion
Internal rotation
Head flexion
Crossed SLR
SLR
Knee extension Foot inversionFoot inversion 1st
toe extension Foot eversion
A Word about S1
S1 radiculopathy cause weakness of plantar flexion,
but is difficult to detect until quite advanced
To i...
Waddell Signs
≥3/5 signs more likely to have non-organic disease
 Excessive Tenderness
 Superficial: Widespread sensitiv...
 Distraction
 Inconsistent findings when patient is distracted, most
commonly seen when testing sitting versus supine SL...
Caution!
use in conjunction with entire presentation and not
as sole basis of discounting a patient’s symptoms
Waddell Sig...
Diagnostic Studies
When is a diagnostic work-up required?
 When there are no red flags, a good history and physical
exam...
Laboratory Tests
Complete blood count (CBC)
Erythrocyte sedimentation rate (ESR)
Plain Radiography
There is a sense among many patients that they should receive
x-rays as part of their evaluation!
Plai...
Radiation Risks
Gonadal radiation from a two view x-ray of the
lumbar spine = radiation exposure from a CXR taken
daily f...
Indications for Back X-rays
Age ≤18 years or ≥50 years
Constitutional symptoms
Pain > 6 weeks
History of traumatic ons...
MRI
Gold standard for evaluation for
 epidural compression
syndromes
 spinal infection (osteomyelitis
and epidural absc...
Management
Nonspecific back pain (∅radiculopathy/∅ red flags)
 important to educate patients that they will
respond to co...
Analgesics
Paracetamol
Excellent analgesic
Proven efficacy comparable to NSAIDs
inexpensive
Small side effect profile ...
NSAIDs
Most are equally efficacious
Lowest dose needed to reach pain reduction should
be attempted
COX-2 inhibitors sho...
The most common recommended approach is to use
a combination of Paracetamol and NSAIDs
One suggested regimen =
Paracetam...
Analgesics
Opiates
Liberal use recommended for patients with
moderate-severe pain
Allows patients to break pain cycle
G...
Muscle Relaxants
e.g. Diazepam
Cause sedation + addiction with chronic use
May be useful if patient demonstrates signif...
Activity Modification/Physical Modalities
Continue routine activities as tolerated + use pain as guide for
activity modif...
Other Modalities
None of the following treatments has shown
significant improvement in the recovery rate from
acute LBP:
...
Management directed at restoring function and
supporting adaptive techniques:
Exercise
Reduction in body weight
Improvi...
Subacute/Chronic LBP
Activity Modification
Medications
Paracetamol/NSAID
Avoid opiates & muscle relaxants
Antidepressants- cyclic
antidepressants
Subacute/Chronic...
LBP with Sciatica
1% -4% of individuals with LBP
Young = herniated disc, Older = spinal stenosis
Herniated disk
 50% r...
Management similar to patient with uncomplicated
LBP
Analgesics- Paracetamol, NSAIDs, short-term opiates
Activity- rout...
Indications for Referral
 Cauda equina syndrome – bowel and bladder dysfunction, saddle
anesthesia, bilateral leg weaknes...
Conclusions
Back pain is a costly and common problem
Evaluation done best by categorizing into 3 categories:
nonspecific...
Thank
You!
Back Pain Made Ez! Dr  Ammar March 2nd
Back Pain Made Ez! Dr  Ammar March 2nd
Back Pain Made Ez! Dr  Ammar March 2nd
Back Pain Made Ez! Dr  Ammar March 2nd
Back Pain Made Ez! Dr  Ammar March 2nd
Back Pain Made Ez! Dr  Ammar March 2nd
Back Pain Made Ez! Dr  Ammar March 2nd
Back Pain Made Ez! Dr  Ammar March 2nd
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Back Pain Made Ez! Dr Ammar March 2nd

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Back Pain By Dr.Ammar
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  • 1st presentation at 6 weeks with no other flags, treat and wait 2-3 weeks i.e. don’t workup
    Trauma-minor in elderly and chronic steroid use
    *frequently not asked about---show of hands!!
  • Transcript of "Back Pain Made Ez! Dr Ammar March 2nd"

    1. 1. Ammar Al-Kashmiri, MDAmmar Al-Kashmiri, MD Emergency PhysicianEmergency Physician Khoula HospitalKhoula Hospital Back Pain Made EZ! Primary Health Care Physicians Wo
    2. 2. Epidemiology Definitions/Classifiication RED FLAGS +Interpretation How to examine? Testing Specific conditions Management Overview
    3. 3. Epidemiology Affects up to 90% of population at some point in their lives ∼ 4% of emergency department visits Highest economic burden after heart disease & stroke 85% have no definite etiology 90% with nonspecific back pain symptoms resolve within 1 month
    4. 4. Risk Factors Increasing age Heavy physical work (long periods of static work postures, heavy lifting, twisting, and vibration) Psychosocial factors (including work dissatisfaction and monotonous work) Depression Obesity (BMI > 30) Smoking Drug abuse History of headache
    5. 5. Definitions Acute LBP = < 6 weeks Subacute LBP = 6-12 weeks Chronic LBP = > 12 weeks
    6. 6.  Nonspecific back pain (majority) = localized  Back pain + radiculopathy/sciatica = radiating  Back pain associated with another specific cause = referred Classification
    7. 7. Clinical Presentation Ranges :  mild (muscle spasm) → severe/unrelenting (epidural abscess) NOT important → recognize a particular classic presentation for various diseases IMPORTANT → evaluate for the red flags Identification of red flags will direct whether further evaluation is required
    8. 8. Very Serious Pathology Vascular  AAA, Aortic Dissection (AD) Malignancy  Mets: breast, prostate, lung, kidney, thyroid  Bone or spinal epidural metastasis (SEM) Infectious Process  Vertebral osteomyelitis ,Spinal epidural abscess (SEA) Spinal cord compressive syndromes (SCCS)  Spinal epidural mets (SEM), central disc herniation, SEA, spinal epidural hematoma
    9. 9. Less Serious Pathology Spinal fractures Spinal stenosis Spondylolysis / spondylolisthesis Regular disc herniations  usually lateral and compress nerves on one side and not the cord / cauda
    10. 10. Red Flags History Age <18,>50 >6 weeks *Systemic complaints:  fever/chills/night sweats  undesired weight loss  malaise Trauma (minor in OP, elderly) Cancer (0.7% → 9%) Immunocompromise IVDU
    11. 11. Red Flags
    12. 12. Red Flags History Think outside the box! Resp- e.g. Pneumonia GI- e.g. Pancreatitis GU- e.g. Pyelonephritis AAA
    13. 13. Historical Red Flags? What do they mean?
    14. 14. Gradual onset of back pain  Malignancy or infection usually progress over weeks to months Age <18  Congenital, spondylolysis/spondylolisthesis Age >50  AAA, malignancy, compression fracture Thoracic back pain  Aortic dissection, SEA, Vertebral osteomyelitis, malignancy  Most common site of malignant spine lesions is thoracic spines (accounts for 60% of cases) History
    15. 15. History Pain > 6 weeks  Malignancy, infection, spinal stenosis, spondylolysis Hx of trauma  Fracture  MVA in normal, fall in elderly/osteoporotic Fever/chills/night sweats, weight loss  Malignancy or infection Pain worse when supine  Malignancy or infection
    16. 16. History Pain worse at night  Malignancy or infection Pain despite good analgesics  Malignancy or infection Hx of malignancy  Hello? Can you guess? Hx of immunosup (corticosteroids)  Infection, osteoporosis
    17. 17. History Recent procedure causing bacteremia  Infection  GU or GI procedures Hx of IV drug abuse  Infection Bowel or bladder incontinence  SCCS Saddle numbness  Cauda compression
    18. 18. Red Flags Examination General appearance o lies still Vs writhes in pain Vital signs o BP : ↑,↓, R to L difference o Fever Pulsatile abdominal mass Spinal process tenderness Neurological deficits
    19. 19. Physical Exam Red Flags? What do they mean?
    20. 20. Examination Fever  Infection BUT fever may not always be present (especially vertebral osteomyelitis) Hypotension  Ruptured AAA Extreme hypertension  AD, especially if thoracic back pain Pulsatile abdominal mass  AAA
    21. 21. Examination BP difference > 20 mm Hg in arms  AD, but: BP difference > 20mm Hg in arms only found in 40% of aortic dissections - 20% of normals have this difference Spinal process tenderness  Fracture, osteomylelitis, SEA, malignancy Focal neuro signs  SCCS
    22. 22. Examination Acute urinary incontinence  SCCS / Cauda compression  Actually is overflow incontinence  Check for urinary residual > 150cc post void Perianal numbness, loss of rectal tone  SCCS / Cauda compression
    23. 23. Neurological Examination of the Back Straight Leg Raise (SLR) Test Motor  L3-S1 Sensory  L3-S1  Rectal tone  Perianal sensation  Urinary retention
    24. 24. SLR
    25. 25. SLR + SLR ∼ 80% sensitive for herniated disk at L4-L5/L5-S1 (95% of DH) Leg passively elevated up to 7o° + test = new/worsening pain below knee along path of a nerve root between 30-70° of elevation Reproduction of back pain or pain in the hamstring is NOT a + test
    26. 26. + test can be verified by: Ankle dorsiflexion Internal rotation Head flexion Crossed SLR SLR
    27. 27. Knee extension Foot inversionFoot inversion 1st toe extension Foot eversion
    28. 28. A Word about S1 S1 radiculopathy cause weakness of plantar flexion, but is difficult to detect until quite advanced To illicit have the patient raise up on tip-toe three times in a row, on one foot alone and then the other
    29. 29. Waddell Signs ≥3/5 signs more likely to have non-organic disease  Excessive Tenderness  Superficial: Widespread sensitivity to light touch of the skin over a wide area of the lumbar skin  Nonanatomic: felt over a wide area, not localized to one structure, and often extends to the thoracic spine, sacrum, or pelvis  Stimulation  Axial loading: ↑LBP with light pressure on skull while standing  Rotation: ↑LBP with passive rotation of shoulders and pelvis in same plane, in standing position
    30. 30.  Distraction  Inconsistent findings when patient is distracted, most commonly seen when testing sitting versus supine SLR  Regional Disturbance  Motor: Generalized giving way or cogwheel resistance in manual muscle  Sensory: Glove or stocking, nondermatomal loss of sensation  Overreaction  Disproportionate verbalization or facial expression with movement  Assisted movement  Rigid or slow movement  Collapsing Waddell Signs
    31. 31. Caution! use in conjunction with entire presentation and not as sole basis of discounting a patient’s symptoms Waddell Signs
    32. 32. Diagnostic Studies When is a diagnostic work-up required?  When there are no red flags, a good history and physical examination suffice  When red flags are elucidated, further evaluation is warranted
    33. 33. Laboratory Tests Complete blood count (CBC) Erythrocyte sedimentation rate (ESR)
    34. 34. Plain Radiography There is a sense among many patients that they should receive x-rays as part of their evaluation! Plain radiographs rarely add helpful information in establishing the diagnosis X-ray early in the course of LBP do not improve outcomes or reduce costs of care They add cost, time and unnecessary radiation Normal plain films do not exclude malignancy or infection in patients with a suspicious history
    35. 35. Radiation Risks Gonadal radiation from a two view x-ray of the lumbar spine = radiation exposure from a CXR taken daily for > 1 year!! Oblique views substantially increase risks of radiation and add little diagnostic information
    36. 36. Indications for Back X-rays Age ≤18 years or ≥50 years Constitutional symptoms Pain > 6 weeks History of traumatic onset History of malignancy Osteoporosis Infectious risk (e.g. IVDU, immunosuppression, indwelling urinary catheter, steroids, skin infection or UTI, recent procedures) Progressive focal neurologic deficit
    37. 37. MRI Gold standard for evaluation for  epidural compression syndromes  spinal infection (osteomyelitis and epidural abscess)  spinal cord injury  intervertebral disk herniation (may be delayed 4-6 weeks) *MRI evaluation to provide reassurance does not lead to better prognosis
    38. 38. Management Nonspecific back pain (∅radiculopathy/∅ red flags)  important to educate patients that they will respond to conservative management over 4-6 weeks (many respond well after several days)  Approach to treatment is focused:  analgesic medications (combination therapy)  activity modification  physical modalities
    39. 39. Analgesics Paracetamol Excellent analgesic Proven efficacy comparable to NSAIDs inexpensive Small side effect profile in comparison to NSAIDs Recommended in the treatment for all patients
    40. 40. NSAIDs Most are equally efficacious Lowest dose needed to reach pain reduction should be attempted COX-2 inhibitors should be used sparingly and only after discussion with the patient about the risks Analgesics
    41. 41. The most common recommended approach is to use a combination of Paracetamol and NSAIDs One suggested regimen = Paracetamol 500-1000 mg QID +/- Ibuprofen 400-800 mg TID or Naproxen 250-500 mg BID Analgesics
    42. 42. Analgesics Opiates Liberal use recommended for patients with moderate-severe pain Allows patients to break pain cycle Gives stronger option when exacerbations of pain occur Only for short period (7-10 days) to ↓ development of dependence Warn patients of problems of driving
    43. 43. Muscle Relaxants e.g. Diazepam Cause sedation + addiction with chronic use May be useful if patient demonstrates significant muscle spasm of the paraspinal musculature Exert benefit only in first 4 days when muscular spasm is at its peak (rarely a significant component of symptoms after 1st week of injury) Analgesics
    44. 44. Activity Modification/Physical Modalities Continue routine activities as tolerated + use pain as guide for activity modification Bed rest has no benefit and may ultimately be harmful in the recovery (not even 2 days!) Active exercise/back strengthening exercises not beneficial during acute crisis Moderate stretching and strengthening of abdominal muscles and back muscles beneficial when acute pain subsides Thermal and ice therapy ?marginally effective
    45. 45. Other Modalities None of the following treatments has shown significant improvement in the recovery rate from acute LBP:  Traction  Diathermy  Cutaneous laser therapy  Ultrasound  Corsets & Lumbar braces  Homeopathy  Acupuncture  Massage  TENS
    46. 46. Management directed at restoring function and supporting adaptive techniques: Exercise Reduction in body weight Improving cardiovascular fitness Smoking cessation Massage- beneficial when combined with exercise Acupuncture-may be beneficial TENS-no benefit Spinal manipulation-no benefit Subacute/Chronic LBP
    47. 47. Subacute/Chronic LBP Activity Modification
    48. 48. Medications Paracetamol/NSAID Avoid opiates & muscle relaxants Antidepressants- cyclic antidepressants Subacute/Chronic LBP
    49. 49. LBP with Sciatica 1% -4% of individuals with LBP Young = herniated disc, Older = spinal stenosis Herniated disk  50% recover in 6 weeks  5-10% ultimately require surgery  Surgery beneficial only in first 2 years  No difference in symptoms at 4 and 10 years post operatively
    50. 50. Management similar to patient with uncomplicated LBP Analgesics- Paracetamol, NSAIDs, short-term opiates Activity- routine, use pain as limiting factor Epidural steroid injection- mild-moderate pain reduction Must be diligent to detect progressive neurological function Patient should be educated to return earlier if the symptoms are worsening LBP with Sciatica
    51. 51. Indications for Referral  Cauda equina syndrome – bowel and bladder dysfunction, saddle anesthesia, bilateral leg weakness and numbness = surgical emergency  Suspected spinal cord compression – acute neurologic deficits in a patient with cancer and risk of spinal metastases  Progressive or severe neurologic deficit  Neuromotor deficit that persists after 4-6 weeks of conservative therapy  Persistent sciatica, sensory deficit, or reflex loss after 4-6 weeks in a patient with positive SLR , consistent clinical findings  Fractures
    52. 52. Conclusions Back pain is a costly and common problem Evaluation done best by categorizing into 3 categories: nonspecific back pain/back pain with radiculopathy/back pain with specific cause Systematic approach is key. Know your red flags well! Remember radiation risk and x-ray only when indicated Chronic back pain is complex and needs comprehensive approach
    53. 53. Thank You!
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