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Back Pain Made Ez! Dr Ammar March 2nd



Back Pain By Dr.Ammar

Back Pain By Dr.Ammar
Thanks To Dr.Ammar for doing this on short notice



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  • 1 st 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!!

Back Pain Made Ez! Dr  Ammar March 2nd Back Pain Made Ez! Dr Ammar March 2nd Presentation Transcript

  • Back Pain Made EZ! Primary Health Care Physic Ammar Al-Kashmiri, MD Emergency Physician Khoula Hospital
  • Overview  Epidemiology  Definitions/Classifiication  RED FLAGS +Interpretation  How to examine?  Testing  Specific conditions  Management
  • 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
  • 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
  • Definitions  Acute LBP = < 6 weeks  Subacute LBP = 6-12 weeks  Chronic LBP = > 12 weeks
  • Classification  Nonspecificback pain (majority) = localized  Backpain + radiculopathy/sciatica = radiating  Backpain associated with another specific cause = referred
  • 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
  • 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
  • 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
  • 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
  • Red Flags History  Atypical pain:  unrelenting  worse at night  no relief with analgesia  awakens from sleep  thoracic back pain  Recent GI/GU procedure  Incontinence  Saddle anesthesia  Neuro symptoms: rapidly progressive bilateral
  • 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?
  • History  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  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
  • 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
  • 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
  • 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
  • Physical Exam Red Flags? What do they mean?
  • 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
  • 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
  • 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
  • Neurological Examination of the Back Straight Leg Raise (SLR) Test Motor  L3-S1 Sensory  L3-S1  Rectal tone  Perianal sensation  Urinary retention
  • SLR
  • 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
  • SLR + test can be verified by:  Ankle dorsiflexion  Internal rotation  Head flexion  Crossed SLR
  • Knee extension Foot 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 illicit have the patient raise up on tip-toe three times in a row, on one foot alone and then the other
  • 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
  • Waddell Signs  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 Caution! use in conjunction with entire presentation and not as sole basis of discounting a patient’s symptoms
  • 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
  • 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!  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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Analgesics 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  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 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
  • Analgesics 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)
  • 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
  • Other Modalities  None of the following treatments has shown significant improvement in the recovery rate from acute LBP:  Traction  Homeopathy  Diathermy  Acupuncture  Cutaneous laser therapy  Massage  Ultrasound  TENS  Corsets & Lumbar braces
  • Subacute/Chronic LBP 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 Activity Modification
  • Subacute/Chronic LBP Medications Paracetamol/NSAID Avoid opiates & muscle relaxants Antidepressants- cyclic antidepressants
  • 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
  • LBP with Sciatica  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
  • 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
  • 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