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!!
  • 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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