This document discusses the evaluation and treatment of low back pain. It notes that low back pain is very common, affecting 90% of people and costing $40 billion annually. For acute low back pain, the short answer is to leave patients alone and for chronic pain, recommend back classes and functional rehabilitation. Red flags to evaluate for include cancer, infection, or neurological deficits. The goal is to distinguish the 95% with simple back pain from the 5% with serious underlying issues. Conservative treatment is usually sufficient, with opioids not recommended for chronic pain due to lack of evidence of long-term benefit and risk of harm.

1. Low Back Pain
Eric Steen MD

2. Objectives
• recognize non musculoskeletal back pain
• recognize syndrome of HNP
• be able to treat muscular back strain

3. Cases – think about these
• 59 yo woman c breast ca and new onset
spine pain
• 60 yo man c 7 yrs of chronic back pain here
for norco
• 30 yo PA with severe back/leg pain after
dragging moose out to road after hunting in
Montana

4. So What ?
• prevalence 90%
• annual cost 40 billion dollars (some years
ago)
• #2 reason for missed work
• #1 cause of workman’s comp
• most common symptom for outpatient
X-Rays

5. Short answer on how to treat
• Acute – leave them alone
• Chronic- back class/functional rehab

6. Why do doctors hate seeing back
pain?
• No easy fix
• patients unhappy
• MD ignorance of topic
• Cannot refer difficult pts away to
ortho/rheum/PMR/pain…

7. Origin of ignorance
• Not taught in med school
• Teachers there do not see it
• Not part of internal medicine

8. Common misconceptions
• usually a surgical problem
• precise diagnosis possible in most patients-
perhaps only 15%
• prolonged bedrest as treatment mainstay
• surgical indications clear

9. Anatomy - the articular triad
• intervertebral joint-hyaline cartilage
endplate separated by
– nucleus pulposus-shock absorbing ball bearing
– annulus fibrosis-elastic support of nucleus
• 2 posterior facet joints-guide, steady, and
limit motion

11. Disease process for “ordinary”
back strain
• with normal aging nucleus desiccates
• no longer acts as shock absorber and ball
bearing
• leads to DJD of facet joints

12. Disease process for herniated
nucleus pulposus
• annulus weakens as nucleus fails
• annulus rupture and nucleus protrudes
• nerve root occasionally struck-L4, L5, S1
• cauda equina can be injured if posterior
longitudinal ligament weak
• nucleus eventual shrinks

13. Goal
separate the simple back pain in 95%
from the 5% who have a serious
underlying disease (whether spinal or
referred) or neurologic impairment.

14. Approach
• systemic disease (possibly referred pain)
involved?
• neurologic deficits present?
• Is there social or psychologic distress which
may prolong or amplify the pain

15. Simplified differential diagnosis
• terms not precise or accurate
• “back strain”
• “sciatica”-herniated disc with nerve
compression
• other/systemic disease e.g.. ca,
infection,compression fx
• consider referred pain (e.g.. pyelo,
pancreatitis, AAA)

16. The understanding of back
disorders has been impaired by
the overemphasis of the
syndrome of HNP- only 5%

17. Diagnose with short but directed
history and physical

18. The history usually eliminates
systemic causes
• personal hx of cancer? weight loss? fever?
• is pain worse with rest and better with
activity?
• does pain wake patient up at night?
• hx IVDA or recent UTI?
• age over 50?

19. Pre test probabilities of diseases
• from 1 October 2002 Annals
• cancer 0.7%
• infection .01%

20. History
• chronological association with illness,
injury, or job
• character of pain
• severity-ability to work, confined to bed,
interfere with sleep?
• early awareness of substance abuse,
depression, and legal issues=roadblocks to
improvement

21. History
• duration
• aggravating/alleviating factors-better
with rest, worse with activity?
• localization/radiation
• pain in back or leg-radicular?

22. “Red Flags”

23. Cancer risk factors
• age >50
• hx ca
• wt loss
• not better with bed rest
• duration> 30d

24. Spinal osteo
• IVDA
• UTI
• skin infection

25. Compression fx
• age 50/70?
• trauma
• corticosteroids

26. Physical
• observe gait for weakness and inconsistency
• inspect
• palpate
• the above are low yield but useful in that
patients like to be examined. Gives them
confidence in you- KEY

27. Herniated disc-causing sciatica
• Usual age 30-55
• 95% involve L5 or S1

28. Hx of radicular pain/”sciatica” is
primary clue to neurologic
impairment. The pain radiates
posteriorly or laterally below the
knee.

29. Cauda equina syndrome
• saddle anesthesia
• urinary retention
• sciatica
• 1% of HNPs requiring op- but need op

30. Spinal stenosis
• 3% of pts
• older patients
• “neurogenic claudication”
• pain better with sitting

31. Motor exam
• extensor hallucis good for L5 root
• quad for L4 and gastrosoleus for S1 not as
useful

32. Reflexes
• knee good for L4
• ankle good for S1
• no reflex for L5

33. Sensory
• medial foot L4
• Webspace behind 1st
-2nd
phalanx L5
• lateral foot S1
• Often just paresthesias

34. Straight leg raise
• Lift leg by heels and if pain mentioned ask
location
• Must be leg pain from 30-70 degrees
• Good test –excludes radiculopathy esp pts
under 30

35. Variations of SLR
• sitting vs.. supine
• dorsi and plantar flexion of foot

36. Turkey tests
• hysteric patients
• “coached” by previous exams
• malingering
• use SLR variations

37. What about plain X Ray films?
• not needed in first 4-6 weeks unless
suspicious for secondary cause
• used to help exclude tumor or infection
• oblique films not needed

38. Other studies
• MRI if considering operation,
infection, or cancer
• ESR? if suspicious for serious
diseases

39. Rx for acute back strain
• remember 90% better in six weeks-if do
nothing
• bedrest 2-3 days at most
• wt loss, abd exercise, stretch, posture,
Tylenol/NSAIA, aerobic exercise
• PT if needed to reinforce the above
• discourage illness/disability behavior

40. Patient education
• most get better slowly
• realize there is no cure
• they cannot be passive participants
• surgery will not help most

41. Rx no red flags
• educate
• Tylenol
• back care
• exercise
• wait-follow

42. What about “muscle relaxants?”
• which drugs are?
• do they work?
• cost?
• why used?

43. Rx red flags
• ESR?
• Plain films
• MRI/CT
• consult others

44. Operative management
• loss of bowel and bladder function
• Radiculopathy-intractable pain?
• Radiculopathy-progressive neurologic
changes?

45. Operative results
• pain relief? no difference at 4 yr... between
op or not
• neuro deficits? no difference at one yr.......
• MMPI best predictor in one study

46. Best candidates
• emotionally stable
• need to get well soon
• most common cause of failure is poor
patient selection

47. Concise treatment algorithm
• If cauda equina syndrome or hemodynamic
collapse (AAA) are present- go to the OR
• If constitutional symptoms are present then
evaluate medically
• Otherwise conservative treatment for six
weeks

48. Acute low back pain
• recognize the patients with a systemic
disease or HNP
• effectively treat 90%

49. Chronic back pain- the 10%
• Not infection or cancer as have had for
years
• Manage expectations
• Back class/work hardening/functional rehab
• Try drugs

50. Expectations are KEY
• No easy cure
• Not possible to be rid of all pain
• Dr Cox “If you are 50 and do not ache, you
are dead.”
• Opiates? Pain /drug lobby- ok for post op?

51. Opiates
• US 5% of global pop uses 80% of opiate rx
• No data on utility for 1 yr, most trials 6 wks
yet given forever
• Feb 17, 2015 Annals had no useful
conclusions on the NIH Workshop or Lit
review of opiates for chronic pain

52. Opiates
• ER/other doctors- give so the pt will go
away fast
• Street value $10-20 pill for norco
• Tylenol #3 less-no euphoria

53. Useful tips
• Psyche, pain in more than 3 areas,
substance abuse hx =high risk
• Do not let pts negotiate- they will wear
your down
• Wean down dose, withdrawal can be
unpleasant

54. More ideas
• “but I have had it for years” opiates are for
acute pain not chronic pain – down
regulation of receptors idea/hyperalgesia
• “My previous doctor gave it to me” – no
long term benefit ever shown and known
harms

55. Best use of norco
• When there is functional improvement
• Pt returns to work
• Not so they will be buzzed lying on the sofa
• Limited number of pills for elderly OA and
not surgical candidates

56. Is there an answer? My opinions
• Reinforce no rapid easy cure
• Use central acting agents like
TCA/cymbalta- gate control pain theory
• I use D Day example- non-mortal wounds
often had less pain , knew they would go
home
• Treat depression-if present key
• Weight loss-easy to say
• Back class

57. Back class
• Work hardening
• Not PT in sense of massage/ultrasound
• Core strengthening, mobility
• Only answer I know
• Up to pts whether they want to get better