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Low Back Pain: Diagnosis to Treatment!
This document provides information on low back pain, including its definition, prevalence, costs, causes, examination, diagnosis, and treatment options. Some key points: - Low back pain is very common, affecting 60-80% of adults at some point. It costs the US over $90 billion annually in direct medical expenses and lost work. - Causes can be non-spinal (e.g. hernia, infection) or spinal (e.g. arthritis, herniated disc, stenosis). - Examination involves assessing gait, range of motion, motor strength, sensation, and reflexes. Common diagnostic tests are x-rays, MRI, CT. - Treatment depends on cause but
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Low Back Pain: Diagnosis to Treatment!
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- 2. Objectives • General Knowledge(facts, stats, etiology, definition) • Examination and Diagnostic Modality Options with the Low Back Pain Patient • Treatment Options
- 3. Low Back PainDefined • Pain felt in your lower back may come from the spine, muscles, nerves, or other structures in that region. It may also radiate from other areas like the mid or upper back, a inguinal hernia, or a problem in the testicles or ovaries. • A variety of symptoms may exist in the presence of back pain. There may be a tingling or burning sensation, a dull aching, or sharp pain. Weakness in the legs or feet may also exist. • There won't necessarily be one event that actually causes low back pain. The patient may have engaged in common activities of daily living improperly -- like standing, sitting, or lifting -- for a long time. Then suddenly, one simple movement, like reaching for something in the shower or bending from your waist, leads to the feeling of pain.
- 4. Numbers • Low backpain affects 60-80% of U.S. adults at some time during their lives, and up to 50% have back pain within a given year • Back symptoms are among the 10 leading reasons for patient visits to emergency rooms, hospital outpatient departments, and physicians' offices • Back pain is the most frequent cause of activity limitation in people younger than 45 years old • Fifteen million American adults currently suffer lower back pain
- 5. Co$t • Low-back pain(LBP) is the most common condition leading to workers' compensation claims associated with time loss (i.e., injuries sufficiently severe to lead a worker to miss days from work • Americans spend at least $90 billion each year on back pain • Each year, Americans lose 93 million days of work, at a cost of $11 billion, due to low back injuries. They spend another $5 to $24 billion in direct medical expenses
- 6. Adding Up TheNumbers A billion dollars is more than 10,000 dollars a day for 300 years! Perspective….. Now Multiply That By 90!
- 7. Etiology (Shedding light onthe subject) • Non - Spinal Causes of Low Back Pain • Spine Related Causes of Back Pain
- 8. Non-Spinal Related Causes BladderInfection Kidney Disease Ovarian Cancer Ovarian Cyst Testicular Torsion Fibromyalgia Pelvic Infections Appendicitis Pancreatitis Prostate Disease Gall Bladder Disease Abdominal Aortic Aneurysm
- 9. Spine Related Causes Arthritis Fibromyalgia Kyphosis Lordosis RheumatoidArthritis Ankylosing Spondylitis Arachnoiditis Bone Cancer Chiari Malformation Compression Fractures Discitis Epidural Abscess Facet Joint Syndrome Fixed Sagittal Imbalance Osteomyelitis Osteophytes Pinched Nerve Ruptured Disc Spina Bifida Spinal Cord Injury Spinal Tumor Spondylolisthesis Spinal Stenosis Spinal Cord Injury Spinal Tumor Sprain or Strain Synovial Cysts Wedge Fractures
- 10. Spine Related Causes Arthritis Fibromyalgia Kyphosis Lordosis RheumatoidArthritis Ankylosing Spondylitis Arachnoiditis Bone Cancer Chiari Malformation Compression Fractures Discitis Epidural Abscess Facet Joint Syndrome Fixed Sagittal Imbalance Osteomyelitis Osteophytes Pinched Nerve Ruptured Disc Spina Bifida Spinal Cord Injury Spinal Tumor Spondylolisthesis Spinal Stenosis Spinal Cord Injury Spinal Tumor Sprain or Strain Synovial Cysts Wedge Fractures
- 11. Low Back Pain….ThePatient History Physical Exam Diagnostic Studies
- 12. History Location Specific Point vs.Across Back Superficial vs. Deep Involve Any other region (lower extremity)
- 13. History Quality Dull Ache (toothache) Sharp/Stabbing Burning Tearing/Pop
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- 15. History Setting Time of daywhen worst/better After strenuous activity
- 16. History Aggravating/Relieving Factors What MakesBetter What Makes Worse BEWARE OF THE PATIENT THAT SAYS NOTHING MAKES PAIN BETTER!
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- 19. Physical Exam General Survey MuscleBulk/Wasting Posture Alignment Gait* Patient Should always be examined in an examination gown
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- 21. Physical Exam Motor Assessment •Motor Strength - assess to breaking • Tone • Bulk Measurements • Rapid Alternating Movements • Point-to-Point Discrimination
- 22. Physical Exam Testing MuscleStrength •0 - No muscular contraction detected •1 - Barley detectable trace or flicker of contraction •2 - Active movement of body part with gravity eliminated •3 - Active movement against gravity •4 - Active movement against gravity with some resistance •5 - Active movement against full resistance without evidence of fatigue
- 23. Physical Exam Motor StrengthFeedback Muscle Nerve of Innervation Muscle Nerves of Innervation Iliopsoas L2 – L4 Hip Adductors L2 - L4 Hip Abductors L4 - S1 Gluteus Max. S1 Quads L2 – L4 Hamstrings L4 – S1 Dorsiflexors L4 – L5 Plantar Flexiors S1
- 24. Physical Exam Sensory Pain Light Touch PositionSense Vibration Temperature Spinothalamic Tract Posterior Column
- 25. Physical Exam Reflexes •Patellar -mediated by L2, L3, L4 •Achilles - mediated by S1 •Babinski - ⇑ toes = upper motor neuron dysfunction •Clonus - rhythmic oscillation between dorsi & plantar flexion indicates central nervous system disease
- 26. Physical Exam Reflexes • Usuallygraded on a 0 to 4+ scale • 4+ Very Brisk, Hyperactive with clonus • 3+ Brisker than average, possibly, but not indicative of disease • 2+ Average; Normal • 1+ Somewhat diminished; low normal • 0 No Response • ** There is no minus in this score system
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- 28. Diagnostic Studies • PlainX-Ray • MRI • CAT Scan • Myelogram • Discogram • Bone Scan • Facet Block • SI Joint Block • EMG • SSEP • DEXAscan • Bone Scan
- 29. Diagnostic Studies • PlainX-Ray • MRI • CAT Scan • Myelogram • Discogram • Bone Scan • Facet Block • SI Joint Block • EMG • SSEP • DEXAscan • Bone Scan
- 30. Diagnostic Studies X-Ray • takento assess the structure of the spine and to determine the alignment of the vertebra
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- 32. Diagnostic Studies MRI • ExtremelySensitive for assessment of Soft tissue structures (nerves, disc) • One of the most commonly ordered test to assess low back pain • $$$$$$$$$$$$$
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- 34. Diagnostic Studies CAT Scan •Most often used to assess bone structures of spine. • Faster and cheaper than MRI • Can be very effective tool when using reconstruction images or combined with other modalities
- 35. Diagnostic Studies Myelogram &Post CT • myelogram consists of a series of plain xrays with a contrast agent injected into the thecal sac. • The C.A.T. scan that usually follows the myelogram depicts this same anatomy from a C.A.T. scan perspective
- 36. Diagnostic Studies Myelogram &Post CT The injection of iodine based contrast into the thecal sac containing the nerves and/or spinal cord, promotes better definition of those structures than the images obtained on the regular C.A.T. scan. Cross-sections and reconstructions of the images in different planes (including 3-D) allows different perspectives on the anatomy. This test is often used to visualize the spinal cord and nerves in relation to the surrounding spine structures (bone, joint, disc, etc)
- 37. Diagnostic Studies Discogram • Involvesthe injection of contrast material into the disc space • Concordant vs. Discordant Pain…..?? • Helpful in assessing discogenic pain • VERY “uncomfortable” test
- 38. Conditions • Strains &Sprains • Stenosis • Disc Herniation • Spondylolisthesis Signs & Symptoms Diagnostic Findings Treatment Options}
- 39. Strains & Sprains •Muscle strains and lumbar sprains are the most common causes of low back pain • May refer to both injuries as a category called "musculoligamentous injuries“ (it doesn't matter what you call the problem because the treatment and prognosis for both back strains and sprains is the same)
- 40. Strains & Sprains Signs& SX • Pain isolated to low back, which may increase with flexion or extension of the lumbar spine • generally relieved with sitting, but symptoms are exacerbated with activities such as prolonged standing or bending • Pain described as deep, dull, sharp at times • P.E. usually shows normal motor and sensory function although pt. may appear weak 2° to pain • P. E. may reveal point tenderness and evidence of spasm
- 41. Strains & Sprains DiagnosticFindings • No tests are typically necessary during the first 4 weeks of symptoms if the injury is non-traumatic • If, however one is ordered, evidence of edema on MRI will be seen in severe musculoligamentous injury, as well as straightening (flattening) of the lordotic curve is presence of spasm
- 42. Strains & Sprains Treatment •Initial treatment involves rest from aggravating activities, medication for pain control, and modalities to decrease pain and inflammation. • The use of cold packs to decrease edema during the first 48 hours after sprain/strain and the application of moist heat or cold thereafter to reduce pain and muscle spasm can be helpful. • Bed rest for up to 48 hours may be beneficial but prolonged bed rest is discouraged. (Extremely Controversial) Relative rest by avoiding activities that exacerbate pain is preferable to complete bed rest. • Temporary use of a lumbosacral support when out of bed may reduce pain and muscle spasm and increase activity tolerance. • A short course of NSAIDs, acetaminophen, or muscle relaxants may be beneficial. Narcotics are generally not necessary but may be used in the very acute stage
- 43. Lumbar Spinal Stenosis •The disorder can be congenital or acquired • Acquired lumbar stenosis usually is caused by degenerative disease of the spine and is typically associated with hyperplasia, fibrosis, and cartilaginous changes in the annulus, posterior longitudinal ligament, and ligamentum flavum • Also can be caused by Spondylolisthesis, spondylolysis, a defect in the pars interarticularis, may be related to injury, bony overgrowth such as occurs in Paget's disease, ankylosing spondylitis, rheumatoid arthritis, and diffuse idiopathic skeletal hyperostosis
- 44. Lumbar Spinal Stenosis Signs& SX •Patients present with pain that is brought on by activity and released by rest or leaning forward •The pain involves the lower back and one or both legs, typically in a radicular distribution, and may be accompanied by numbness or weakness •Examination often reveals no abnormality, except perhaps for a depressed knee or ankle reflex. SLR is usually negative
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- 46. Lumbar Spinal Stenosis DiagnosticFindings • MRI is the most sensitive technique for detecting the disorder • Stenosis may be multifactorial….. Which will impact upon treatment options
- 47. Lumbar Spinal Stenosis Treatment •Conservative Management – Non-steroidal anti-inflammatory drugs, such as aspirin, naproxen (Naprosyn), ibuprofen (Motrin, Nuprin, Advil), to reduce inflammation and relieve pain. New generation Cox-2 inhibitors have shown remarkable results in many cases – Corticosteroid injections into the outermost of the membranes covering the spinal cord and nerve roots to reduce inflammation and treat acute pain that radiates to the hips or down a leg. – Physical therapy and/or prescribed exercises to maintain motion of the spine and build endurance to help stabilize the spine – lumbar brace or corset to provide some support and help the patient regain mobility
- 48. Lumbar Spinal Stenosis Treatment •Surgery – most common surgical solution to spinal stenosis is a laminectomy – Other procedures include Laminotomy, Decompressive Laminectomy, Foraminotomy, Medial Facetectomy, Lumbar Discectomy and Fusion
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- 50. Disc Herniation • Inthe lumbar spine, at least 90% of disc herniations occur at the L5–S1 or L4–5 levels. L3–4 herniations make up only 5% of cases, with the remainder occurring at L2–3 and L1–2 • Clinically, a herniated disc at one level usually affects the nerve root that exits at the level below. For instance, a left L4–5 disc herniation usually compresses the left L5 nerve root
- 51. Disc Herniation Signs &SX • Initial complaints are backache, and in most of those affected, there is no history of antecedent trauma • Prior similar complaints of back pain or sciatica are common complaints • The patient 's back pain is usually followed by severe pain that radiates into the lower extremities • Numbness or paresthesias may occur in the same distribution as the pain, and weakness of selected muscle groups can occur
- 52. Clinical Findings ofCommon Lumbar Disc Herniations Disc Nerve Root Pain Sensory Change Motor Deficits Reflex Loss L3–4 L4 Anterior thigh, anterior leg, and medial ankle Anterior leg Quad Knee jerk L4–5 L5 Posterior hip and posterolateral thigh and leg Medial dorsum of foot and occasionally medial ankle Foot and toe extension None L5– S1 S1 Hip, buttock, and posterior thigh and leg Lateral foot and ankle Plantar flexion Ankle jerk
- 53. Disc Herniation Signs &SX • Physical Exam – Paraspinal muscle spasm is frequently present – Radicular pain on flexion of the straight leg at the hip present – Complete motor, sensory, and reflex testing should be performed, however variability should be expected due to subtle neuroanatomic differences in patients or to specific characteristics of the actual disc herniation – Motor, Sensory, and reflex findings may be present individually or in combination
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- 57. Disc Herniation Treatment –Non Surgical • The mainstay of therapy for herniated lumbar disc is conservative treatment due to the majority of patients the symptoms resolving or subsiding to a level allowing normal activity within 4-6 weeks. • Analgesics or muscle relaxants often help to relieve pain. • The most commonly prescribed drug therapy involves NSAIDS reducing inflammation that may be the causative factor underlying nerve root pain. • Physical Therapy has also become a mainstay in treating patients with HNP in order to strengthen the core support musculature • Patients must be advised that continued home exercise is a must in order to prevent recurrent pain • The vast majority of patients are treated with nonoperative techniques.
- 58. Disc Herniation Treatment –Surgical • Indications for surgery include radicular pain that does not improve with conservative measures, recurrent episodes of incapacitating pain, disc herniations associated with significant weakness in the appropriate muscle groups, or massive midline herniations with signs of cauda equina compression • EVIDENCE OF FOOT DROP OR INCONTINENCE IS A NEUROSURGICAL EMERGENCY. Pressure must be taken off the nerve root within 24hrs, or damage may become permanent
- 59. Disc Herniation Treatment –Surgical The standard treatment of these disorders uses a midline incision over the affected interspace followed by a hemilaminectomy to expose the dural sac and nerve root. Gentle medial retraction of these structures exposes the herniated disc fragments, which are removed along with any loose disc material identified within the disc space. The nerve root is then explored thoroughly along its course to ensure that it is adequately decompressed. In cases of large disc herniations or in those cases with a free, extruded disc fragment, a complete laminectomy at the appropriate level may be necessary (microdiscectomy)
- 60. Spondylolisthesis • Spondylolisthesis isthe anterior displacement of one vertebral body over another • The severity of the slippage in spondylolisthesis is classified according to the migration of the cephalad vertebrae over the caudad. Grade I represents 0% to 25% slippage; grade II, 25% to 50% slippage; grade III, 50% to 75% slippage; and grade IV, 75% to 100% slippage
- 61. Spondylolisthesis Signs & SX •The patient usually complains of gradual onset of low back pain. • Pain is characterized as deep and aching and is localized to the affected levels. • Patients may also complain of pain in the buttock or iliac crest. • Movement makes the pain worse, as do Valsalva maneuvers • Radicular type symptoms exist most often due to nerve root irritation
- 62. Spondylolisthesis Diagnostic Findings • Mostall diagnostic imaging modalities can pick up a Spondy, however dynamic studies are the most telling
- 63. Spondylolisthesis Treatment Non-Surgical • Ifthe spondylolisthesis is non-progressive, no treatment except observation is required. Symptoms often abate once precipitating activities cease. Conservative treatment includes, restriction of activities causing stress to the lumbar spine (e.g. heavy lifting, stooping), physical therapy, anti- inflammatory and pain reducing medications, and/or a corset or brace.
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Editor's Notes
- #31 Spine Basics: Diagnostic Tests RaysPlain xrays are taken to determine the structure of the spine and to determine the alignment of the vertebra. Plain xrays may be useful for certain congenital defects, instability of the spine, deformity (scoliosis, kyphosis, lordosis), and tumors.