Lower Back Pain MS3 Sports Medicine Workshop Objectives l l l l l l Review the functional anatomy of lumbo-sacral spine List essential components of a LBP history, including RED FLAGS Describe common causes of LBP Review proper indications for imaging and referral Review Physical Examination of LS spine Correlate pathology with pertinent physical findings вЂњRed FlagsвЂќ in back pain l l l l l l l l l l l Age < 15 or > 50 Fever, chills, UTI Significant trauma Unrelenting night pain; pain at rest Progressive sensory deficit Neurologic deficits вЂ“ Saddle-area anesthesia вЂ“ Urinary and/or fecal incontinence вЂ“ Major motor weakness Unexplained weight loss Hx or suspicion of Cancer Hx of Osteoporosis Hx of IV drug use, steroid use, immunosuppression Failure to improve after 6 weeks conservative tx Epidemiology of back pain l l l l Fifth most common reason for all physician visits in US Second only to common cold as cause of lost work time 25% of US adults have LBP x1d in last 3 mos The most common cause of disability in persons under the age of 45 Your patient with LBP has paresthesias in the lateral foot, decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root? 1. 2. 3. 4. L4 L5 S1 S2 Better anatomy knowledge = Better diagnoses and treatments l Vertebra вЂ“ Body, anteriorly l Functions to support weight вЂ“ Vertebral arch, posteriorly l Formed by two pedicles and two laminae l Functions to protect neural structures Ligaments l l l l l Anterior longitudinal ligament Posterior longitudinal ligament Ligamentum flavum Interspinous ligament Supraspinous ligament Ligamentous Anterior longitudinal ligament Muscles l l l l l l l l Spinalis Longissimus Iliocostalis Quadratus lumborum вЂ“ Ilium to lumbar TPs Intertransversalis Interspinals Multifidus Erector spinae Sciatica is defined asвЂ¦ bu tt in n w el o t in gb di a ra n Pa i Pa i th e th ig th e o t in gt di a ra n Pa i th e kn ee h k ba c th e p t in gu di a 4. ra 3. 25% 25% 25% 25% n 2. Pain radiating up the back Pain radiating to the thigh Pain radiating below the knee Pain in the butt Pa i 1. Neuro-anatomy вЂўL4 вЂўL5 вЂўS1 PATIENT HISTORY вЂњOPQRSTUвЂќ l l l l l l l Onset Palliative/Provocative factors Quality Radiation Severity/Setting in which it occurs Timing of pain during day Understanding - how it affects the patient Which one is NOT considered a вЂњred flagвЂќ of LBP? tic a 25% Sc ia rc hi ll s 25% Fe ve ro ov er 50 25% Ag e nc er ca 4. of 3. 25% or y 2. History/suspicion of cancer Age over 50 Fever or chills Sciatica Hi st 1. вЂњRed FlagsвЂќ in back pain l l l l l l l l l l l Age < 15 or > 50 Fever, chills, UTI Significant trauma Unrelenting night pain; pain at rest Progressive sensory deficit Neurologic deficits вЂ“ Saddle-area anesthesia вЂ“ Urinary and/or fecal incontinence вЂ“ Major motor weakness Unexplained weight loss Hx or suspicion of Cancer Hx of Osteoporosis Hx of IV drug use, steroid use, immunosuppression Failure to improve after 6 weeks conservative tx Onset l l l l Acute - Lift/twist, fall, MVA Subacute - inactivity, occupational (sitting, driving, flying) ?Pending litigation Pain effect on: вЂ“ work/occupation вЂ“ sport/activity (during or after) вЂ“ ADLвЂ™s Other History l l l l l Prior h/o back pain Prior treatments and response Exercise habits Occupation/recreational activities Cough/valsalva exacerbation Diagnoses & Red Flags l Cancer вЂ“ вЂ“ вЂ“ вЂ“ вЂ“ l IVDU Steroid use Fever Unrelenting night pain Failure to improve Fracture вЂ“ вЂ“ вЂ“ вЂ“ Age > 50 History of Cancer Weight loss Unrelenting night pain Failure to improve Infection вЂ“ вЂ“ вЂ“ вЂ“ вЂ“ l l Age >50 Trauma Steroid use Osteoporosis Cauda Equina Syndrome вЂ“ вЂ“ вЂ“ вЂ“ Saddle anesthesia Bowel/bladder dysfunction Loss of sphincter control Major motor weakness Physical Examination Msk Big-6 l l l l l l Inspection Palpation Range of motion Strength testing Neurologic examination Special tests Approach to LBP History & physical exam Classify into 1 of 4: вЂ“ BAD: LBP from other serious causes Cancer, infection, cauda equina, fracture вЂ“ LBP from radiculopathy or spinal stenosis вЂ“ Non-specific LBP вЂ“ Non-back LBP Workup or treatment BAD low back pain (examples) What to do about Possible BAD Low Back Pain Cauda Equina: вЂ“ MRI STAT пѓ Neurosurgery consult Fracture: x-rays вЂ“ MRI/CT if still suspect Cancer: x-rays + CRP, ESR, CBC (+/- PSA) вЂ“ MRI if still suspect Infection: x-rays; CRP, ESR, CBC, +/- UA Radiculopathy, Spinal Stenosis Sciatica (pain below knee) May have abnl neuro exam Radiates to leg Pain worse walking, better sitting (pseudoclaudication) What to do about Suspected Radiculopathy or Spinal Stenosis Refer to Physical Therapy Follow in 2-4 weeks for progress If no improvement by 6-12 weeks вЂ“ Plain films, MRI, +/- EMG/NCV вЂ“ Refer for interventions Epidural steroid injections for radiculopathy Causes of вЂњNon-specific LBPвЂќ Acute lumbar strain Facet pain Discogenic pain Ligamentous pain Spondylosis (Osteoarthritis of facet/disk) Spondylolysis/-listhesis Kyphosis/scoliosis Management of an acute low back muscle strain should consist of all the following EXCEPT: 1. 2. 3. 4. X-rays to rule out a fracture Educate the patient on generally good prognosis Non-opiate analgesics Remain active What to do about Non-specific Low Back Pain Educate patient about expected good prognosis Advise to remain active as tolerated Provide analgesics and self-care directions FU in 2-4 weeks; adjust tx as needed DonвЂ™t do x-rays unless it becomes chronic WU if no improvement вЂњThink Outside the BackвЂќ Renal dz (pyelo, stones, abscess) Pelvic dz (PID, endometriosis, prostate) Gastrointestinal dz (cholecystitis, ulcer, cancer) Retroperitoneal dz Aortic aneurysm Zoster Diabetic radiculopathy Rheumatologic disorders вЂ“ вЂ“ вЂ“ вЂ“ Reiters Ankylosing Spondylitis Inflammatory bowel dz Psoriatic spondylitis Neoplasia (multiple myeloma, metastatic CA, lymphoma, leukemia, spinal cord tumors, vertebral tumors) What to do about Non-back LBP WU and tx as appropriate for suspected diagnoses Diagnostic Studies Radiographs вЂ“ Early if RED FLAGS вЂ“ Symptoms present > 6 weeks despite tx Diagnostic Studies MRI indications вЂ“ Possible cancer, infection, cauda equina synd вЂ“ >6-12 weeks of pain вЂ“ Pre-surgery or invasive therapy Disadvantages вЂ“ False-positives; may not be causing pain вЂ“ More costly, increased time to scan, problem with claustrophobic patients Diagnostic Studies Bone Scan indications Adolescent LBP (r/o spondy) SPECT scan Cost ~$300 вЂ“ Diagnostic Studies EMG/NCV вЂ“ вЂ“ вЂ“ вЂ“ вЂ“ r/o peripheral neuropathy localize nerve injury correlate with radiographic changes order after 6-12 weeks of symptoms Pre-surgical or invasive therapy Lab Studies Indications вЂ“ Chronic LBP вЂ“ Suspected systemic disease CBC, CRP, ESR, +/- UA, SPEP, UPEP Avoid RF, ANA or others unless indicated Issues specific to CHRONIC LBP (>6 weeks and/or non-responsive) Evaluation вЂ“ X-rays, labs вЂ“ Evaluate for вЂњYELLOW FLAGSвЂќ Management вЂ“ Medication selection вЂ“ Interventions YELLOW FLAGS in Chronic LBP Affect: anxiety, depression; feeling useless; irritability Behavior: adverse coping, impaired sleep, treatment passivity, activity withdrawal Social: h/o abuse, lack of support, older age Work: believe pain will be worse at work; pending litigation; workers comp problems; poor job satisfaction; unsupportive work envвЂ™t Medications in Chronic LBP FIRST: Acetaminophen Second: NSAIDs вЂ“ If one fails, change classes Meloxicam пѓ naproxen пѓ COX2вЂ™s Third: tramadol Fourth: tri-cyclic antidepressants вЂ“ Radiculopathy: gabapentin LOATHE: narcotics Non-pharmacologic treatments EFFECTIVE Acupuncture Exercise therapy Behavior therapy Massage TENS Spinal manipulation Multidisciplinary rehab program NOT EFFECTIVE/ CONFLICTING EVIDENCE BACK SCHOOLS LOW-LEVEL LASER LUMBAR SUPPORTS PROLOTHERAPY SHORT WAVE DIATHERMY TRACTION ULTRASOUND Epidural Steroid Injections Indicated for radiculopathy not responding to conservative mgmt вЂ“ Conflicting evidence вЂ“ Small improvement up to 3 months вЂ“ Less effective in spinal stenosis Surgery for Chronic LBP Most do NOT benefit from surgery Should have ANATOMIC LESION C/W PAIN DISTRIBUTION Significant functional disability, unrelenting pain вЂ“ Several months despite conservative tx Procedures: spinal fusion, spinal decompression, nerve root decompression, disc arthroplasty, intradiscal electrothermal therapy Break for Physical Examination Hands-on Session Inspection Observe for areas of erythema вЂ“ Infection вЂ“ Long-term use of heating element Unusual skin markings вЂ“ CafГ©-au-lait spots Neurofibromatosis вЂ“ Hairy patches, lipomata Tethered cord вЂ“ Dimples, nevi (spina bifida) Inspection (cont.) Posture вЂ“ Shoulders and pelvis should be level вЂ“ Bony and soft-tissue structures should appear symmetrical Normal lumbar lordosis вЂ“ Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall Posture вЂ“ Shoulders and pelvis should be level вЂ“ Bony and soft-tissue structures should appear symmetrical Normal lumbar lordosis вЂ“ Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall Bone Palpation Palpate L4/L5 junction (level of iliac crests) Palpate spinous processes superiorly and inferiorly вЂ“ S2 spinous process at level of posterior superior iliac spine Absence of any sacral and/or lumbar processes suggests spina bifida Visible or palpable step-off indicative of spondylolisthesis Soft Tissue Palpation 4 clinical zones вЂ“ Midline raphe вЂ“ Paraspinal muscles вЂ“ Gluteal muscles вЂ“ Sciatic area вЂ“ Anterior abdominal wall and inguinal area ANTERIOR PALPATION Flexion - 80Вє Range of Motion Extension - 35Вє Side bending - 40Вє each side Twisting - 3-18Вє Neurologic Examinaion Includes an exam of entire lower extremity, as lumbar spine pathology is frequently manifested in extremity as altered reflexes, sensation and muscle strength Describes the clinical relationship between various muscles, reflexes, and sensory areas in the lower extremity and their particular cord levels Neurologic Examination (T12, L1, L2, L3 level) Motor вЂ“ Iliopsoas - main flexor of hip вЂ“ With pt in sitting position, raise thigh against resistance Reflexes - none Sensory вЂ“ Anterior thigh Neurologic Examination (L2, L3, L4 level) Motor вЂ“ Quadriceps - L2, L3, L4, Femoral Nerve вЂ“ Hip adductor group - L2, L3, L4, Obturator N. Reflexes вЂ“ Patellar - supplied by L2, L3, and L4, although essentially an L4 reflex and is tested as such L2, L3, L4 testing Neurologic Examination (L4 level) Motor вЂ“ Tibialis Anterior Resisted inversion of ankle Reflexes вЂ“ Patellar Reflex (L2, L3, L4) Sensory вЂ“ Medial side of leg Neurologic Examination (L5 level) Motor вЂ“ Extensor Hallicus Longus вЂ“ Resisted dorsiflexion of great toe Reflexes - none Sensory вЂ“ Dorsum of foot in midline Neurologic Examination (S1 level) Motor вЂ“ Peroneus Longus and Brevis вЂ“ Resisted eversion of foot Reflexes вЂ“ Achilles Sensory вЂ“ Lateral side of foot Special Tests Tests to stretch spinal cord or sciatic nerve Tests to increase intrathecal pressure Tests to stress the sacroiliac joint Tests to Stretch the Spinal Cord or Sciatic Nerve Straight Leg Raise Cross Leg SLR Kernig Test Test to increase intrathecal pressure Valsalva Maneuver вЂ“Reproduction of pain suggestive of lesion pressing on thecal sac Kernig Sign Pain present Pain relieved Tests to stress the Sacroiliac Joint FABER Test Gaenslen sign FABER test: Flexion ABduction External Rotation Gaenslen sign Non-organic Physical Signs (вЂњWaddellвЂ™s signsвЂќ) Non-anatomic superficial tenderness Non-anatomic weakness or sensory loss Simulation tests with axial loading and en bloc rotation producing pain Distraction test or flip test in which pt has no pain with full extension of knee while seated, but the supine SLR is markedly positive Over-reaction verbally or exaggerated body language Waddell, et al. Spine 5(2):117-125, 1980. Hoover Test Helps to determine whether pt is malingering Should be performed in conjunction with SLR When pt is genuinely attempting to raise leg, he exerts pressure on opposite calcaneus to gain leverage Other Rectal tone Anal wink Cremasteric reflex Questions?