Ammar Al-Kashmiri, MDAmmar Al-Kashmiri, MDEmergency PhysicianEmergency PhysicianKhoula HospitalKhoula Hospital

Back Pain Made EZ!

Primary Health Care Physicians Workshop

Epidemiology

Definitions/Classifiication

RED FLAGS +Interpretation

How to examine?

Testing

Specific conditions

Management

Overview

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 ageHeavy physical work (long periods of static work

postures, heavy lifting, twisting, and vibration)Psychosocial factors (including work

dissatisfaction and monotonous work)DepressionObesity (BMI > 30)SmokingDrug abuseHistory of headache

Definitions

Acute LBP = < 6 weeks

Subacute LBP = 6-12 weeks

Chronic LBP = > 12 weeks

Nonspecific back pain (majority) = localized

Back pain + radiculopathy/sciatica = radiating

Back pain associated with another specific cause

= referred

Classification

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 FlagsHistory

Age <18,>50>6 weeks*Systemic complaints:

fever/chills/night sweatsundesired weight lossmalaise

Trauma (minor in OP, elderly)Cancer (0.7% 9%)ImmunocompromiseIVDU

Red Flags

Red FlagsHistoryThink outside the box!

Resp- e.g. Pneumonia

GI- e.g. Pancreatitis

GU- e.g. Pyelonephritis

AAA

Historical Red Flags? What do they mean?

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

History

Pain > 6 weeks Malignancy, infection, spinal stenosis,

spondylolysisHx 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 FlagsExamination

General appearanceo lies still Vs writhes in pain

Vital signso BP : ,, R to L differenceo Fever

Pulsatile abdominal massSpinal process tendernessNeurological 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) TestMotor

L3-S1Sensory

L3-S1Rectal tonePerianal 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

+ test can be verified by:Ankle dorsiflexionInternal rotationHead flexionCrossed SLR

SLR

Knee extension Foot inversion 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

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

Waddell Signs

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 yearsConstitutional symptoms Pain > 6 weeksHistory of traumatic onsetHistory of malignancyOsteoporosisInfectious 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

ParacetamolExcellent analgesic Proven efficacy comparable to NSAIDsinexpensive Small side effect profile in comparison

to NSAIDsRecommended in the treatment for all

patients

NSAIDsMost are equally efficaciousLowest dose needed to reach pain reduction

should be attemptedCOX-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

Analgesics

OpiatesLiberal use recommended for patients with

moderate-severe painAllows patients to break pain cycle Gives stronger option when exacerbations of

pain occur Only for short period (7-10 days) to

development of dependenceWarn patients of problems of driving

Muscle Relaxantse.g. DiazepamCause sedation + addiction with chronic useMay 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

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 Diathermy Cutaneous laser therapy Ultrasound Corsets & Lumbar braces

Homeopathy Acupuncture Massage TENS

Management directed at restoring function and supporting adaptive techniques:

Exercise Reduction in body weight Improving cardiovascular fitness Smoking cessation Massage- beneficial when combined with

exerciseAcupuncture-may be beneficialTENS-no benefitSpinal manipulation-no benefit

Subacute/Chronic LBP

Subacute/Chronic LBP

Activity Modification

MedicationsParacetamol/NSAIDAvoid opiates & muscle relaxantsAntidepressants- cyclic antidepressants

Subacute/Chronic LBP

LBP with Sciatica

1% -4% of individuals with LBPYoung = herniated disc, Older = spinal

stenosisHerniated disk

50% recover in 6 weeks5-10% ultimately require surgery

Surgery beneficial only in first 2 years No difference in symptoms at 4 and 10

years post operatively

Management similar to patient with uncomplicated LBP

Analgesics- Paracetamol, NSAIDs, short-term opiates

Activity- routine, use pain as limiting factorEpidural steroid injection- mild-moderate pain

reduction Must be diligent to detect progressive neurological

functionPatient should be educated to return earlier if the

symptoms are worsening

LBP with Sciatica

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

Thank You!