Low Back Pain:

Approach to the patient in the E.D.

Lala M. Dunbar, M.D., Ph.D. Clinical Professor of Medicine LSU HSC

Epidemiology
60 90% of adults experience back pain at some point in their life. - incidence age 35- 55 y.o. - 90% resolve in 6 weeks - 7% become chronic - M/ F equally affected 85% never given precise pathoanatomical dx 5th Leading reason for medical office visits 2nd to respiratory illness as reason for symptom-related MD visits

Epidemiology (cont.)
#1 Cause and #1 Cost of work related disability
Healthcare expenditures $90 Billion (1998) - $26.3 Billion attributable to back pain

Important Questions
1. Is systemic disease the cause? 2. Is there social or psycological distress that prolongs or amplifies symptoms? 3. Is there neurologic compromise that requires surgical intervention?

To Answer These Important Questions

1. Careful History and Physical Exam

2. Imaging and Labs WHEN indicated

Differential Diagnosis of Low Back Pain

Evaluation in older adults

Probabilities change Cancer, compression fractures, spinal stenosis, aortic aneurysms more common Osteoporotic fractures without trauma Spinal Stenosis secondary to degenerative processes and spondylolisthesis more common Increased AAA associated with CAD Early radiography recommended

Clues To Systemic Disease

Age History of Cancer Fever Unexplained Weight Loss Injection Drug Use Chronic Infection Elsewhere Duration and Quality of Pain -Infection and Cancer not relieved supine Response to previous therapy h/o inflammatory arthritis elsewhere

Imaging
Plain Radiography limited to patients with: -findings suggestive of systemic disease -trauma Failure to improve after 4 to 6 weeks CT and MRI more sensitive for cancer and infections also reveal herniation and stenosis Reserve for suspected malignancy,infection or persistent neurologic defecit

MRI
Shows tumors and soft tissues (e.g., herniated discs) much better than CT scan Almost never an emergency
Exception: Cauda equina syndrome

CT Scan
Shows bone (e.g., fractures) very well Good in acute situations (trauma) Sagittal reconstruction is mandatory Soft tissues (discs, spinal cord) are poorly visualized CT-myelogram adds contrast in the CSF and shows the spinal cord and nerves contour better

Abdomen, X-ray, Anteroposterior View

1. 1st Lumbar vertebra 2. 2nd Lumbar vertebra 3. 3rd Lumbar vertebra 4. 4th Lumbar vertebra 5. 5th Lumbar vertebra 6. T12 7. Twelfth rib 8. Sacroiliac joint 9. Sacrum 10. Sacral foramen 11. Ilium 12. Pelvic brim 13.Superior ramus of pubic bone 14. Pubic symphysis

Lower Third of Spinal Cord, MRI

1. Vertebral body 2. Spinal cord 3. Conus medullaris

4. Intervertebral disc
5. Filum terminale (internum)

6. Subarachnoid space

Sagittal Section through the Spinal Cord

1. Intervertebral disc 2. Vertebral body

3. Dura mater
4. Extradural or epidural space

5. Spinal cord
6. Subarachnoid space

Lumbrosacral Dermatones

Common Pathoanatomical Conditions of the Lumbar Spine

Disc Herniation Physiology

Tears in the annulus Herniation of nucleus pulposus

Disc Herniation Physiology

Compression of the nerve root in the foramen leads to pain

Lumbar Disc Herniation Treatment

Conservative Tx.
Moderate bed rest Spinal manipulation Physical therapy Medication
NSAIDs Muscle relaxants Rarely narcotics

Surgical Tx.
Microdiscectomy Less than half of an inch incision Go home the same or next day Good results in up to 90% of cases

Results of Surgical Treatment

Good outcome in 80-90% of cases Residual pain may last up to 6 months postop Results are worse if pain was present for over 8 months before the operation (permanent nerve damage?)

Low Back Pain

Second most common cause of missed work days Leading cause of disability between ages of 19-45 Number one impairment in occupational injuries

Low Back Pain

Most episodes of LBP are self limited These episodes become more frequent with age LBP is usually due to repeated stress on the lumbar spine over many years (degeneration), although an acute injury may cause the initiation of pain

Disc Degeneration Physiology

With age and repeated efforts, the lower lumbar discs lose their height and water content (bone on bone) Abnormal motion between the bones leads to pain

Disc Degeneration Treatment

Conservative Tx.
Moderate bed rest Spinal manipulation Physical therapy Medication
NSAIDs Muscle relaxants Rarely narcotics

Surgical Tx.
Lumbar fusion OR Replacement with artificial disc

Indications for Surgical Treatment

Low back pain for at least 2 years Incapacitating Resistant to physical therapy and medication Positive MRI findings (degenerative changes) at L4-5 and/or L5-S1 For selected cases:
Concordant pain on discography Psychological evaluation

Natural History
Recovery from nonspecific LBP generally rapid 90% within 2 weeks some studies less rapid (2/3 at 7 weeks) Herniated Discs slower to improve only about 10% considered for surgery after 6 weeks With surgery, no earlier return to work symptomatic and functional outcome sometimes better

Physical Examination
Fever possible infection Vertebral tenderness - not specific and not reproducible between examiners Limited spinal mobility not specific (may help in planning P.T. If sciatica or pseudoclaudication present do straight leg raise Positive test reproduces the symptoms of sciatica pain that radiates below the knee (not just back or hamstring) Ipsilateral test sensitive not specific: crossed leg is insensitive but highly specific L-5 / S-1 nerve roots involved in 95% lumbar disc herniations

Assessment of Function
98% disc herniations: L4-5; L5-S1 Impairment: Motor and Sensory L5-S1
L5: Weakness of ankle and great toe dorsaflexion S1: Decrease ankle reflex L5 & S1: Sensory loss in the feet

STRAIGHT LEG RAISE TEST STRAIGHT LEG RAISE TEST

The straight leg raise test is positive if pain in the sciatic distribution is reproduced between 30 and 70 passive flexion of the straight leg. Dorsiflexion of the foot exacerbates the pain

Waddell Signs For Non-organic Pain

Superficial non-anatomic tenderness Pain from maneuvers that should not ellicit pain Distraction maneuvers that should ellicit pain BUT dont Disturbances not consistent with known patterns of pain Over-reacting during the exam Not definitive to rule out organic disease

Imaging Studies
Progressive Neurologic Defecits Failure to Improve Hx of Trauma Risk for Malignancy or infection

Nerve Root Pain

Associated w/ Radiculopathy Sciatica -herniated disk -foramenal or spinal stenosis -ligamentous hypertrophy -other space filling lesions: cysts, tumor, abscess -viral or immune inflammation -can occur w/ peripheral nerve involvement Spinal stenosis -neurogenic claudication (pseudo claudication)
1 or both legs

-radiation to buttocks, thighs, lower legs -pain increase with extension (standing, walking) -pain decrease with flexion (sitting, stooping forward)

Indications for Surgical Referral

Therapy: Non-specific LBP

NSAIDS Muscle relaxants Use on schedule than p.r.n. Spinal manipulation/ P.T. (effects limited) Delay referral until pain persists >3 weeks
50% will improve b/f this time period

Rapid return to normal activities Avoid heavy lifting, trunk twisting, vibrations Alternative Tx: acupuncture and massage Surgery- ineffective unless:
sciatica, pseudoclaudication, spondylolisthesis

Therapy: Herniated Disks

If no evidence cauda equina or progressive neurologic defecit:
Treat non-surgically minimum one month Treat similar to non-specific LBP Limited narcotics Epidural steroids (helps in some)

If severe pain or neuro defecits persist:

CT/ MRI / consider for surgery

Diskectomy
Improved relief vs. non-surgery at 4 yrs./ ? 10yrs. Percutaneous and laser less effective than std. Arhroscopic techniques techniques comparable to std. surgery

Therapy: Spinal Stenosis

Conservative management may be useful For severe persistant pain decompressive laminectomy Surgery better pain relief and functional recovery 30% recurrent severe pain in 4 years
10% reoperated

Therapy: Chronic LBP

Sx often difficult to explain Intensive exercises help (hard to maintain) Anti-depressant therapy useful if depressed Long term opioids not recommended Referral to pain center Massage therapy is promising Therapeutic goals optimize daily function

Long Term Outcomes

Herniated Discs w/o neurologic deficits
Diskectomy - > relief at 4 yrs; ? Better at 10 yrs

Microdiskectomy similar to standard Laser Diskectomy less effective Arthroscopic diskectomy - promising