Low Back Pain Case Study Ppt
Presentation on theme: "Low Back Pain: Case Based Evaluation and Management"— Presentation transcript:
1 Low Back Pain: Case Based Evaluation and Management
Patrick Kortebein, M.D.Departments of PM&R and GeriatricsUniversity of Arkansas for Medical Sciences5/31/09Slides:
2 ObjectivesUnderstand the evaluation and management of common sources of low back and related painUnderstand the significance of abnormal findings on lumbar spine MRI in individuals with low back and related pain.Understand the evaluation and management of chronic low back pain.
3 Low Back Pain Common; 2nd primary care visits Acute episodes
5-15% per year60-80% lifetimeAcute episodes75-90% recover w/in 3 months25-75% will have recurrence w/in 6 months
4 LBP: Anatomy Bone / Vertebrae Disc Muscles / Ligaments
AnnulusNucleus PulposusMuscles / LigamentsSpinal Nerve Roots
5 LBPFacet jointZygopophyseal jointSynovial
6 LBPSacroiliac JointTight, SynovialLigaments“SI Dysfunction”
7 Case #1 28 yo M presents with CC: LBP
Started 4 days ago while bending over to pick up his 14 mo old childPMHX: L knee arthroscopyMeds: AcetaminophenNKDASocial Hx: Married, insurance salesmanWhat other information is important?
8 Acute LBP: History Location Onset: Traumatic, Insidious Duration:
Axial or Radiating (Sciatica) ?Onset: Traumatic, InsidiousDuration:Acute: < 12 weeksChronic: > 12 weeksCharacter/Quality: Ache, Burning, etcExacerbating / Alleviating Factors
9 Acute LBP: History “Red Flags” (AHCPR 1994) Fracture: Cauda Equina
Major/minor traumaAge > 70 yrs (~50 yrs)Chronic corticosteroidsCauda EquinaB/B dysfunctionSaddle AnesthesiaLE weakness
10 Acute LBP: History “Red Flags” (AHCPR 1994) Infection Cancer Fever
Steroids / Immunosuppression / IV Drug UseUTI / Systemic InfectionCancerHx of CancerUnintentional Weight LossSupine/Night PainAge > 50
11 “Red Flag” Evaluation
12 Acute LBP: Physical Exam
Lumbar Spine:InspectionPalpationROM: Flexion / Extension+/- LE Neurologic Exam
13 Acute LBP: ImagingWhen?What imaging?
14 Acute LBP: Imaging When? What? Minimum 6 weeks + “Red Flags” X-ray
3-view:AP / Lat / L5 SpotObliques:Limited informationRadiation exposure
15 Acute LBP: ImagingLumbar MRI
16 Acute LBP: Imaging Abnormal findings “Degenerative disc disease”
“Bulging disc”“Herniated disc”
17 LBP: Imaging MRI Abnormalities in Normals / No LBP
Boden et al (N=67) JBJS 1990HNP: 21-36%Bulging Disc: 50-80%Degenerative Disc Changes: 34-93%Jensen et al (N= 98) NEJM 1994Bulging Disc: 52% (28-100%)Disc Protrusion: 27% (21-30%)
18 Case #1 History Onset: 4 days ago, constant
Location: R lumbosacral junctionNo radiation / neurological symptomsNo clear exacerbating / alleviating factorsPhysical ExamMild tenderness R low lumbar regionIncreased pain with flexionNormal LExt neuro exam
19 Case # 1Diagnosis ?Management ?
20 LBP: Differential Diagnosis
Deyo NEJM 2001
21 Case # 1 Diagnosis: “Mechanical” LBP
Education / Activity ModificationBedrest: ~ 2 days (Deyo NEJM 1986)Analgesics:AcetaminophenNSAID’sTramadolMuscle RelaxantsCyclobenzaprine
22 “Mechanical” LBP Physical Therapy Chiropractic Acupuncture Exercise
ModalitiesLumbar SupportChiropracticAcupunctureBack Heat
23 LBP: Zygapophyseal (Facet) joint
History/ExaminationAxial LBP +/- post thighNo neuro sxsWorse w/ static postureLumbar ExtensionStand / WalkNeuro exam normal
24 LBP: Zygapophyseal (Facet) joint
ManagementAnalgesicsTylenol, NSAIDPhysical TherapyInjectionsDiagnosticTherapeutic
25 LBP: Sacroiliac (SI) Joint
HistoryAtraumatic > TraumaticAxial; LumbosacralUni- > BilateralNo radiation / neuro sxsPhysical Exam~ NormalTender SI region
26 LBP- SI JointDiagnosis / TreatmentPhysical TherapyInjection
27 LBP: Discogenic History / Exam Axial LBP No radiation / neuro sxs
Aggravating:Static posture- Sitting or Sit to standNormal neurological exam
28 LBP: Discogenic Management Physical Therapy Surgery: Core Strength
FusionArtificial DiscNot yet
29 Case # 238 yo with left LE radicular pain > LBP for ~6 weeks. Also left foot tingling and weakness.PMHx: HTN, HyperlipidemiaMeds: HCTZ, AtorvastatinAllergies: SulfaSocial Hx: Divorced, Landscaper
30 Case # 2 Physical Exam L-spine: Non-tender
Left LExt: + SLR / Crossed SLRNeuroMotor: 5/5 except Plantar FlexionReflex: KJ +2/+2, AJ +2 / 0Sensory: Dec to LT lateral heel
31 Case # 2Diagnosis ?
32 LBP: Radiculopathy Diagnosis Physical Exam MRI EMG CT Myelogram
* Correlate anatomy w/ sxs and exam
33 LBP: Radiculopathy Neurological Exam: Motor Reflex Sensory
L2/3: Hip Flex/Add Knee Med Thigh /KneeL4: Knee Ext/DFlex Knee Med AnkleL5: Great toe/EHL Int. HS Dorsum FootS1: Plantarflex Ankle Lat HeelFunctional: Squat, Heel / Toe Walk, Heel Raise
34 LBP: EvaluationSLR / Dural Tension
35 Case # 2 MRI: Left L5-S1 disc herniation impinging on S1 nerve root
36 LBP: Radiculopathy Management Medications Steroids; NSAID’s
AcetaminophenTramadolNeuropathicSteroids;Oral (? dose) vs epidural
37 LBP: Radiculopathy Management Physical Therapy McKenzie
Extension therapyTENS~ No benefit
38 LBP: RadiculopathyInjectionsEpidural Selective
39 LBP: Radiculopathy Surgery Indications SPORT trial Cauda equina
Progressive neuro deficitsNo relief w/ conservative treatmentSPORT trialJAMA 2006
40 LBP: Spinal Stenosis History (Neurogenic claudication) Physical Exam
Prox LE Pain +/- Neuro sxsWalk / StandUphill > DownhillGrocery CartPhysical Exam~ NormalStand / Walk
41 LBP: Spinal Stenosis Diagnosis Management MRI EMG Medications PT
NeuropathicPTEpidural InjectionSurgery: (SPORT trial)
42 Case # 351 yo M truck driver injured at work 2 years ago lifting a 30# box, and applying for disabilityContinued axial LBP and “numb” R LENo “Red Flags”Treatments to date:Medications: NSAIDs, Tramadol, HydrocodonePhysical Therapy: 24 sessionsWork restrictions; not workingInjections: Epidural / Facet / Sacroiliac
43 Case # 3 Physical Examination Lower Extremity Neurologic
Lumbar: Diffuse tenderness to light palpationExaggerated pain behavior w/ trunk rotationLower Extremity Neurologic50% decreased sensation entire LExtNormal strength / reflexesSupine SLR: LBP; Seated SLR: No pain
44 Case # 3 Lumbar MRI: Diagnosis? Treatment?
Mild DD changes with diffuse disc bulge at L4-5 and L5-S1Diagnosis?Treatment?
45 Chronic LBP Duration Poor Correlation > 12 weeks Symptoms
46 Chronic LBP Strong Association Depression Anxiety Poor Coping Skills
“My back hurts, but I’m here because I can’t cope with this episode, as well as the turmoil at home (or work)”- N Hadler “Last Well Person”
47 Chronic LBP
48 Chronic LBP **Goal** Improve Function Minimize focus
on treating pain itselfBiopsychosocial Model of PainMaladaptive BehaviorNeuroplasticity
49 Chronic LBP
50 Case # 3 Multidisciplinary Pain Management Education Medications PT
Chronic Opioids ?PTFunctional RestorationPsychologyPain Management
51 Recommended ReadingKinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician 2007; 75:1181-8,Deyo et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22:62-8.LBP Handbook 2003Cole & Herring
53 Questions ?
55 LBP: Evaluation Waddell’s Signs (Non-organic PE) Tenderness
OverreactionRegionalDistractionSimulation> 3/5* Behavioral Component of PainSpine 1980
An important part of the physical examination is the general observation of the patient. The patient presents with pain in the low back region and often places his or her whole hand against the skin to indicate a regional pain; however, in some cases the patient may indicate a more precise location.
Realize that much of the physical examination is subjective because a patient-generated response or interpretation to the examiner's questions or maneuvers is required. For example, sensory findings observed during the physical examination and reported symptoms in response to provocative testing are reliant on the patient's response and, hence, represent a somewhat subjective portion of the physical examination. A well-performed and well-documented physical examination, with consistent findings from one visit to the next, can yield important information that may be able to stand up to rigorous scrutiny by any involved third parties (eg, insurance company, attorney, workers' compensation judge). These physical examination findings would need to be put into the context of the patient's symptoms and diagnostic test results.
Equipment often used for the examination includes a stethoscope, goniometer, inclinometer, pinwheel or safety pin, tape measure, and reflex hammer.
Observe the patient walking into the office or examining room. Observe the patient during the history-gathering portion of the visit for development, nutrition, deformities, and attention to grooming.
Measure blood pressure, pulse, respirations, temperature, height, and weight.
Inspect the back for signs of asymmetry, lesions, scars, trauma, or previous surgery.
Note chest expansion. If it is less than 2.5 cm, this finding can be specific, but not sensitive, for ankylosing spondylitis.
Take measurements of the calf circumferences (at midcalf). Differences of less than 2 cm are considered normal variation.
Measure lumbar range of motion (ROM) in forward bending while standing (Schober test).
The neurologic examination should test 2 muscles and 1 reflex representing each lumbar root to accurately distinguish between focal neuropathy and root problems.
Measure leg lengths (anterior superior iliac spine to medial malleolus) if side-to-side discrepancy is suspected.
Using the inclinometer, measure forward, backward, and lateral bending. With the goniometer positioned in a horizontal plane over the axial skeleton (ie, over the head), measure trunk rotation.
The AMA Guides to the Evaluation of Permanent Impairment (5th edition) include reference tables for all motions, but these figures are not based on empiric data, only on consensus.  The ROM measurements in the AMA Guides do not correlate with disability and are not consistent within the document itself.
Palpate the entire spine to identify vertebral tenderness that may be a nonspecific finding of fracture or other cause of low back pain (LBP). Note any asymmetry, misalignment, or step-off between vertebral bodies. Remember also to palpate the sacroiliac joints.
Test for manual muscle strength in both lower extremities. The Medical Research Council rating is an ordinal scale used for this purpose (0 = absent strength, 1 = trace muscle movement, 2 = poor muscle strength [less than antigravity], 3 = fair muscle strength [antigravity strength through normal arc of motion], 4 = good strength, and 5 = normal strength).
Table 1. Functional Muscle Testing (Open Table in a new window)
|Nerve Root||Motor Examination||Functional Test|
|L3||Extend quadriceps||Squat down and rise|
|L4||Dorsiflex ankle||Walk on heels|
|L5||Dorsiflex great toe||Walk on heels|
|S1||Stand on toes*||Walk on toes (plantarflex ankle)|
|*When testing the S1 innervated gastrocnemius muscle, the ability to stand on the toes once represents fair (3/5) strength. The patient must stand on his or her toes 5 times in a row to be rated normal (5/5) strength. Note that this approach should allow the physician to detect weakness at a much milder stage than if gastrocnemius strength were assessed only by using the examiner's hand to apply resistance to ankle plantar flexion.|
Test for sensation and reflexes using 0-2 ordinal scale for pinprick sensation (0 = no sensation, 1 = diminished sensation, and 2 = normal sensation), and 0-4 ordinal scale to rate reflexes (0 = no reflex, 1 = hyporeflexic, 2 = normal reflex, 3 = hyperreflexic, and 4 = hyperreflexic with clonus).
Table 2. Dermatomal Sensory and Reflex Testing (Open Table in a new window)
|Nerve Root||Pin-Prick Sensation||Reflex|
|L3||Lateral thigh and medial femoral condyle||Patellar tendon reflex|
|L4||Medial leg and medial ankle||Patellar tendon reflex|
|L5||Lateral leg and dorsum of foot||Medial hamstring|
|S1||Sole of foot and lateral ankle||Achilles tendon reflex|
Clinical tests for signs of sciatic nerve tension are as follows:
Supine straight leg raising (SLR) test - Reproduction of pain caused by elevation of the contralateral limb raises the probability of a disk herniation to 98%. Remember that the SLR test result can be negative in persons with spinal stenosis.
Sitting SLR (knee extension) test (for lower roots) - The patient should sit on the table edge with both hips and knees flexed at 90° and extend the knee slowly. This maneuver stretches the nerve roots as much as a moderate degree of supine SLR. The SLR test result, if positive, reproduces symptoms of sciatica with pain that radiates below the knee.
The prone SLR test (also called the reverse SLR test or the femoral nerve stretch test) assesses the upper lumbar roots, a less common site of radiculopathy worth remembering.
Nonphysiologic testing (Waddell signs) should be performed. The presence of 3 or more positive findings out of the 5 types may be clinically significant in terms of psychosocial issues or poor surgical outcome. Isolated positive signs are of limited value.
Nonorganic tenderness consists of the following:
Superficial - Skin tenderness to light pinch over a wide area of lumbar surface
Nonanatomic - Deep tenderness over a wide area, often extending cephalad to the thoracic spine or caudad to the sacrum
Simulation tests give the patient the impression that a particular examination is being conducted, including the following:
Axial loading - Vertical loading over the patient's head while he or she is standing, producing LBP
Rotation - Back pain when the shoulders and pelvis are rotated passively in the same plane with the feet together
Distraction tests indicate a positive finding when the patient's attention is distracted.
SLR - Observing an improvement of 30-40° when the patient is distracted, compared with formal testing.
Flip test - The patient is seated with the legs dangling over the examination table. Instruct the patient to steady himself or herself by holding the edge of the table. When the affected leg is flipped up quickly, the patient falls back and lets go, placing both hands behind him or her on the table.
Regional disturbances that do not correlate with anatomy include the following:
Weakness - Cogwheeling (giving way) of many muscle groups upon manual muscle testing of strength
Sensory - Diminished light touch or pinprick sensation in a stocking pattern, rather than a dermatomal pattern, in an individual who is not diabetic
Nonanatomic sensory loss
Overreaction during the examination may be observed in several manifestations (eg, disproportionate verbalization, facial grimacing, muscle tension and tremor, collapsing, sweating). Care must be taken to account for cultural variations.
In addition, evaluate the patient's function. Observe ROM and flexibility, ability to dress and undress, and ability to rise from a chair or the examination table.