Download Differential Diagnosis of Low Back Pain

Differential Diagnosis of Low
Back Pain
Arnold J. Weil, MD, MBA
Non-Surgical Orthopaedics, P.C.
Atlanta, GA
Objectives
 Identify primary pain generators that contribute to low back pain
 Discuss the routine evaluation of low back pain
 Identify common causes of low back pain
Introduction to Low Back Pain
 LBP very disabling and accounts for over 50% of Workers’ Comp costs
 80-$100 billion per year
 Affects up to 85% of adults
 Leading cause of disability ages 19-45
 In 2010 in the United States there were over 15 million office visits to
physicians for low back pain, second only to the common cold as a
symptomatic reason for a physician visit
 75% of costs due to 5% of patients
 95% of all LBP is non-surgical
Risk Factors
 Smoking
 Obesity
 Older age
 Gender
 Strenuous or sedentary work
 Job satisfaction
 Psychological factors (anxiety, depression, etc)
The Natural History
of Back Pain
 By 6 weeks
– 65% of patients have recovered
 By 12 weeks
– 85% of patients are improved
 After 12 weeks
– Recovery is less likely
 After 26 weeks
– Fewer than half ever return to work
 After 104 weeks
– Likelihood of returning to work is virtually nil
The Evolving Approach
Towards Back Pain
Then
 Prolonged bed rest
 Absence from work
 Sedating medications
 Physical modalities
 Passive patient
 Routine diagnostic testing
 Aggressive surgical approaches
Now
 Minimal or no bed rest
 Rapid return to work
 Sedation not desired
 Active rehabilitation
 Active patient participation
 Look for the red flags first
 Aggressive non-surgical treatment
Lumbar Anatomy
 Bones/joints
 Muscles
 Discs
 Ligaments
 Nerve roots
Lumbar Spine
Low Back Pain
 Multiple anatomic sources
 No standard methods for categorizing,
diagnosing, or treating pain syndromes
 Treatment protocols varied
• Rest, exercise
• Physical therapy
• Spinal manipulation
• Oral medications
• Injection therapies
• Surgery/other
Sources of Low Back Pain
 Discs
 Bone/joint
 Muscles/ligaments
 Nerve roots
 Inflammatory
History
 Evidence of systemic disease
 Evidence of neurologic compromise
 Social or psychological issues
 Risk factors
 Mechanism of injury
 Red flags (neoplasms, cauda equina, etc)
Causes of Low Back Pain
 Hereditary disorders
 Degenerative disorders
 Traumatic injuries
 Soft tissue/muscle injuries
 Insidious onset
 Other
Common Disorders of the Spine
 Herniated disc
 Degenerative disc
 Facet arthropathy
 Sacroiliac joint dysfunction
 Lumbar strain
 Fibromyalgia
 Arthritis
Common Symptoms Associated With Back Pain
 Low back discomfort
 Sciatica/leg pain
 Muscle spasms
 Hip, buttock, or groin pain
 Numbness or tingling into the extremity
 Motor weakness
 Other “unusual” symptoms
Herniated Disc
 Bulging/protruding
 Herniated
 Ruptured
 Extruded fragment
Herniated Disc (cont’d)
Herniated Disc (cont’d)
Herniated Disc Symptoms
 Symptoms commonly involve back pain
 Radiation into the extremities
 Associated with muscle spasm
 Treatment is non-surgical
Degenerative Disc
 Hereditary
 Traumatic
 Progressive
 Exacerbated by obesity,
inactivity
 Thinning of disc material
with nerve root compression
Symptoms of Degenerative Disc Disease
 Symptoms are centrally located
 May involve buttock or proximal leg pain
 Associated with facet syndrome
 Non-surgical
Fractures
Sacroiliac Joint Dysfunction
 Localized pain in the SI joint
 Common in women and with trauma
 Conservative treatment
Lumbar Strain
 Muscular pain and weakness
 Local lumbar pain with lateral radiation
 Over utilized diagnosis and misdiagnosed
 Difficult to treat—know anatomy
Musculoskeletal Pain
Soft Tissue Injuries
 Sprains and strains
–strain = stretching injury to muscle
• trapezius, rhomboids
–sprain = injury to ligament
• capsular injury connecting lumbar facet joint and vertebrae
 Piriformis syndrome
 Myofascial pain
Nerve Injuries
 Sciatic nerve injury
 Peripheral nerve injuries
 Nerve root injuries
 Distal nerve injuries
Fibromyalgia
 Chronic pain syndrome
 Non-specific complaints
 Non-specific objective findings
 Usually overlying back pain
Arthritis
 Osteoarthritis
 Rheumatoid arthritis
 Seronegative spondyloarthropathies
 Autoimmune diseases
Other Disorders Associated With Back Pain
 Hip
 Piriformis
 Hamstring
 Pelvic or abdominal mass
 Gynecological (adhesions, fibroids, endometriosis)
Other Spine Entities
 Meningioma
 Destructive/lytic lesions
Physical Examination
 Observation & palpation/tenderness
 Range of motion
 Straight leg raise
 Neurological exam
 Evaluation for malignancy
 Non-organic or Waddell’s signs
 Psychological assessment
Diagnostic Studies
 X-rays
 MRI
 CT
 EMG/NCS
 Discography
X-Rays
MRI
CT
EMG/NCS
Discogram
Treatment
 Medications
 Therapies
 Alternative medicine
 Injections
Medications
 Anti-inflammatory medications
 Muscle relaxants
 Analgesics
 Neuropathic medications
 Topical medications
Therapy
 Physical therapy
 Massage therapy
 Chiropractic therapy
Injections
 Trigger point injections
 Botulinum toxin type A injections
 Epidural steroid injections
 Joint injections
 Facet injections
Trigger Point Injections
Botulinum Toxin Type A Injections
Epidural Steroid Injections
 Acute radiculopathies
 Disc bulges
 Disc herniations
 Deg disc disease
 Spinal stenosis
Intra-articular Injections
Facet Injections
Radiofrequency Lesioning
Percutaneous Disc Decompression
IntraDiscal ElectroThermal Therapy (IDET)
Spinal Cord Stimulation
 Trial SCS for 1 to 2 weeks
 If > 50 % pain relief may benefit
from permanent implant
 Dual electrodes available for
bilateral extremity coverage or
complex pain patterns
Surgical Treatment
 Discectomy
 Fusion
 Disc decompression
 Fracture stabilization
Summary
 Back pain is 2nd most common reason for MD visit
 Focused history and examination
 Variety of causes for low back pain
 Physician must identify and treat the cause
 Conservative treatment
 Surgery is the last option
References
 Schwarzer, A.C., Aprill, C.N., Derby, R., Fortin, J., Kine, G., and Bogduk, N. Clinical features of patients with
pain stemming from the lumbar zygapophyseal joints(Is the lumbar facet syndrome a clinical
entity?). Spine. 1994; 19: 1132–1137
 Saal, J.S. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical
appraisal of current diagnostic techniques. Spine. 2002; 27: 2538–2545
 Schwarzer, A.C., Aprill, C.N., and Bogduk, N. The sacroiliac joint in chronic low back
pain. Spine. 1995; 20: 31–37
 Slipman, C.W., Lipetz, J.S., Plastaras, C.T. et al. Fluoroscopically guided therapeutic sacroiliac joint
injections for sacroiliac joint syndrome. Am J Phys Med Rehabil. 2001; 80: 425–432
 Slipman, C.W. and Chow, D.W. Therapeutic spinal corticosteroid injections for the management of
radiculopathies. Phys Med Rehabil Clin N Am. 2002; 13: 697–711
 Schwarzer, A.C., Wang, S.C., Bogduk, N., McNaught, P.J., and Laurent, R. Prevalence and clinical features
of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann
Rheum Dis. 1995; 54: 100–106
 Braddom's Physical Medicine and Rehabilitation