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M. Andrew Greganti, MD Back Pain Accounts for 2.5% of medical visits – second most common reason for office visits in US Prevalence varies widely – 1.2 to 43% Risk factors: Obesity Smoking Female gender Physically strenuous or sedentary work – lifting over 25 lbs Low educational level Job dissatisfaction Somatization disorder, anxiety, depression Workers’ Compensation Insurance Genetic background Cultural differences Prognosis Generally good, especially if expectation is to improve – most do get better with no intervention Less than 5% have serious underlying pathology A cause can be found only in a minority of patients Chronicity seems to correlate with: Female gender Increasing age Pre-existing psychosocial factors Clinical Evaluation Key concepts: Most patients have mechanical low back pain – no infectious, inflammatory, or neoplastic cause. Degenerative disc disease plays a substantial role but exactly how much of one is unclear. Many patients without pain have discs on MRI. Muscular and ligamentous sources of pain are probably equally important. Tender fibro-fatty nodules (back mice) may play some role but correlation with back pain remains in question. History Consider 3 major concerns: Evidence for a systemic process – hx of cancer, age over 50, weight loss, nocturnal pain, unresponsiveness to Rx Evidence for neurologic compromise – cauda equina syndrome, radiation of pain below the knee, pseudoclaudication as in spinal stenosis, focal weakness Social or psychological distress contributing to chronic, disabling pain Physical Examination Check for spinal curvature – kyphosis, scoliosis, etc. Check for spinal tenderness Straight leg raising and crossed straight leg raising Evaluate for deficits in L4, L5, and S1 distributions. Lymph node, breast, and prostate exams if neoplasia is suspect Check peripheral pulses Diagnostic Imaging Imaging is essential in these situations: Progression of neurological findings History of trauma History of neoplasia Age <18 or >50 Special situations: Injection drug use Immunosuppression Indwelling Foley catheter or recent GU procedure Concomitant steroid use Plain Films, MRI, CT If symptoms persist for 4 to 6 wks with no improvement, order two views of plain films without obliques Implications of spondylosis, spondylolisthesis, spondylolysis Order MRI or CT to evaluate progressive neurologic deficits, to evaluate for cancer, or to evaluate patients with refractory symptoms – greater than 12 wks of persistent pain Treatment of Back Pain Bed rest is not indicated – may actually delay recovery NSAIDS and narcotics have similar efficacy – use of NSAIDS should be limited to 2 to 4 wks Adverse effects more common in older patients Acetaminophen is probably as good as NSAIDS. Muscle relaxers are more effective than placebo for short-term relief NSAIDS + muscle relaxants may be better - based on observational data. Treatment of Back Pain Opioids are effective in acute back pain but obviously have multiple side effects and are addicting Tramadol is a non-opioid and works on the opioid receptor – is worth a trial. Oral glucocorticoids probably are not beneficial for acute pain. Lidocaine patches, anticonvulsants, antidepressants are of limited effectiveness in acute pain. Treatment of Back Pain Epidural injection: Efficacy remains unclear – conflicting results from controlled trials Probably best in radiculopathy secondary to HNP – has short-term (at 6 wks) but no long-term benefit at 3 , 6, or 12 months Not of proven benefit in spinal stenosis and nonspecific pain No difference in translaminar, transforaminal, and caudal approaches 2 of 7 trials found epidural injection vs placebo associated with lower rates of subsequent surgery. Adverse events: dural puncture, bleeding, infection Treatment of Back Pain Local or trigger point injection rarely works Facet joint steroid injection doesn’t help at 1 and 3 months Medial branch of dorsal ramus nerve blocks are of unknown efficacy Sacroiliac joint steroid injection was more effective than anesthetic injection in one small trial Probably does work for spondyloarthropathies Rx effectiveness of piriformis syndrome using injected steroids remains unclear Treatment of Back Pain Chemonucleolysis for HNP should only be used in patients who do not want surgery – not often done in US Paravertebral botulinum toxin injection was superior to placebo at 3 and 8 weeks Evidence for the efficacy of radiofrequency nerve ablation remains inconsistent – would only consider in the most refractory situations Prolotherapy should not be used Treatment of Back Pain Exercise is not good for acute pain in contrast to more chronic pain. Encourage mobilization as soon as possible. Physical therapy is, in general, very helpful but no difference in heat/cold, ultrasound, electrical stimulation TENS effectiveness is very questionable at best. Spine manipulation by chiropractors may be helpful. Accupuncture is probably equivalent to NSAIDS. Traction does not help lumbar pain. Hip Pain Basic issues: The major dilemma is to differentiate among gluteus medius superficial and deep bursitis and osteoarthritis The hip is “fixed” by the pelvic girdle, making it more difficult to differentiate pain originating in the lumbar spine and knee from hip pain. The gluteus medius and gluteus minimus muscles abduct the hip and attach at the greater trochanter. The gluteus maximus extends the hip and attaches just distal to the greater trochanter The iliopsoas muscle, the major hip flexor, attaches at the lesser trochanter. Clinical Presentation of Hip Pain Hip pain with weight bearing and improvement with rest is most compatible with DJD. Constant pain and pain while supine are more likely with infectious, inflammatory, and neoplastic processes. Lateral hip pain is often from the joint or from the greater trochanteric bursa, especially if there is point tenderness. Hip joint pain is more often anterior Lateral paresthesias raise the possibility of meralgia paresthetica. Clinical Presentation of Hip Pain Anterior hip or groin pain is most often seen in DJD of the hip joint. Important to differentiate DJD from osteonecrosis If not worse with repetitive hip flexion, have to consider inguinal hernia and intraabdominal process. Anterior thigh pain just above the knee presents the most difficulty Posterior hip pain is not usually from the hip. More commonly is secondary to lumbar disc, sacroiliac disease, facet joint disease. Clinical Presentation of Hip Pain Trochanteric bursitis is caused by exaggerrated movement of the gluteus medius tendon and tensor fascia lata over the lateral femur. More likely to develop with leg length discrepancy, knee arthritis, ankle sprain, LS spine stiffness Point tenderness over trochanteric bursa Hip DJD presents with groin pain worse with movement, limited internal rotation (<15 º), limited flexion (<115 º) Osteonecrosis presents in the groin, thigh, or buttock Rest pain is common as is nocturnal pain Hip Examination Observe patient’s gait - ? antalgic, short leg limp, Trendelenburg gait Passive internal and external rotation - ? endpoint stiffness – endpoint pain raises osteonecrosis, occult fracture, acute synovitis, metastatic disease Fabere or Patrick test Straight leg raising to evaluate lumbar origin Check sensation lateral thigh - ? meralgia Evaluate L4, L5, and S1 nerve root distribution Check for tenderness over the sacroiliac joint Check leg pulses Evaluation of Hip Pain AP of pelvis and hip films MRI if occult hip or pelvic fracture is suspected – also to evaluate early osteonecrosis Local anesthetic blocks of sacroiliac joint, trochanteric area below gluteus medius tendon, lateral femoral cutaneous nerve Treatment of Hip Pain Very similar to Rx of back pain Acetaminaphen, tramadol, NSAIDS Physical therapy Joint replacement
