Download Back Pain - York VTS

Back Pain
Neck and Back Pain Study Day
January 2013
Anatomy of the Lumbar Spine
Anatomy of the Lumbar Spine
Anatomy: Ligaments
Anatomy: Spinal Musculature
Assessment:
Diagnostic Triage
• Simple backache (95% of cases)
• Nerve root pain (<5% of cases)
• Red flag serious spinal pathology (<1% of
cases)
(Clinical Standards Advisory Group,1994)
Subjective Assessment
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Site, nature and type of pain +/- altered sensation
Aggravating and easing factors
Diurnal pattern
Special questions / red flags
History of present episode and previous episodes
PMH
DH
SH
– Yellow flags
Hierarchical List of Red Flags
(Greenhalgh and Selfe, 2010)
• 4 red flags
– Age >50 years + history of cancer + unexplained weight
loss + failure to improve after 1 month of evidence-based
conservative therapy.
• 3 red flags
– Age <10 and >51 years
– Medical h/o (current or past) of: Ca, TB, HIV/AIDS or IVDU,
Osteoporosis
– Weight loss >10% body weight (3-6 months)
– Severe night pain affecting sleep
– Loss of sphincter tone and altered S4 sensation
– Bladder retention or bowel incontinence
– Positive extensor plantar response
Hierarchical List or Red Flags
• 2 red flags
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Age 11-19
Weight loss 5-10% body weight (3-6 months)
Constant progressive pain
Abdominal pain and changed bowel habits, but with
no change in medication
Inability to lie supine
Bizarre neurological deficit
Spasm
Disturbed gait
Hierarchical List of Red Flags
• 1 red flag
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Loss of mobility,difficulty with stairs,falls,trips
Legs misbehave, odd feelings in legs, legs feeling heavy
Weight loss <5% body weight (3-6 months)
Smoking
Systemically unwell
Trauma
Bilateral pins and needles in hands and/or feet
Previous failed treatment
Thoracic pain
Headache
Physical appearance
Marked partial articular restriction of movement
Group Exercise
• In your groups you will be given a spinal
condition. Discuss:
– How you would expect a patient with the
condition to present:
• Subjectively
• Objectively
– Would any investigations be required
– How would you manage a patient with this
condition
• Present findings back for wider discussion
Acute LBP
• At least 80% of individuals will experience a significant
episode of LBP in their lifetime
• LBP for up to 6 weeks
• Variable type and severity and can fluctuate
• Can radiate into buttocks and upper legs
• Sudden or gradual onset
• Insidious or jarring/strenuous incident
• Difficult to identify exact cause
Management
• Reassure: usually benign and self-limiting
• Pain relief
• Advise to keep as active as tolerated
• Physiotherapy
Chronic LBP
• LBP present greater than 3 months
• Variable type, nature and severity of pain
• Source of pain not known and original injury/source
may be completely healed
• Exact mechanism not fully understood but thought to
be due to sensitisation of nerve pathways
Management
• ? Investigations /referral to MSK CATS service
• Reassure / empathise
• Physiotherapy
• Medications
• Pain Clinic
Degenerative Disc Disease
Sciatica / Radiculopathy
• Commonly due to a prolapsed disc impinging a nerve root
or due to degenerative changes
• Pain usually unilateral spreading through the buttock and
down the back of the leg into the calf or foot
• Often associated with paraesthesia and occasionally with
weakness
• Severe, shooting in nature aggravated by cough/sneeze
Management
• Pain medication
• Reassurance as usually resolves in 2-3 months
• Cauda Equina symptoms: emergency admission
• Progressive worsening neuro: refer neurosurgeon
• Physiotherapy
• ? MRI
• Nerve root block
• Surgical miscrodiscectomy
Disc Prolapse
Cauda Equina Syndrome
• Acutely due to large central disc prolapse or more gradually
due to degenerative central changes causing compression
of the cauda equina or due to sinister causes
• Bilateral radiating leg pain
• Saddle Anaesthsia
• Progressive motor weakness affecting more than one nerve
root +/- gait disturbance
• Urinary retention, altered micturation, overflow
incontinence or reduced bladder or urethral sensation
• Bowel disturbance and loss of anal tone / sensation
• Sexual dysfunction
Management
• Emergency admission to A&E for further investigations
Spinal Stenosis / Claudication
• Radiating leg pain, paraesthesia aggravated by walking and
standing and distance - limiting
• Pain progression usually from buttocks to periphery
• Relief gained by sitting and bending forwards
• Neurological symptoms (paraesthesia, numbness and/or
muscular weakness) also resolve with rest
• Peripheral pulses normal
Management
• Medication
• Physiotherapy
• ? MRI
• Referral to neurosurgeon if symptoms severe for possible
decompression +/- fusion
Osteoporotic Wedge fractures
• Sudden LBP in patients at risk or with
osteoporosis
• May be associated with radicular pain
• May be no history of injury
Management
• X-ray, bone density scan
• If symptoms severe and failing to improve
consider referral for vertebroplasty with MRI (to
check whether #’s have healed)
• Physiotherapy
Objective Assessment: Practical
• Observations: deformity, gait, balance
• Movement: quality, range, limiting factors
• Neurological assessment: relexes, SLR, PKB,
myotomes, dematomes, plantar reflexes
• Hips
• SIJ’s
• Palpation and percussion
Sensory, motor and reflex distributions
Nerve
root/nerve
Dermatome
Myotome
Reflex
L1
Back, over greater trochanter and groin
Hip flexion
none
L2
Back, anterior superior thigh and medial thigh
above knee
Hip flexion
(patellar tendon)
L3
Back, upper gluteal, anterior thigh, medial
knee and lower leg
Knee extension (quads)
Patellar tendon
L4
Medial gluts, lateral thigh and knee, ant
medial lower leg, dorsomedial aspect of foot
and great toe
Ankle dorsiflexion and inversion
(tibialis anterior)
Patellar tendon
L5
Lateral knee and upper lateral lower leg,
dorsum of foot
Great toe extension (extensor
hallucis)
Medial hamstring
tendon
S1
Buttock, posterolateral thigh, lateral side and
plantar surface of the foot
Ankle plantarflexion (gastroc,
soleus) and ankle eversion, hip
extension, knee flexion
Achilles tendon
S2
Buttock, posteromedial thigh, post medial
heel
Knee flexion, great toe flexion
Lateral hamstring
tendon
General Exercises
• Practical exercise to go through general
exercise advise for patients with acute and
chronic LBP
• Discussion on role of Physiotherapy
• Core stability
• Pilates and Yoga
• Referral Guidelines to Neurosurgery for Patients with Simple Lumbar or
Cervical Discogenic/Degenerative Spinal Disease
• Who Should be Referred?
• Acute severe radicular arm or leg pain, not showing any improvement with
conservative measures (such as physiotherapy) by six weeks following onset.
Note that some improvement is likely to imply eventual resolution without
requirement for surgery. Pain will be in a nerve root distribution. Neurological
symptoms (paraesthesia, numbness and/or muscular weakness) will be in a
nerve root distribution and normally exacerbated by cough and/or movement.
Progressive neurological symptoms and/or severe radicular pain are
indications for urgent referral.
• Refractive longer term radicular pain (i.e. greater than three months)
significantly interfering with lifestyle, disturbing sleep, or causing extended
periods off work.
• Significant spinal claudication, (i.e., radiating leg pain/paraesthesia/numbness
coming on with walking and distance-limiting). Pain progression is normally
from buttocks to the periphery. Relief is gained by rest and bending forwards.
Neurological symptoms (paraesthesia, numbness and/or muscular weakness)
also resolve with rest. Peripheral pulses are normal.
• Patients with signs of myelopathy. All patients should be referred, whether
asymptomatic or not, with positive long tract signs or when an MRI has been
done and where, even in the absence of long tract signs, there is cord signal
change at a stenotic spinal level. Symptoms include numb, clumsy hands,
jumping, stiff legs, falls, poor balance and urinary frequency.
• Who Shouldn’t be Referred?
• Patients with referred pain. For the purposes of differential
diagnosis, referred arm, leg or neck pain is more
generalised in distribution and does not follow a specific
nerve root distribution. Pain does not generally spread
below the elbow or knee.
• Patients with degenerative neck or back pain generally have
no surgically remedial cause and so should not be referred.
Patients should be managed with analgesia, advice and
physiotherapy.
• Patients with non-specific neurological
symptoms/somatisation disorder. Such patients should be
referred to a neurologist or to the pain clinic.
• Where radicular pain is significantly improving or resolved.
• Where there is residual dermatomal numbness following a
previous radicular pain episode.
• Where the patient does not want any surgery (other than
patients who are considered to be myelopathic).
Any Questions?
Thank you