Download Low Back Pain

Low Back Pain
What is low back pain?
Pain in the low back
Epidemiology
 80% of the population will have at
least one episode of LBP in their
lifetime
 Annually $20 million in direct cost
and $50 million when indirect cost is
added
 3% of workers’ comp case but
account 30% of the cost and receive
75% of the payment
Common causes of LBP?
 Nonspecific – ligamentous or articular
structures, strain, myofascial disorders,
psychosocial factors
 Arthritis
 Spondylolisthesis
 Disc herniation - >95% L4-5, L5-S1
 Spinal stenosis
 Fracture
 Tumor
History?
 Characterize the pain
 Diffuse, tight, gradual onset, worse after sitting or
with cold, relieved with warmth, associated stiffness
– myofascial disorder
 Brief, shooting, worse with coughing, standing or
sitting, relieved when lying down, radiating down the
leg – nerve root, sciatica
 Persistent, burning, tingling, worse when lying down
at night – peripheral nerve or lumbosacral plexus
 Radiating to buttock, thighs, legs, worse with back
extension, relieved with sitting – spinal stenosis
 Associated with horse saddle – cauda equina
syndrome
History – rule out “red flags”
symptoms?
Trauma
Fever
Weight loss
Neurologic deficits – numbness,
bowel/bladder incontinence
 History of IVDA, cancer, steroid use
 Last longer than one month
 Associated with abdominal pain
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Physical exam?
 Gait
 Muscle weakness – atrophy, pelvic tilt
 Knee flexion – guard against root
traction
 ROM
 Palpation – tenderness, step off
Physical exam
 Motor strength
 Heel – L5
 Tiptoe – S1
 Sensation – dermatomes
 L4 – big toe
 L5 – middorsum of foot
 S1 – lateral foot
Physical exam
 Reflex
 Knee – L3, L4
 Ankle – S1
 Straight leg raise
 Crossed straight leg raise - >
specificity than straight leg raise
 Rectal exam
Inconsistent examinations
 Axial loading
 Whole body rotation at the hip
 Straight leg raise in sitting position
Tests for patients without “red
flags” symptoms?
 None
 90% resolve spontaneously in 4
weeks
Tests with “red flags” symptoms?
 CBC and ESR
 X-ray
 CT scan – fracture, fact joint
Tests with “red flags” symptoms?
 MRI
 Infection, cancer, disc herniation
 Age >50, asymptomatic, disc bulging 7580% and 30% disc protrusion
 Bone scan – cancer
 EMG
 Nerve root involvement after multiple
back surgeries
 Fastitious weakness
Treatments – acute LBP?
 Activity versus bed rest
 Without radiculopathy, activity as
tolerated
 With radiculopathy, may consider bed
rest < 3 days
Treatments – acute LBP?
 Medications
 Acute – around the clock rather than prn
 Analgesics: acetaminophen, NSAID, cox2 inhibitor, narcotics
 Muscle relaxants – short term
 Subacute/chronic: TCA, SSRI, phenytoin,
tramadol, gabapentin
Treatments – acute LBP
 Soft tissue injection – controversial
 Back exercise
 Limited benefit
 Not during acute attack
Treatments – acute LBP
 Disc herniation
 Multiple conservative modalities - >90%
resolved
 Discectomy
 Sciatica
 Conservative treatment initially for 1-3
months - 80% resolved spontaneously
 73% recurred at least once
Treatment – chronic LBP?
 Back exercise
 Antidepressants – mixed result,
confounding depression
 Steroid injection in
 Epidural space – may help in some patients,
conflicting reports
 Facets – limited data, one small study showed
relief at 6 months but not month 1-3
 Spinal stenosis – laminectomy
 Minimally invasive procedures
 Spinal fusion – multiple laminectomy,
unstable
Treatment – chronic LBP
 Lumbar disc replacement
 Behavior therapy
 Spinal manipulation – mildly effective
in some patients but no better than
other routine modalities
 TENS – no benefits