Download Back Pain

Musculoskeletal Pain
Back Pain
Rodrigo Rodrigues, MD
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M/S Pain – Back Pain
• More then 2/3 of adults will have back pain at some
time in their lives
• 5th most common reason for visiting an internist and
causes the most work-related disability in persons
younger than 45yo
• The incidence of LBP is highest in the 3rd decade,
and overall prevalence increases with age until the
60-65yo
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M/S Pain – Back Pain
• Back pain of <6wks is acute, and >3mo is chronic
• Risk factors:
–
–
–
–
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Smoking, obesity, older age, female gender
Physically strenuous work, sedentary work
Psychologically strenuous work, low educational attainment
Workers' Compensation insurance, job dissatisfaction
Somatization disorder, anxiety, and depression
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M/S Pain – Back Pain
• Sciatica:
– It’s a symptom, not a diagnosis
– Caused by herniated disk, spinal stenosis, degenerative
disc disease, spondylolisthesis, or other abnormalities
of vertebrae can all cause pressure on the sciatic nerve.
– Piriformis Sd. usually develops after an injury
– Pain or numbness due to sciatica can vary widely and
can be severe enough to cause immobility
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M/S Pain – Back Pain
• Sciatica:
– Pain may get worse at night, after standing or sitting for
long periods of time, when sneezing, coughing, or laughing;
or after bending backwards or walking >50 - 100 yards
– Sciatica pain usually goes away within 6 weeks, unless there
are serious underlying conditions
– Pain that gets worse with sitting, coughing, sneezing, or
straining may indicated a longer recovery
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M/S Pain – Back Pain
• Herniated disk:
–
–
–
–
Common cause of severe back pain and sciatica
Bulge, protrusion or extrusion of the vertebral disk
Pain in the leg may be worse than the back pain
Many people have disks that bulge or protrude and do
not suffer back pain
– Extrusion (which is less common than the other two
conditions) is highly associated with back pain
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M/S Pain – Back Pain
• Herniated disk:
– Abnormalities in the annular ring may be associated with
chronic low back pain
– Cauda equina Sd. is the impingement of the cauda equina.
It’s a surgical emergency. Symptoms include: dull back pain,
weakness or numbness in the buttocks, legs, or feet; may
cause stumbling or difficulty in standing; bowel/bladder
incontinence; and pain accompanied by fever (can indicate
an infection)
– It can cause permanent incontinence if not promptly
treated with surgery.
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M/S Pain – Back Pain
• Spondylosis:
– Osteoarthritis of the joints of the spine, usually as a
result of aging, previous back injuries, excessive wear
and tear, previously herniated discs, prior surgeries,
and fractures
– Results in gradual loss of mobility of the spine,
narrowing and degeneration of the spinal discs
– Symptoms may be similar to that of a herniated disc,
lumbar strain, or spinal stenosis
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M/S Pain – Back Pain
• Spinal stenosis:
– Narrowing of the spinal canal and neural foramina
resulting in insidious back pain
– Usually associated with aging, arthritis (DDD), infection
and birth defects
– Pain or numbness, can occur in both legs, or on just
one side, weakness or heaviness in the buttocks or legs
– Symptoms are worse when standing or walking upright
and improve when sitting down or leaning forward.
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M/S Pain – Back Pain
• Spondylolisthesis:
– Anterior displacement of a vertebra on the one
beneath it. Usually between L4-L5. More common in
>65yo and women
– The most common cause is DDD
– Other causes include stress/traumatic fractures and
bone disease
– It can produce increased lordosis
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M/S Pain – Back Pain
• Spondylolisthesis:
– Symptoms may include: Lower back pain, pain in
the thighs and buttocks, stiffness, muscle tightness
and/or weakness of the legs
– Pain generally occurs with activity and is better
with rest
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M/S Pain – Back Pain
• Inflammatory disorders:
– Ankylosing spondylitis: chronic inflammation of the spine
that may gradually result in a fusion of vertebrae. Insidious
symptoms of back discomfort lasting >3mo. The back is
usually stiff in the morning and pain improves with
movement or exercise. It’s more common in Caucasian
males in their mid-20s.
– About 20% of people with inflammatory bowel disease and
about 20% of people with psoriasis develop a similar form
of arthritis involving the spine
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M/S Pain – Back Pain
• Osteoporosis:
– The bones become fragile and prone to fractures. It
usually does not cause pain unless the vertebrae
collapse suddenly, in which case the pain is often
severe. More than one vertebra may be affected.
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M/S Pain – Back Pain
• Compression fractures:
– The bone tissue of the vertebra collapses
– Often responsible for loss of height
– Symptoms depend upon the area of the back that
is affected; however, most fractures are stable and
do not produce neurological symptoms.
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M/S Pain – Back Pain
• More than 95% of lumbar disk herniations occur at L5
or S1 n. roots
• A seated or supine straight leg raising test is 80%
sensitive but only 40% specific, differently from
crossed-straight-leg raising and ankle plantar flexion
weakness (more specific).
• Wide-based gait and abnormal Romberg are highly
specific for spinal stenosis.
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M/S Pain – Back Pain
• Diagnosis
Recommendation 1:
– “Clinicians should conduct a focused history and physical
examination to help place patients with low back pain into 1
of 3 broad categories: nonspecific low back pain, back pain
potentially associated with radiculopathy or spinal stenosis,
or back pain potentially associated with another specific
spinal cause. The history should include assessment of
psychosocial risk factors, which predict risk for chronic
disabling back pain.”
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
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M/S Pain – Back Pain
• Diagnosis:
– Description of the pain (P3QR2ST2)
– Red flags (history of trauma or cancer, unintentional wt loss,
immunosuppression, use of steroids or IV drugs,
osteoporosis, age >50 years, focal neurologic deficit, and
progression of symptoms, psychosocial factors)
– Physical exam (Inspection, palpation, ROM, straight leg
raising test, neurologic test)
– Imaging
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M/S Pain – Back Pain
• Imaging
Recommendation 2:
– “Clinicians should not routinely obtain imaging or other
diagnostic tests in patients with nonspecific low back pain”
– Majority of patients with back pain alone improve rapidly
– Gonadal radiation from a two view radiograph of the
lumbar spine is equivalent to radiation exposure from a
chest x-ray taken daily for more than one year
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
Copyleft by CM Gibson
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M/S Pain – Back Pain
• Imaging
Recommendation 3:
– “Clinicians should perform diagnostic imaging and
testing for patients with low back pain when severe
or progressive neurologic deficits are present or
when serious underlying conditions are suspected
on the basis of history and physical examination”
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
Copyleft by CM Gibson
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M/S Pain – Back Pain
• Indications for early imaging in patients w/ back pain:
Clinical finding
Rationale
Major trauma
Possible fracture
Corticosteroid use
Increased risk of osteoporotic fracture
Age >50yo
Increased risk of osteoporotic
fracture/malignancy
Hx of Cancer
Increased risk of malignancy
Unexplained wt loss
Increased risk of malignancy/infection
Fever, immunossupression, IVDU, infection
Risk of spinal infection
Saddle anesthesia, bowel/bladder
incontinence
Possible cauda equina Sd.
Severe or progressive neurologic deficit
Possible cauda equina Sd. or severe n. root
compression
M/S Pain – Back Pain
• Imaging
Recommendation 4:
– “Clinicians should evaluate patients with persistent
low back pain and signs or symptoms of
radiculopathy or spinal stenosis with magnetic
resonance imaging (preferred) or computed
tomography only if they are potential candidates
for surgery or epidural steroid injection (for
suspected radiculopathy)”
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
Copyleft by CM Gibson
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M/S Pain – Back Pain
• Imaging:
– Plain radiographs — If clinical improvement has not
occurred after 4 - 6wks
– CT and MRI scanning — More sensitive than plain
radiographs for detecting infection and cancer, and can
show herniated discs and spinal stenosis
– MRI or CT findings may be incidental and unrelated to the
etiology of low back pain
– MRI is preferred over CT scan for better visualization of soft
tissue and absence of radiation exposure
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
Copyleft by CM Gibson
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M/S Pain – Back Pain
• Treatment:
– Therapy should focus on temporary symptomatic
relief, to maximize patient comfort
Recommendation 5:
– “Clinicians should provide patients with evidencebased information on low back pain with regard to
their expected course, advise patients to remain active,
and provide information about effective self-care
options”
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
Copyleft by CM Gibson
www.wikidoc.org
M/S Pain – Back Pain
• Treatment
Recommendation 6:
– “For patients with low back pain, clinicians should
consider the use of medications with proven benefits in
conjunction with back care information and self-care.
Clinicians should assess severity of baseline pain and
functional deficits, potential benefits, risks, and relative
lack of long-term efficacy and safety data before
initiating therapy. For most patients, first-line
medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.”
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
Copyleft by CM Gibson
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M/S Pain – Back Pain
• Treatment
Recommendation 7:
– “For patients who do not improve with self-care
options, clinicians should consider the addition of
nonpharmacologic therapy with proven benefits—for
acute low back pain, spinal manipulation; for chronic or
subacute low back pain, intensive interdisciplinary
rehabilitation, exercise therapy, acupuncture, massage
therapy, spinal manipulation, yoga, cognitivebehavioral therapy, or progressive relaxation.”
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
Copyleft by CM Gibson
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M/S Pain – Back Pain
• Treatment:
LBP
Self-care
Acute Subacute or chronic
Advice to remain active
X
X
Books, handouts
X
X
Application of superficial heat
X
Recommendation 5
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
Copyleft by CM Gibson
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M/S Pain – Back Pain
• Treatment:
LBP
Pharmacologic
therapy
Acute Subacute or chronic
Acetaminophen
X
X
NSAIDs
X
X
Muscle relaxants
X
Antidepressants (TCAs)
X
Benzodiazepines
X
X
Opioids
X
X
Recommendations 6 and 7
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
Copyleft by CM Gibson
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M/S Pain – Back Pain
• Treatment:
LBP
Nonpharmacologic
therapy
Spinal manipulation
Acute Subacute or chronic
X
X
Exercise therapy
X
Massage
X
Acupuncture
X
Yoga
X
Cognitive behav. therapy
X
Progressive relaxation
X
Intensive interdisciplinary
Rehabilitation
X
Recommendations 6 and 7
American College of Physicians/American Pain Society Low Back Pain Guidelines Panel
Copyleft by CM Gibson
www.wikidoc.org
M/S Pain – Back Pain
• Indications for referral:
– The cauda equina syndrome (surgical emergency)
– Suspected spinal cord compression (requires
emergent evaluation for surgical decompression or
radiation therapy)
– Progressive or severe neurologic deficit
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M/S Pain – Back Pain
• Indications for referral:
– Patients may also be referred to a neurologist or
physiatrist if the neuromotor deficit persists after
four to six weeks of conservative therapy; OR
persistent sciatica, sensory deficit, or reflex loss
after four to six weeks in a patient with positive
straight leg raising sign, consistent clinical findings,
and favorable psychosocial circumstances.
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M/S Pain – Back Pain
• Prognosis:
– The long-term outcome of low back pain is generally
favorable
– Patients who have high expectations for recovery have
better outcomes
– Psychosocial variables are stronger predictors of longterm disability than anatomic findings found on
imaging studies
– Predictors of disabling chronic low back pain include
maladaptive pain coping behaviors, functional
impairment, poor general health status, presence of
psychiatric comorbidities, or nonorganic signs
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Thank you
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