Low Back Pain

1. Low Back Pain • BCM Med-Peds Continuity Clinic

2. Background • Low back pain is an extremely common complaint in adults - 5th leading reason for medical office visits in the U.S. • Back pain lasting at least 2 weeks affects approximately 14 percent of adults each year, about 1 to 2 percent have sciatica • There is no strong association with sex, height, body weight, or physical fitness.

3. Causes of Low Back Pain • Nonspecific back symptoms • Sciatica - can be due to a herniated disc, spinal stenosis, spondylolisthesis, ligamentous hypertrophy • Tumor • Infection (osteomyelitis, discitis, Pott’s Disease) • Spinal fracture • Ankylosing Spondylitis

4. Evaluation - History • History and physical should focus on identifying ‘red flags’ for signs of serious underlying disease. • pain that is constant at night, incompletely relieved by lying down, associated with bowel//bladder/sexual function deficits, leg weakness, unexpected weight loss

5. History cont. • Identify psychosocial factors - psychological distress, job dissatisfaction, other types of chronic pain, disputed compensation issues • Smoker?

6. Physical Exam • Inspection of movement and gait • Palpation • Neuromuscular - strength, sensory, reflexes • Straight leg raising - should be performed with patient in supine and sitting positions; in sciatica, pain worsened by dorsiflexion of ankle, relieved by flexion of the knee and hip • Crossed straight leg raising - highly specific, low sensitivity

7. Diagnostic/Imaging • In setting of acute low back pain - plain radiographs should not be routinely ordered. Cost-effectiveness analysis concluded little benefit. • Plain films do not reveal herniated discs or spinal stenosis. • Plain film should be obtained if patient has red flags suggestive of infection, cancer, or fracture. If negative, then consider bone scan.

8. Diagnostic/Imaging • MRI findings that been associated with back pain have also been seen in asymptomatic individuals. • Indications for MRI: • to rule out neurologic injury, infection or tumors • persistent pain in absence of neurologic signs or symptoms after 4 to 8 weeks

9. Treatment • Pharmacologic • Nonpharmacologic • Injections • Surgery

10. Pharmacologic • Antiinflammatory medications - ‘evidence for their efficacy is not compelling,’ may be given a trial, not for chronic use. • Muscle relaxants - marginal reduction in pain intensity compared to placebo • Antidepressants - specifically TCAs (not SSRI), 20 to 40% greater reduction in pain than with placebo • These therapies are limited by their side effect profile.

11. Nonpharmacologic • Massage • Exercise - strengthening, stretching, passive end-range motion treatments • Manipulation • Studies have not shown a clear advantage of any particular method over another. • Most have shown to have some mild to moderate benefit.

12. Other options • Injections - randomized trials have shown no benefit in patients with low back pain without radiculopathy • Surgery - controversial, in general reserve for those with severe degenerative issues.

13. Case 1 • 62 yo male complains of low back pain for several months. Walking and prolonged standing causes fatigue and weakness in the legs. He experiences the pain in his lower back, buttocks and hamstrings. His pain is relieved after sitting. His physical exam is unremarkable. • What is his diagnosis? and what is the therapy?

14. Case 1 - Answer • Lumbar spinal stenosis • narrowing of one or more levels of spinal canal and subsequent compression of nerve roots • can be due to enlargement of facet joints, stiffening of ligaments, bony overgrowth

15. Lumbar Spinal Stenosis • Therapy: • NSAIDS, steroids, injections • exercise and physical therapy that focuses on flexing the spine - this increases intraspinal volume, relieves neural compression • Surgical options: decompression - posterior lumbar laminectomy, foraminotomy

16. Case 2 • 50 yo woman presents complaining of chronic low back pain for several weeks. The pain radiates posteriorly below the knees bilaterally and is worse with standing. On exam, she has a limited straight leg raise, and is very limited in her ability to bend forward.

17. Case 2 cont. • What is the diagnosis? • Spondylolisthesis • What is the therapy? • exercise to strengthen the abdominal, paraspinal muscles, stretching of the hamstrings, may need orthosis, severe cases spinal fusion

18. Case 3 • 16 yo male presents with low back pain for 3-4 weeks. He has been taking OTC analgesics with little relief. He has been trying out for the school football team as an offensive lineman and doing weight training. On his exam, he has paraspinal tenderness, which worsens with hyperextension of the back. • What is the most likely diagnosis?

19. Case 3 • Spondylolysis • need to obtain lumbosacral series with oblique views • will see ‘scotty dog’ with a collar on oblique • can lead to spondylolisthesis if left untreated

20. Conclusion • Back pain is a common reason for medical encounters. • Therapies are of limited value in back pain not associated with radiculopathies. • Primary goal is to maximize function, and reassure the patient that some ongoing or recurrent back pain is likely but not dangerous.