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DIAGNOSTIC CHALLENGES IN EARLY CHRONIC LOW BACK PAIN

DIAGNOSTIC CHALLENGES IN EARLY CHRONIC LOW BACK PAIN. ABDOU EL-LABBAN PROFESSOR OF RHEUMATOLOGY AND REHABILITATION MINIA UNIVERSITY. EGYPT abellabban@yahoo.com. Agenda. LBP background. Examples of common pathological causes of LBP. Key Questions for clinical practice guidelines.

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DIAGNOSTIC CHALLENGES IN EARLY CHRONIC LOW BACK PAIN

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  1. DIAGNOSTIC CHALLENGES IN EARLY CHRONIC LOW BACK PAIN ABDOU EL-LABBAN PROFESSOR OF RHEUMATOLOGY AND REHABILITATION MINIA UNIVERSITY. EGYPT abellabban@yahoo.com

  2. Agenda LBP background. Examples of common pathological causes of LBP. Key Questions for clinical practice guidelines. Summary of evidence for diagnostic specificity and sensitivity in common causes of LBP.

  3. Low Back pain Low back pain (LBP) is a common musculoskeletal complaint, with a reported lifetime incidence of 60-90%. Various structures have been incriminated as possible sources of chronic LBP, including: The posterior longitudinal ligament. Dorsal root ganglia. Dura and neural elements in the vertebral column. Annular fibers of the inter vertebral disc. Muscles of the lumbar spine. Facet joints and bone of the vertebral column.

  4. Back pain Chronic LBP is the pain that last for more than 3 months in the area below the inferior border of the 12th rib and above the gluteal folds. Chronic LBP can be categorized into 2 broad diagnostic groups: Non inflammatory LBP (NILBP). Inflammatory LBP (ILBP). Depending on the extent of spinal inflammation. Croft PR, et al. Spine 1995;20:2731-7.

  5. NILBP: Is the most common diagnosis. Inflammation play only a minor role in it’s pathological process . The symptoms in NILBP are often attributed to: Non measurable physical pathology. Normal level of acute phase responses. No radiologic evidence of inflammatory changes in the spine. Defined by exclusion of inflammatory arthritis. It affects around 25% of individuals in any 1 year. . Harkness EF,et al. Rheumatology 2005.

  6. ILBP Symptoms in ILBP are often attributed to: Measurable physical pathology. Raised acute phase responses. Radiologic evidence of inflammatory changes in the spine. Can be diagnosed after fulfillment of specific diagnostic criteria of inflammatory spinal disease. It affects 0.2% of western populations. Heuft-Dorenbosch L, et al. Ann Rheum Dis 2007.

  7. Low Back pain “Prevalence” It is an extremely common medical problem, although it’s estimates vary widely. In the U.S. NILBP represent : The 5th most common reason for all physician visits. The 2nd most common symptomatic reason, accounting for 2.3% of all physician visits. Deyo RA, et al. Spine, 2006. Studies in developed countries report: Point prevalences of 12% to 33%. One-year prevalences of 22% to 65%. Lifetime prevalences of 11% to 84%. Walker BF. J Spinal Disorders 2000.

  8. Only 5-10 % of back pain can manifest with a serious pathology like: • Vascular catastrophes. • Malignancy. • Spinal cord compression syndrome. • Autoimmune inflammatory disease process. • Infectious disease processes. 1- Fraymoyer et al. Orthop. Clin. North Am. 1991.

  9. The prevalence of different causes of back pain of a serious pathology. • Cancer in approximately 0.7% of cases. • Compression fractures in 4%. • Spinal infection in 0.01%. • Ankylosing spondylitis (AS) in 0.3 - 5%. 5. Spinal stenosis in 3%. 6. Herniated disc in 4%. 7.Cauda equina syndrome in 0.04% and most commonly associated with massive midline disc herniation. Jarvik et al, Ann int medi., 2002, 137 (7),

  10. Facettal joint Facettal joints biomechanically: Play prominent role in resisting inter vertebral (IV) stress. Resist most of the I V shear force Share in resisting the I V compressive force, only in lordotic postures. In the rotation of the spine, the facet capsular ligaments are the spinal ligaments that undergo by far the most strain. They protect the IV disks by preventing excessive movement. Schmidt H, et al.Spine.2008.

  11. Facettal joint arthropathy The prevalence of facettal joint pain among chronic LBP patients is 4 -7.7%. Techniques for diagnosis and treatment of FJ arthritis: Intra- articular joint blocks and medial branch nerve blocks. Intra-articular steroids injection. Surgical ablation. Radiofrequency (RF) denervation. Controversy continues regarding: The true prevalence. Most accurate diagnostic methods, Most efficacious treatment of symptomatic lumbar facet joints. Kuslich SD, et al.Orthop Clin North Am.Apr1991.

  12. Malignancy and Back pain Malignancy is a rare cause of low back pain. A combination of: Age ≥50 years. Previous history of cancer. Unexplained weight loss. Elevated ESR Reduced hematocrit value. Failure to improve after 1 month. Had a reported sensitivity of 100%. NicholasH , et al. European Spine Journal , 2007.

  13. Spinal metastasis: CT study A 43- Y old man with a 2-week history of progressive back pain and an abdominal mass. Sagittal CT scan shows an osteolytic lesion of the L3 vertebral body. The primary tumor was renal. Fracture of the vertebral end plate may cause first symptoms of pain. ESR and CRP are almost always elevated with systemic Neoplasia

  14. Spinal metastasis: MRI study • A 63-year-old woman with history of hepatocellular carcinoma, presented with bilateral leg weakness and back pain. • T2-weighted MRI shows pathologic compression fracture of the L2 vertebral body with retropulsion of fracture fragments into the canal and severe central canal stenosis. ESR and CRP are almost always elevated with systemic Neoplasia

  15. Imaging features of benign vs. malignant compression fractures • BENIGN • Solitary lesion with smooth margins • Superior end plate fracture with abnormal band-like signalparallel to superior end plate. • Normal fatty marrow • No pedicle involvement • Fracture line • No convex cortical contour • No extra osseous soft tissue mass • Intravertebral fluid • Fragmentation • MALIGNANT • Multiple lesions, heterogeneous enhancement in multiple vertebrae • Inferior end plate fracture or abnormal signal only in lower portion of vertebral body. • Absent normal fatty marrow. • Pedicle involvement. • No fracture line • Convex cortical contour • Extra osseous soft tissue mass • No intravertebral fluid • No fragmentation. ADAPTED FROM TAHRANZADEH J, TAO C. ADVANCES IN MR IMAGING OF VERTEBRAL COLLAPSE. SEMIN ULTRASOUND CT MRI 2004; 25:440–460. WITH PERMISSION FROM ELSEVIER

  16. Features of neoplastic and degenerative disk diseases Neoplastic disease • Age > 50 years • Pain is not relieved by rest, recumbency or conservative therapy • Pain worsens at night. • Anemia. • Elevated ESR, CRP level. • History of cancer Degenerative disk disease • Subsides with rest, NSAID, and rehabilitation medicine. • Increases with activity • Laboratory studies are typically normal • Patient may have pain after a history of spine surgery or known injury. ADAPTED FROM INFORMATION PRESENTED IN DEYO RA, DIEHL AK. CANCER AS A CAUSE OF BACK PAIN: FREQUENCY, CLINICAL PRESENTATION, AND DIAGNOSTIC STRATEGIES. J GEN INTERN MED 1988; 3:230–238 AND PATEL RK, SLIPMAN CW. LUMBAR DEGENERATIVE DISK DISEASE. EMEDICINE. WWW.EMEDICINE.COM/PMR/TOPIC67.HTM.

  17. Summary of evidence ‘ Cancer’ Diagnosis of cancer in 1ry care patients with LBP, the presence of any of the following was associated with a high sensitivity (1.00) and moderate specificity (0.60) in one higher-quality study: Age >50 years. History of non-skin cancer. Unexplained weight loss. Failure of standard non-invasive therapy (positive likelihood ratio 2.5, negative likelihood ratio 0.0). Vertebral tenderness or neurologic deficits have poor or inconsistent sensitivity for cancer, but high specificity in some studies (level of evidence: fair).

  18. Infections of the Spine Spinal infections ( osteomyelitis and discitis) can manifest by tenderness and back pain. It may be severe, and usually gets worse with weight-bearing exercise. The most common cause of spinal osteomyelitis is a bacterial urinary tract infection and acute bacterial prostatitis that spreads to the bone. It is occasionally caused by a fungal infection.

  19. Infection and back pain Needle guided biopsy may be needed to differentiate: abscess, hematoma , tumor, and inflammation L2 A 32-year-old woman with SLE who is on chronic steroid therapy and who has a 6-week history of back pain. T2-weighted Sagittal MRI shows a disk space infection at L2–L3, with ventral para spinal soft tissue enhancement consistent with early abscess formation. L3

  20. Summary of evidence “ Infection” For diagnosis of infection in patients with LBP, few studies evaluated the accuracy of history and physical exam: History of intravenous drug use. Skin infection. Urinary tract infection. only had modest sensitivity in one study (level of evidence: poor).

  21. Assessments in Ankylosing Spondylitis (ASAS) Working Group LBP if 2/4 are present LBP if 4/ 5 are present LBP if 4/5 are present 1,Calin A et al, JAMA 1977, 2, Rudwaleit et al. A&R, 2006, 3, Sieper E et al, A&R, 2009.

  22. The Calin criteria 5 features thought to characterize inflammatory back pain: (1) Insidious onset. (2) Patient age at onset younger than 40 years. (3) Duration 3 months or longer. (4) Associated with morning stiffness. (5) Improvement with exercise. Although these criteria are used widely, they rarely have been tested rigorously for sensitivity and specificity in distinguishing inflammatory from non inflammatory back pain.

  23. Revised criteria for inflammatory back pain A recent revision of the proposed criteria for inflammatory back pain in adults age 50 years or younger, as follows: (1) Morning stiffness for longer than 30 minutes. (2) Improvement with exercise but not with rest. (3) Awakening because of the pain during only the 2nd HALF of the night. (4) Alternating buttock pain. Sieper J, Rudwaleit M.. Ann Rheum Dis 2005.

  24. Revised criteria for inflammatory back pain In this study-assuming that SP A (including AS) accounts for 5% of chronic LBP in adults in this age group-the probability of SP A was only: 2.6% in a patient with back pain who showed at most 1 of these 4 features. 10.8% when 2 features were present. 39% when 3 or 4 features were present. By inquiring about these features, physicians can increase or decrease the level of suspicion of a diagnosis of SP A dramatically. Sieper J, Rudwaleit M.. Ann Rheum Dis 2005.

  25. Imaging of AS The classic radiographic features of AS-including: Erosions and widening of the sacroiliac joint that progress to joint fusion. Variety of changes in: The vertebral bodies. Facet joints. Spinal ligaments. Have been well described and are widely known. However, these late findings have limited value in making an early diagnosis. Therefore, more emphasis is now being placed on use of MRI for detecting early sacroiliitis and spondylitis.

  26. Imaging of AS In early sacroiliitis, some specialized MRI techniques with fat suppression are adequately sensitive for detecting: Intra-articular inflammation. Early cartilage changes Underlying bone marrow edema. Osteitis. The greatest success has been obtained with the techniques of short tau inversion recovery, or STIR, sequences; T1-weighted sequences that have contrast enhancement, usually with gadolinium-DPTA; and fast spin-echo T2-weighted sequences. Rudwaleit et al., Ann Rheum Dis 2004.

  27. The diagnosis of AS is delayed over 5–10 years after the occurrence of 1ST symptomsThis is probably due to: No pathognomonic clinical feature or laboratory test to make the diagnosis of AS. Underwood MR, et al. Br J Rheumatol 1995;34:1074-7. Low awareness of Sp Aamong the large group of back pain patients in 1ry care might be a cause of delay in diagnosis of AS. Bennett, et al. A&R, 2008. Thus it is a huge challenge to attempt to identify the estimated 0.3 -5% of chronic low back pain that represents AS.

  28. MRI has being increasingly used to diagnose: Active disease and inflammation in sacroiliac joints, and spine ( abnormal enhancement and subchondral bone marrow edema). Chronic disease ( Ankylosis and subchondral sclerosis of the sacroiliac joint). Lesions on MRI are already visible long time before structural changes can be seen on plain radiographs. Bennett, et al. A&R, 2008.

  29. Recent studies have suggested that assessment of structural changes First by conventional radiography followed by Assessment of inflammation on MRI. In patients with negative radiographic studies, yields the highest probability of detecting involvement of the SI joints in patients with recent onset IBP. Bennett, et al. A&R, 2008.

  30. Coronal T1-weighted MR image shows:Subchondral fatty marrow changes (arrows). Irregularity of sacroiliac joint.

  31. Coronal STIR image shows mild subchondral edema (arrows).

  32. Coronal fat-saturated contrast-enhanced T1-weighted image shows moderate enhancement (arrows).

  33. Coronal STIR image shows mild bilateral inferior edema of sacroiliac joint (arrows).

  34. Summary of evidence “AS” Presence of at least two of the following was associated with a positive likelihood ratio of 3.7 Morning stiffness of >30 minutes duration. Improvement in back pain with exercise but not with rest. Awakening because of back pain during the 2nd half of the night only. Alternating buttock pain (positive likelihood ratio of 12.3 when at least 3 findings present).

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  37. Ankylosing spondylitis Two systematic reviews evaluated diagnostic accuracy of history for identifying patients with AS found: I. Younger age at onset associated with high sensitivity but poor specificity: * Sensitivity and specificity 0.92 and 0.30 for onset <35 years. * 1.00 and 0.07 for onset <40 years. Most other historical features had only modest predictive value or gave inconsistent results. For example, the specificity of a history of sacral pressure varied from 0.68 to 0.92 in three studies. III- Combined historical findings (positive response to 4 of 5 of the following screening questions: Onset before age 40. Chronic onset, duration >3 months. Morning stiffness. Improvement with exercise. did not improve diagnostic accuracy (positive likelihood ratio of 1.3 and negative likelihood ratio of 0.94). Jarvik JG, Deyo RA. Ann Intern Med. 2002

  38. Summary of evidence “AS” For diagnosis of AS, younger age at onset of back pain was sensitive but not specific. Physical exam findings for AS were generally associated with poor sensitivity and relatively high specificities. Recently proposed changes in criteria used to diagnose early As (i.e. prior to the development of sacroiliitis) are likely to affect estimates of diagnostic accuracy (level of evidence: fair).

  39. Summary of evidence “ Spinal stenosis” In lower-quality studies, a wide-based gait and combination of findings on treadmill testing were associated with higher likelihoods for spinal stenosis. Age > than 65 years was associated with a positive likeli-hood ratio of 2.5 and negative likelihood ratio of 0.33. The predictive value of pain relieved by sitting ranged from poorly to highly (level of evidence: fair).

  40. Level of Evidence Cauda equina syndrome CES Cauda equina syndrome is most commonly caused by massive midline inter vertebral disc herniation. Though there is little data on accuracy of history and physical exam for identifying patients with this condition, the most frequent finding in Cauda equina syndrome is: + ve Urinary retention (sensitivity 90%) . - ve Urinary retention, will decrease the probability of CES to 1 in 10,000. Deyo RA, et al. JAMA. 1992.

  41. Summary of evidence “ Radiculopathy” Describing typical symptoms of sciatica has a relatively high diagnostic sensitivity but inconsistent specificity. A positive straight leg raise was associated with a pooled sensitivity of 0.91 and specificity of 0.26 in one higher-quality systematic review. A positive crossed straight leg raise was associated with a pooled sensitivity of 0.29 and a specificity of 0.88. The specificity of neurologic deficits consistent with nerve root compression ranges from modest to high (level of evidence: fair).

  42. Summary of evidence “Compression fracture” For diagnosis of compression fracture, one systematic review found that: Corticosteroid use has a higher predictive value (positive likelihood ratio 12.0) than age or history of trauma. Age >50 years was associated with a sensitivity of 0.84 and specificity of 0.61 (positive likelihood ratio 2.2 and negative likelihood ratio 0.26). Age >70 years was associated with a sensitivity of 0.22 and specificity of 0.96 (positive likelihood ratio 5.5 and negative likelihood ratio 0.81). Jarvik JG, Deyo RA. Ann Intern Med. 2002

  43. Summary of evidence “ Spinal stenosis” For diagnosis of spinal stenosis, features of the history and clinical exam associated with high sensitivity (such as radiating leg pain) generally associated with low specificity, or vice versa, resulting in modest or poor predictive values. Changing symptoms on downhill treadmill testing was associated with the highest positive likelihood ratio (3.1).

  44. Inflammatory Back pain Symptoms in ILBP, as opposed to NILBP, are often attributed to: Measurable physical pathology. Raised acute phase responses. Radiologic evidence of inflammatory changes in the spine. This difference between ILBP and NILBP may reflect the different perception by healthcare professionals of the organic basis underlying the 2 conditions. Martindale J, et al. Rheumatology, 2006.

  45. Key Questions for clinical practice guidelines. .(5Q). 1a. How accurate are: Features of the history and physical exam for predicting serious underlying conditions “red flags”. Other conditions that may be responsive to specific therapies in patients with back pain ( like nerve root compression or spinal stenosis)? 1b. How accurate are features of: The history and physical exam for predicting persistent back pain and disability. “yellow flags”? 1c. How effective is identification and treatment of yellow flags for improving back pain outcomes? 2a. How accurate are different diagnostic tests for identifying serious conditions. (e.g., tumor, infection, compression fracture)? 2b. How accurate are diagnostic tests for identifying (nerve root compression, herniated disc, spinal stenosis) that may respond to specific therapies?

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