Approach to the patient with Low Back Pain in Primary Care

1. Approach to the patient with Low Back Pain in Primary Care

2. Objectives • Differentiate between concerning and non-concerning causes for acute low back pain • Identify historical red flags • Identify examination red flags • Briefly review evidence-based treatment options for low back pain

3. Acute Low Back Pain • Easy Visit??? • Frustrating Visit???

4. Acute Low Back Pain • Easy • Usually not serious • Limited management options • Often quick exam • Frustrating • Difficult patients • Limited management options • Can feel unsatisfying

5. Differential Diagnosis: • 30 seconds • List differential diagnosis for Low back pain • 30 seconds • List differential diagnosis for “bad” causes of Low back pain

6. Differential Diagnosis of Low Back Pain • Mechanical low back pain (97%) • Lumbar strain or sprain (≥ 70%) Diffuse pain in lumbar muscles; some radiation to buttocks • Degenerative disk or facet process (10%) Localized lumbar pain; similar findings to lumbar strain • Herniated disk (4%) Leg pain often worse than back pain; pain radiating below knee • Osteoporotic compression fracture (4%) Spine tenderness; often history of trauma • Spinal stenosis (3%) Pain better when spine is flexed or when seated, aggravated by walking downhill more than uphill; symptoms often bilateral • Spondylolisthesis (2%) Pain with activity, usually better with rest; usually detected with imaging; controversial as cause of significant pain

7. Nonmechanical spinal conditions (1%) • Neoplasia (0.7%) Spine tenderness; weight loss • Inflammatory arthritis (0.3%) Morning stiffness, improves with exercise • Infection (0.01%) Spine tenderness; constitutional symptoms

8. Nonspinal/visceral disease (2%) • Pelvic organs—prostatitis, pelvic inflammatory disease, • endometriosis • Lower abdominal symptoms common • Renal organs—nephrolithiasis, pyelonephritis Usually involves abdominal symptoms; abnormal urinalysis • Aortic aneurysm - Epigastric pain; pulsatile abdominal mass • Gastrointestinal system—pancreatitis, cholecystitis, peptic ulcer Epigastric pain; nausea, vomiting • Shingles – (zona) Unilateral, dermatomal pain; distinctive rash

9. Differential Take-Home • 97% is mechanical • 4% Herniated disc (95% L4-L5; L5-S1) • 0.2% Cauda Equina • 2% Non-back sources • 1% Cancer and Infection

10. Our Job… • In 15 minutes, differentiate benign from serious causes of low back pain

11. We Need a Strategic Timeline • Good history – 3-5 minutes • Focused Exam – 2-4 minutes • Treatment options and pt education – 4-5 minutes

12. The Case Begins: • 87 yo M presents to clinic for back pain • Located mid to low back • Started about 3-4 days ago

13. Outline • List essential components of a LBP history, including Red flags • Review Physical Examination for LBP • Identify Red flags • Review proper indications for lab and imaging • Discuss acute management options

14. General Questions • Onset • Location • Mechanism of Injury • Radiation • Positional change • Numbness, tingling • Weakness

15. Red Flags • Age > 50 • IV drug use • Hx/o cancer • Prolonged steroid use • Osteoporosis • Distal numbness • Saddle anestesia • Bowel or bladder loss • Fever • Trauma • Unexplained wt loss • Pain at rest/night • Weakness

16. Diagnoses & Red Flags • Cancer • Age > 50 • History of Cancer • Weight loss • Unrelenting night pain • Failure to improve • Infection • IVDU • Steroid use • Fever • Unrelenting night pain • Failure to improve • Fracture • Age >50 • Trauma • Steroid use • Osteoporosis • CaudaEquina Syndrome • Saddle anesthesia • Bowel/bladder dysfunction • Loss of sphincter control • Major motor weakness

17. Diagnoses & Red Flags • Cancer • Age > 50 • History of Cancer • Weight loss • Unrelenting night pain • Failure to improve • Infection • IVDU • Steroid use • Fever • Unrelenting night pain • Failure to improve • Fracture • Age >50 • Trauma • Steroid use • Osteoporosis • CaudaEquina Syndrome • Saddle anesthesia • Bowel/bladder dysfunction • Loss of sphincter control • Major motor weakness

18. Our case • Red flags • Age 87 • Hx/o Non-Hodgkin’s • Remission for the past 4 years

19. Our Case • No hx/o back problems • No trauma • No radiation • No focal weakness • No numbness or tingling • No change in bowel or bladder function

20. Outline • List essential components of a LBP history, including Red flags • Review Physical Examination for LBP • Identify Red flags • Review proper indications for lab and imaging • Discuss acute management options

21. Physical ExamRule-out most concerning things • Concerning features • Decreased strength • Diminished reflexes • Sensory loss • Reassuring features • Paraspinal muscle spasm • Full strength • No sensory deficits

22. Six-Point MSK Exam • Inspection • Palpation • ROM • Strength • Neurovascular • Special Tests

23. Inspection • Ensure • No obvious deformities • No erythema • Skin lesions (Zoster)

24. Palpation • Soft Tissue • 4 clinical zones • Paraspinal muscles • Gluteal muscles • Sciatic area • Anterior abdomen/abdominal wall • Bones • Primarily palpating spinous processes and facets

25. NeurologicTesting • Sensation • Strength • Reflexes

26. Special Tests • Tests to stretch spinal cord or sciatic nerve • Tests to stress the sacroiliac joint

28. Straight leg raise • Looking for lumbar disk herniation • Performed supine for best sensitivity • Positive when radiating pain observed at 30-70 degress of hip flexion • Very high sensitivity, but low specificity • Should also do the crossed-leg straight leg raise • Positive when they have pain when you lift and adduct the opposite leg

29. FABER test: Flexion A- Bduction External Rotation

30. Tests • Lab • Based on clinical picture • Think Red Flags • Imaging • XR • CT • MRI

31. Imaging Guidelines • Choice to do imaging based on: • Historical red flags • Trauma, chronic steroid use = XRay • Suspect abscess, cauda equina = MRI • Exam red flags • New/severe sensory or strength loss = consider MRI

32. Outline • List essential components of a LBP history, including Red flags • Review Physical Examination for LBP • Identify Red flags • Review proper indications for lab and imaging • Discuss acute management options

33. Back pain treatment • NSAIDs (A) • Improve pain vs. placebo in controlled trials • No difference between them • NNT for 50% pain relief is 2-3 • Muscle relaxants (A) • Most beneficial in the first week • Shown effective in trials • Work best when combined w/ NSAIDs

34. Treatment • Pain relievers • Both opioid and non-opioid • Steroids • No benefit shown w/ orals • Short-term benefit shown for epidural • Bed rest • NO!!! • Activity increases functional status and decreases time missed from work and pain

35. Treatment • Exercise plan • No benefit during the acute phase, but helpful afterwards for prevention in MSK back pain (although USPSTF is neither for nor against) • Massage • Mixed evidence, but not harmful • Acupuncture • Most good studies show no benefit, but overall results are mixed • Ice/Heat (B) • Equivalent in a Cochrane review

36. Clinical recommendation and Evidence rating • In the absence of “red flag” findings or signs of caudaequina syndrome, four to six weeks of conservative care is appropriate for patients with acute low back pain. C • Nonsteroidal anti-inflammatory drugs, acetaminophen, and skeletal muscle relaxants are effective first-line medications in the treatment of acute, nonspecific low back pain. A • A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series.

37. Clinical recommendation and Evidence rating • Bed rest for more than two or three days in patients with acute low back pain is ineffective and may be harmful. Patients should be instructed to remain active. A • Education about activity, aggravating factors, natural history, and expected time course for improvement may speed recovery of patients with acute low back pain and prevent chronic back pain. C • Specific back exercises for patients with acute low back pain are not helpful. A

38. Clinical recommendation and Evidence rating • Heat therapy may be helpful in reducing pain and increasing function in patients with acute low back pain. B • Spinal manipulative therapy for acute low back pain may offer some short-term benefits but probably is no more effective than usual medical care. B

39. Conclusions • History is very important • Don’t forget your red flags • Look for focal findings on exam • There is evidence to help with treatment • Pt’s w/ low back pain or sciatica w/o red flag SYMPTOMS should try conservative management for about 6 wks prior to imaging or intervention

40. References • Evaluation and Treatment of Acute Low Back Pain. AAFP. 75(8), 2007. • Acute Lumbar Disk Pain. AAFP. 78(7), 2008. • When to Consider Osteopathic Manipulation. JFP. 59(9), 2010. • ACSM Primary Care Sports Medicine. • Physical Exam of the Spine and Extremities. Hoppenfeld, S. et al.

41. Questions???