Musculoskeletal Pain Back Pain

1. Musculoskeletal PainBack Pain Rodrigo Rodrigues, MD www.wikidoc.org Copyleft by CM Gibson

2. 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 www.wikidoc.org Copyleft by CM Gibson

3. M/S Pain – Back Pain • Back pain of <6wks is acute, and >3mo is chronic • Risk factors: • 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 www.wikidoc.org Copyleft by CM Gibson

4. 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 www.wikidoc.org Copyleft by CM Gibson

5. 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 www.wikidoc.org Copyleft by CM Gibson

6. 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 www.wikidoc.org Copyleft by CM Gibson

7. M/S Pain – Back Pain • Herniated disk: • Abnormalities in the annular ring may be associated with chronic low back pain • Caudaequina Sd. is the impingement of the caudaequina. 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. www.wikidoc.org Copyleft by CM Gibson

8. 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 www.wikidoc.org Copyleft by CM Gibson

9. 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. www.wikidoc.org Copyleft by CM Gibson

10. 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 www.wikidoc.org Copyleft by CM Gibson

11. 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 www.wikidoc.org Copyleft by CM Gibson

12. 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 www.wikidoc.org Copyleft by CM Gibson

13. 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. www.wikidoc.org Copyleft by CM Gibson

14. 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. www.wikidoc.org Copyleft by CM Gibson

15. 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. www.wikidoc.org Copyleft by CM Gibson

16. 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 www.wikidoc.org Copyleft by CM Gibson

17. 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 www.wikidoc.org Copyleft by CM Gibson

18. 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 www.wikidoc.org Copyleft by CM Gibson

19. 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 www.wikidoc.org Copyleft by CM Gibson

20. M/S Pain – Back Pain • Indications for early imaging in patients w/ back pain:

21. M/S Pain – Back Pain • Imaging Recommendation 4: • “Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathyor 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 www.wikidoc.org Copyleft by CM Gibson

22. 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 www.wikidoc.org Copyleft by CM Gibson

23. M/S Pain – Back Pain • Treatment: • Therapy should focus on temporary symptomatic relief, to maximize patient comfort Recommendation 5: • “Clinicians should provide patients with evidence- based 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 www.wikidoc.org Copyleft by CM Gibson

24. 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 non-steroidal anti-inflammatory drugs.” American College of Physicians/American Pain Society Low Back Pain Guidelines Panel www.wikidoc.org Copyleft by CM Gibson

25. 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, cognitive-behavioral therapy, or progressive relaxation.” American College of Physicians/American Pain Society Low Back Pain Guidelines Panel www.wikidoc.org Copyleft by CM Gibson

26. M/S Pain – Back Pain • Treatment: Recommendation 5 American College of Physicians/American Pain Society Low Back Pain Guidelines Panel www.wikidoc.org Copyleft by CM Gibson

27. M/S Pain – Back Pain • Treatment: Recommendations 6 and 7 American College of Physicians/American Pain Society Low Back Pain Guidelines Panel www.wikidoc.org Copyleft by CM Gibson

28. M/S Pain – Back Pain • Treatment: Recommendations 6 and 7 American College of Physicians/American Pain Society Low Back Pain Guidelines Panel www.wikidoc.org Copyleft by CM Gibson

29. 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 www.wikidoc.org Copyleft by CM Gibson

30. 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. www.wikidoc.org Copyleft by CM Gibson

31. 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 long-term 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 www.wikidoc.org Copyleft by CM Gibson

32. Thank you www.wikidoc.org Copyleft by CM Gibson