Low Back Pain Jamous M, MD, Ph.D., FAANS Department of Neurosciences, JUST

1. Low Back PainJamous M, MD, Ph.D., FAANSDepartment of Neurosciences, JUST

2. Anatomy/ Spine

3. Anatomy Vertebra – body, neural arch, bony process Ligaments & muscles

4. Epidemiology 50-60% Life time incidence of LBP 15-30% prevalence among adults 1% of population are disabled because of LBP 15% of the sick leave 85% no specific diagnosis can be made Highest prevalence 40-60 year of age Overall incidence of LBP 45/1000 person per year M=F

5. Clinical presentation LBP +/- radiculopathy Pain exacerbated with physical stress and relieved with bed rest P/E differentiate mechanical (non-specific) LBP from serious spinal conditions (radiculopathy or cauda equina syndrome caused by PID, tumors, infections…..)

6. History / red flags Hx of cancer (prostate, breast, kidney, thyroid, lung) Unexplained wt loss Immunosuppression Pain that worse at rest psuedoclaudication Pain not responding to conservative Rx Skin or other systemic infection Urine and fecal incontinence

7. Examination / red flags Fever Spinal deformity Tenderness & L.O.M +ve SLR test Motor and /or sensory deficits

8. Recommendationsabsent red flags Bed rest Activity modification Analgesia Reassurance > 85 % show improvement within 4 weeks without the need for diagnostic studies

9. Diagnostic work / pts with red flags Plain L.S Xray L.S CT scan L.S. MRI L.S. Myelography

10. Lower back pain + red flags PID; Traumatic (Acute) vs degenerative (gradual) Spinal tumors (intradural vs extradural) Spinal infections (osteomyelitis, epidural abcess)

11. PID Displacement of disc material beyond confines of the disc space Pain start with back pain, which after days or weeks produce radicular pain with reduction of the back pain Precipitating factors are identified < 20% of cases Radicular pain is relieved by flexing the knee and hip Pain exacerbated by coughing and sneezing or straining (cough effect) Bladder symptoms (usually retention) < 5%

12. PID

13. PID Physical signs (NL-sensory & motor loss) Lesègue sign (slow leg raising test)

14. PID

15. Disc Herniation L4-5, L5-S1 most common Cervical and thoracic do occur Thoracic: abrupt neuro deficits Narrow canal Postero-lateral aspect of the disc

16. Disc Herniation X-ray only good if inter-vertebral disc is narrow MRI is gold standard Electromyelography localizes the specific nerve root

17. Disc Herniation

18. PID Most common at L4-L5 & L5-S1 Bulge, protrusion, extrusion, sequestered, migrated Midline or lateral

19. PID

20. PID

21. DDD Aging process Progressive dehydration of the nucleus pulposus and loss of disk volume Degenerative tear in the annulus with herniation of the nucleus pulposus through this tear. Present with L.B.P and L.O.M

22. DDD Three Phases: phase I, circumferential tears or fissures in the outer annulus. +/- endplate separation or failure, interrupting blood supply to the disk and impairing nutritional supply and waste removal. Such changes may be the result of repetitive microtrauma. Circumferential tears may coalesce to form radial tears.

24. DDD Phase II; The unstable phase, loss of mechanical integrity of the trijoint complex. Internal disk disruption (IDD), loss of disk-space height. Concurrent changes in the facet joints include cartilage. leading to segmental instability (Spondylolisthesis).

25. DDD Phase III; Stabilization phase, characterized by further disk resorption, disk-space narrowing, endplate destruction, disk fibrosis, and osteophyte formation

26. DDD

27. Disc Herniation Initial therapy is to decrease pressure on the root Bed rest up to 4 weeks Non-steroid anti-inflammatory Muscle relaxants

28. Disc Herniation Absolute indication for surgery Significant muscle weakness Progressive neurological deficit with bed rest Bowel or bladder dysfunction

29. Disc Herniation Relative indication for surgery Pain despite bed rest Recurrent episodes of severe pain

30. PID / Discectomy

31. PID / Discectomy

34. Discectomy / Complications Infection (superficial vs deep) Increased deficit (injury to neural structure) Dural tear (CSF leak) Complications of positioning Failed surgery (incorrect dx, incomplete surgery) Vascular injury

35. Discectomy When pain wont wane, it is usually in the brain When pain remains, there is secondary gain

36. Thecal sac compression Malignant epidural spinal cord compression (MESCC) Spinal epidural abscess (SEA) Spinal epidural hematoma (SEH)

37. Thecal sac compression Factors Force of compression Direction of compression Rate of compression

38. MESCC Hematogenous spread Bone marrow Compress cord and vascular supply Edema, infarction

39. MESCC Prostate Lung Breast Non-Hodgkin’s lymphoma Multiple myeloma Renal cell cancer

40. MESCC Initial presentation in 20% of malignancies Cervical, thoracic & lumbar by proportion of vertebral body volume Thoracic is most common

41. MESCC 95% have back pain Precedes other symptoms by 1-2 months Percussion tendencies, thoracic location, worse lying down

42. MESCC 75% have weakness by time of diagnosis Weakness symmetric Ascending numbness Autonomic dysfunction, urinary retention

43. MESCC Plain X-ray 10-17% false negative 30-50% of bone must be destroyed for X-ray to be positive MRI, CT myelography are standards

44. MESCC Plain X-ray 10-17% false negative 30-50% of bone must be destroyed for X-ray to be positive MRI, CT myelography are standards

45. MESCC

46. MESCC Corticosteroids first line for edema Dexamethosone, 20-100 mg load, 4-24 mg 4 times/day Radiation therapy within 24 hours

47. MESCC Surgery for: unresponsive to radiation therapy Acute neurological deteriorations Chemotherapy – Non-Hodgkin’s lymphoma

48. The Case 55 yo male with low back pain. Right-sided, worse with movement and non-radiating. He has no weakness, numbness or incontinence. No hx of trauma. Pmhx: HTN, irritable bowel syndrome Meds: none Sochx: alcohol use PE: afebrile, VSS Back: mild tenderness right paraspinal area, L2-3 Neuro: normal What do you want to do?

49. The Case He is given NSAI which makes him better and is sent home. 5 days later he is at a new hospital with the complaint of back pain, says it is the same as before, “I ran out of my medicine”. PE: Afebrile, VSS Back: right paraspinal tenderness, worse with movement Neuro: numbness anterior and med thigh What do you want to do?

50. The Case He has an abdominal CT scan to R/O renal stone which was normal. He is given a shot of paracetamol which makes him feel better and is discharged with paracetamol and Valium. He returns 2 days later with worsening pain that radiates to the right foot and left knee. He has numbness to the thighs and groin, and has been incontinent of stool. PE: Afebrile, VSS Back: diffuse tenderness to lumbar spine palpation Neuro: RLE- 3/5 strength, numbness anterior and med thigh, decreased reflex. LLE- 4/5 strength. What do you want to do?

51. The Case

52. The Case MRI is done which confirms a compressive lesion from L2 to L4. WBC = 18,000. The patient is given antibiotics and is admitted to neurosurgery. An L3-L4 laminectomy is done and pus is drained. Organism= Streptococcus Patient was discharged to a rehab facility on hospital day 13 for 6 weeks of Vancomycin therapy. At the time of discharge he was continent, but could only ambulate with assisted use of a walker.

53. Conclusion Back pain is common in the ED Radicular pain requires diligence to find the cause The severity of spinal cord compression is related to force, duration and rate Emergent therapy is necessary “Spinal Cord Attack”

54. SEARisk Factor IVDA Diabetes Trauma Prior spinal surgery or nerve blocks Immune compromised host

55. SEAPresenting Complaints Back pain Paresthesias Motor deficits Fever

56. SEADiagnosis WBC Sedimentation Rate MRI = gold standard

57. SEAOrganisms Staphylococcus aureus - Methicillin resistant – 15% Streptococcus Escherichia coli Pseudomonas Klebsiella Mycobacterium Tuberculosis

58. SEATreatment Surgery – depending on severity of neuro deficits Extent of spine involved Infecting organism Antibiotics

59. SEANon-Operative Indications Panspinal involvement Lumbosacral SEA and normal neuro exam Fixed neuro deficit for > 48 hours

60. SEAAntibiotics Start immediately Vancomycin Aminoglycoside or 3rd generation cephalosporin 4 to 6 weeks

61. Vertebral Osteomyelitis

62. VO / Epidural abcess

63. Spinal Epidural Hematoma (SEH)Risk Factors Coagulapathy Trauma Vascular lesion Surgery Epidural catheterization

64. SEHDiagnosis Back pain, neuro deficit Symptom onset to max. neuro deficit = 13 hours All segments of spinal cord MRI = gold standard Plain X-ray or CT scan for fractures or dislocation

65. SEHTreatment Surgical evacuation Immediate surgery within 12 hours of presentation had better outcome than later surgery

66. LBP Spinal stenosis Ankylosing spondylitis Spinal tumors

67. First line of therapy for epidural spinal cord compression from metastatic cancer is: A. Radiation therapy B. Surgery C. Corticosteroids D. Chemotherapy

68. The most common site of epidural spinal cord compression from metastatic cancer is: A. Cervical spine B. Thoracic spine C. Lumbar spine D. Sacral spine

69. All of the following are indications for non-operative treatment of spinal epidural abscesses except: A. Pan-spinal involvement B. Lumbosacral SEA and normal neurological exam C. Fixed neurological deficits for greater than 48 hrs D. Urinary incontinence and sensory deficit

70. All of the following contribute to the severity of spinal cord compression except: A. Force of compression B. Length of spinal cord compressed C. Duration of compression D. Rate of compression

71. The most common organism cultured in spinal epidural abscesses is: A. Streptococcus B. Pseudomonas C. Staphylococcus aureus D. Klebsiella E. Mycobacterium tuberculosis

72. Objectives Discuss the different types of LBP Review anatomical principles Review nontraumatic etiologies for LBP Treatment options for patients with LBP

73. Nerve Root DiagnosisL4 Pain = lateral back, antero-lateral thigh, anterior calf Numbness = anterior thigh Weakness = quadriceps Diminished knee jerk Squat and rise

74. Nerve Root DiagnosisL5 Pain = hip, groin, postero-lateral thigh, lateral calf and dorsum of foot Numbness = lateral calf Weakness = dorsiflex great toe Heel walking

75. Nerve Root DiagnosisS1 Pain = mid-gluteal region, posterior thigh, posterior calf to heel & sole Numbness = posterior calf Weakness = plantar flex great toe Diminished ankle jerk Walk on toes