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Published on : Mar 14, 2014
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Slide 1 - Low Back Pain: Approach to the patient in the E.D. Lala M. Dunbar, M.D., Ph.D. Clinical Professor of Medicine LSU HSC
Slide 2 - Epidemiology 60 – 90% of adults experience back pain at some point in their life. -  incidence age 35- 55 y.o. - 90% resolve in 6 weeks - 7% become chronic - M/ F equally affected 85% never given precise pathoanatomical dx 5th Leading reason for medical office visits 2nd to respiratory illness as reason for symptom-related MD visits
Slide 3 - #1 Cause and #1 Cost of work related disability Healthcare expenditures $90 Billion (1998) - $26.3 Billion attributable to back pain Epidemiology (cont.)
Slide 4 - Important Questions 1. Is systemic disease the cause? 2. Is there social or psycological distress that prolongs or amplifies symptoms? 3. Is there neurologic compromise that requires surgical intervention?
Slide 5 - To Answer These Important Questions 1. Careful History and Physical Exam 2. Imaging and Labs WHEN indicated
Slide 6 - Differential Diagnosis of Low Back Pain
Slide 7 - Evaluation in older adults Probabilities change Cancer, compression fractures, spinal stenosis, aortic aneurysms more common Osteoporotic fractures without trauma Spinal Stenosis secondary to degenerative processes and spondylolisthesis more common Increased AAA associated with CAD Early radiography recommended
Slide 8 - Clues To Systemic Disease Age History of Cancer Fever Unexplained Weight Loss Injection Drug Use Chronic Infection Elsewhere Duration and Quality of Pain -Infection and Cancer not relieved supine Response to previous therapy h/o inflammatory arthritis elsewhere
Slide 9 - Imaging Plain Radiography limited to patients with: -findings suggestive of systemic disease -trauma Failure to improve after 4 to 6 weeks CT and MRI more sensitive for cancer and infections – also reveal herniation and stenosis Reserve for suspected malignancy,infection or persistent neurologic defecit
Slide 10 - MRI Shows tumors and soft tissues (e.g., herniated discs) much better than CT scan Almost never an emergency Exception: Cauda equina syndrome
Slide 11 - CT Scan Shows bone (e.g., fractures) very well Good in acute situations (trauma) Sagittal reconstruction is mandatory Soft tissues (discs, spinal cord) are poorly visualized CT-myelogram adds contrast in the CSF and shows the spinal cord and nerves contour better
Slide 12 - Abdomen, X-ray, Anteroposterior View 1. 1st Lumbar vertebra 2. 2nd Lumbar vertebra 3. 3rd Lumbar vertebra 4. 4th Lumbar vertebra 5. 5th Lumbar vertebra 6. T12 7. Twelfth rib 8. Sacroiliac joint 9. Sacrum 10. Sacral foramen 11. Ilium 12. Pelvic brim 13.Superior ramus of pubic bone 14. Pubic symphysis
Slide 13 - 1. Vertebral body 2. Spinal cord 3. Conus medullaris 4. Intervertebral disc 5. Filum terminale (internum) 6. Subarachnoid space Lower Third of Spinal Cord, MRI
Slide 14 - Sagittal Section through the Spinal Cord Intervertebral disc 2. Vertebral body 3. Dura mater 4. Extradural or epidural space 5. Spinal cord 6. Subarachnoid space
Slide 15 - Lumbrosacral Dermatones
Slide 16 - Common Pathoanatomical Conditions of the Lumbar Spine
Slide 17 - Disc Herniation – Physiology Tears in the annulus Herniation of nucleus pulposus
Slide 18 - Disc Herniation – Physiology Compression of the nerve root in the foramen leads to pain
Slide 19 - Lumbar Disc Herniation – Treatment Conservative Tx. Moderate bed rest Spinal manipulation Physical therapy Medication NSAIDs Muscle relaxants Rarely narcotics Surgical Tx. “Microdiscectomy” Less than half of an inch incision Go home the same or next day Good results in up to 90% of cases
Slide 20 - Results of Surgical Treatment Good outcome in 80-90% of cases Residual pain may last up to 6 months postop Results are worse if pain was present for over 8 months before the operation (permanent nerve damage?)
Slide 21 - Low Back Pain Second most common cause of missed work days Leading cause of disability between ages of 19-45 Number one impairment in occupational injuries
Slide 22 - Low Back Pain Most episodes of LBP are self limited These episodes become more frequent with age LBP is usually due to repeated stress on the lumbar spine over many years (“degeneration”), although an acute injury may cause the initiation of pain
Slide 23 - Disc Degeneration – Physiology With age and repeated efforts, the lower lumbar discs lose their height and water content (“bone on bone”) Abnormal motion between the bones leads to pain
Slide 24 - Disc Degeneration – Treatment Conservative Tx. Moderate bed rest Spinal manipulation Physical therapy Medication NSAIDs Muscle relaxants Rarely narcotics Surgical Tx. Lumbar fusion OR Replacement with artificial disc
Slide 25 - Indications for Surgical Treatment Low back pain for at least 2 years Incapacitating Resistant to physical therapy and medication Positive MRI findings (degenerative changes) at L4-5 and/or L5-S1 For selected cases: Concordant pain on discography Psychological evaluation
Slide 26 - Natural History Recovery from nonspecific LBP generally rapid – 90% within 2 weeks – some studies less rapid (2/3 at 7 weeks) Herniated Discs – slower to improve – only about 10% considered for surgery after 6 weeks With surgery, no earlier return to work – symptomatic and functional outcome sometimes better
Slide 27 - Physical Examination Fever – possible infection Vertebral tenderness - not specific and not reproducible between examiners Limited spinal mobility – not specific (may help in planning P.T. If sciatica or pseudoclaudication present – do straight leg raise Positive test reproduces the symptoms of sciatica – pain that radiates below the knee (not just back or hamstring) Ipsilateral test sensitive – not specific: crossed leg is insensitive but highly specific L-5 / S-1 nerve roots involved in 95% lumbar disc herniations
Slide 28 - Assessment of Function 98% disc herniations: L4-5; L5-S1 Impairment: Motor and Sensory L5-S1 L5: Weakness of ankle and great toe dorsaflexion S1: Decrease ankle reflex L5 & S1: Sensory loss in the feet
Slide 29 - STRAIGHT LEG RAISE TEST The straight leg raise test is positive if pain in the sciatic distribution is reproduced between 30° and 70° passive flexion of the straight leg. Dorsiflexion of the foot exacerbates the pain STRAIGHT LEG RAISE TEST
Slide 30 - Waddell Signs For Non-organic Pain Superficial non-anatomic tenderness Pain from maneuvers that should not ellicit pain Distraction maneuvers that should ellicit pain BUT don’t Disturbances not consistent with known patterns of pain Over-reacting during the exam Not definitive to rule out organic disease
Slide 31 - Imaging Studies Progressive Neurologic Defecits Failure to Improve Hx of Trauma Risk for Malignancy or infection
Slide 32 - Nerve Root Pain Associated w/ Radiculopathy Sciatica -herniated disk -foramenal or spinal stenosis -ligamentous hypertrophy -other space filling lesions: cysts, tumor, abscess -viral or immune inflammation -can occur w/ peripheral nerve involvement Spinal stenosis -neurogenic claudication (pseudo claudication) 1 or both legs -radiation to buttocks, thighs, lower legs -pain increase with extension (standing, walking) -pain decrease with flexion (sitting, stooping forward)
Slide 33 - Indications for Surgical Referral
Slide 34 - Therapy: Non-specific LBP NSAIDS Muscle relaxants Use on schedule than p.r.n. Spinal manipulation/ P.T. (effects limited) Delay referral until pain persists >3 weeks 50% will improve b/f this time period Rapid return to normal activities Avoid heavy lifting, trunk twisting, vibrations Alternative Tx: acupuncture and massage Surgery- ineffective unless: sciatica, pseudoclaudication, spondylolisthesis
Slide 35 - Therapy: Herniated Disks If no evidence cauda equina or progressive neurologic defecit: Treat non-surgically minimum one month Treat similar to non-specific LBP Limited narcotics Epidural steroids (helps in some) If severe pain or neuro defecits persist: CT/ MRI / consider for surgery Diskectomy Improved relief vs. non-surgery at 4 yrs./ ? 10yrs. Percutaneous and laser less effective than std. Arhroscopic techniques techniques comparable to std. surgery
Slide 36 - Therapy: Spinal Stenosis Conservative management may be useful For severe persistant pain decompressive laminectomy Surgery – better pain relief and functional recovery 30% recurrent severe pain in 4 years 10% reoperated
Slide 37 - Therapy: Chronic LBP Sx often difficult to explain Intensive exercises help (hard to maintain) Anti-depressant therapy useful if depressed Long term opioids – not recommended Referral to pain center Massage therapy is promising Therapeutic goals – optimize daily function
Slide 38 - Long Term Outcomes Herniated Discs w/o neurologic deficits Diskectomy - > relief at 4 yrs; ? Better at 10 yrs Microdiskectomy – similar to standard Laser Diskectomy – less effective Arthroscopic diskectomy - promising
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