BACK to Basics: The Diagnosis and Management of Low Back Pain - - PowerPoint PPT Presentation

2016 Annual Review in Family Medicine

December 5, 2016

BACK to Basics:

The Diagnosis and Management of Low Back Pain

Cindy J. Chang M.D.

UCSF Primary Care Sports Medicine Associate Clinical Professor of Orthopaedics and Family and Community Medicine

Disclosures

I have nothing to disclose

Objective

• Perform an effective

problem-focused history and physical examination for evaluation of low back pain

• Develop treatment plans

for the most common causes of low back pain

Important Points

• With a good history…

you should arrive at the correct diagnosis 90% of the time



Or at least a confident top 3 differential!

• With a good history, and comfortable knowledge of

basic anatomy… it will make your exam focused, quick and efficient

 And give you more time to chart…

• With a good history, and comfortable knowledge of

basic anatomy, you will not need to palpate until the END of the exam…

 Or you risk your patient not letting you finish the exam!

Hampton JR et al, BMJ 1975

Exam Room Tips

• Stock gowns/ sheets and paper shorts in the room
• Be able to get to both sides of the exam table
• Have a step stool handy

Low Back - History

• 1. Age, occupation, etc.
• 2. Date of injury/ symptom onset
• 3. Injury Mechanism:
• a. Acute: pop, ability to continue activity
• b. Chronic/ Overuse: precipitating activity
• 4. Swelling: location
• 5. Symptoms: Mechanical/ Other
• a. Locking, tightness, weakness, bowel/ bladder
• 6. Symptoms: Pain/ Numbness/ Tingling
• a. Location - Point to where it is
• b. Radiation - come from or go anywhere else

c.

Type - burning, sharp, dull, achy, constant, at night, w/ activity or position, Grade pain

• 7. Modifying/ Other Factors
• a. Better/ worse, previous injury/ surgery, red flags

Red Flag Symptoms

• History of cancer
• Progressive motor
• r sensory deficit
• Prolonged steroid

use, IV drug use

• Major trauma
• Numbness in

groin/ saddle

• Bilateral leg

weakness

• Fever and chills
• Unrelenting

severe pain with rest

• Loss of bowel or

bladder function

Sprain/Strain Dysfunction/ Postural Derangement ONSET Sudden, simple move Gradual Sudden, simple move; trauma; acute load PAIN Severe ache, diffuse, spasm Ache, intermittent Sharp, burning, Localized or Radiating MOBILITY Reduced; any movement increases pain Reduced b/c of joint and CT stiffness Guarded flexion & extension decreases pain; guarded in all ranges GOALS OF TX Decrease pain + spasm Restore ROM Posture Strength/Flex Decrease pain Increase ROM Posture Strength/Flex Decrease pain Stabilize spine Posture Strength/Flex Prevention

Guide to Lumbar Spine Conditions

Bones and Joints

Intervertebral Discs

Nerves

• 31 prs of

nerves

• C7 nerve

exits b/ w 6th and 7th cervical vertebrae

• L4 nerve

exits b/ w 4th and 5th lumbar vertebrae

Nerves

• Dermatomes
• Myotomes

 L1/ L2 – Hip flexion  L3/ L4 – Knee

extension

 L4 – Ankle

dorsiflexion

 L5 – Great toe

extension

 S1 – Ankle

plantarflexion

Nerves

• Dermatomes

Lee MWL et al, Clin Anat 2008

• Superficial

 Thoracic group  Abdominal group  Erector Spinae

group

 Spinalis  Longissimus  Iliocostalis

• Deep

 Transversospinal

group

 Multifidus  Rotatores  Intertransversarius

Muscles

Low Back – A systematic exam

• Observation: abrasions, bruising, comfort, motion
• Sitting: slump test, reflexes, sensation, strength
• Supine:

 SLR  Hip ROM / pain  Hamstring/ Hip flexor tightness

• Prone:

 Tenderness LS spine, SI joints  Femoral nerve stretch, passive extension hips/ spine  Hamstring/ glut max strength, L5 reflex

• Standing:

 ROM: flex, ext, sidebend, rot/ exten  One legged extension, Gillet test (pelvic motion)  Feet, gait, heel/ toe walk, functional testing

Low Back – A systematic exam

Case #1

Case #1- History

• 1. Age—22 professional soccer player
• 2. Date of injury/ symptom onset--ACUTE
• 3. Injury Mechanism:
• a. Acute: DIRECT BLOW; UNABLE TO CONTINUE PLAY
• 4. Swelling: AT SITE OF TRAUMA
• 5. Symptoms: Mechanical/ Other
• a. TIGHTNESS, NO LOSS OF BOWEL/ BLADDER
• 6. Symptoms: Pain/ Numbness/ Tingling
• a. Location – MID-LEFT LUMBAR SPINE
• b. Radiation – TO LEFT BUTTOCKS

c.

Type – CONSTANT, SHARP, WITH ANY CHANGE IN POSITION, 13/ 10 PAIN

• 7. Modifying Factors
• a. NO PREVIOUS INJURY/ SURG; BEST WHEN LYING

STILL

Case #1 - Exam

• Observation: DISCOMFORT, IN PAIN
• Sitting: LOCAL PAIN WITH SLUMP TEST, NO
• RADIATION. NL REFLEXES, STRENGTH, SENSATION
• Supine:

 (-)SLR, FROM HIP NO PAIN

• Prone:

 + TENDER LEFT LUMBAR SPINE L3 AND L4 LEVELS

• Standing:

 ROM: + PAIN IN ALL RANGES  PAIN WITH WALKING

Case #1 - Exam

Dx: Left L3 Transverse Process Fracture

Transverse Process Fracture

• Sudden extreme twisting or side-bending

movement, or direct impact

Transverse Process Fracture

• Majority treated conservatively, no surgery needed
• A brace may be used
• Gradual introduction of movement and PT/ rehab
• nce pain decreased
• Full return to activity expected

Case #2- History

• 1. Age, occupation, etc.: 50 YO OVERWT FEMALE, SELF-

EMPLOYED AS CARPENTER

• 2. Date of injury/ symptom onset: 2 DAYS AGO
• 3. Injury Mechanism:
• a. Acute: WENT TO CATCH HAMMER THAT WAS FALLING

OFF COUNTER

• 4. Swelling: NONE
• 5. Symptoms: STIFFNESS, BOWEL/ BLADDER OK
• 6. Symptoms: Pain/ Numbness/ Tingling
• a. Location – ENTIRE LOW BACK
• b. Radiation – NO

c.

Type – BURNING, NO NIGHT PAIN, W/ MOTION, 4/ 10

• 7. Modifying/ Other Factors
• a. BETTER WITH ICE, IBUPROFEN, KNEES TO CHEST,

NO RED FLAGS

Case #2 - Exam

• Observation: STIFFNESS
• Sitting: NEG SLUMP, NL REFLEXES, SENS, STRENGTH
• Supine:

 NEG SLR, HIP FROM W/ O PAIN

• Prone:

 NO CENTRAL SPINE OR BONY PAIN  TENDER BILAT PARASPINAL MM ON PALP  NEG FEMORAL NERVE STRETCH, HAM/ GLUT MAX

STRENGTH 5/ 5

• Standing:

 ROM: STIFF/ PAIN ESP FF W/ SPASM, PAIN WHEN

RETURNING TO ERECT POSITION

 SLOW GAIT, HEEL/ TOE WALK OK

Case #2 - Exam

Diagnosis – Muscle strain

• Acute sudden movement or

action

• Overuse from poor posture,

mm strength, endurance

• Common and self-limiting
• Treatment:

 NSAIDS/ MM relaxers  Ice/ Heat  Proper posture and

movement patterns

 Physical Therapy if no

resolution

 Active daily exercise, e.g.

walking in proper shoewear

 Weight management

“Your back went out because

your front went out.”

Case #3- History

• 1. Age, occupation, etc.: 51 YO OVERWT CARPENTER
• 2. Date of injury/ symptom onset: 1 MONTH AGO
• 3. Injury Mechanism:
• a. ON A DEADLINE AND MOVING FASTER THAN USUAL;

LIFTING MORE BOXES

• 4. Swelling: NONE
• 5. Symptoms: STIFF, WEAK, BOWEL/ BLADDER OK
• 6. Symptoms: Pain/ Numbness/ Tingling
• a. Location – LOW BACK, L BUTTOCKS
• b. Radiation – L LAT LEG TO ALL TOES

c.

Type – ACHY PAIN AT NIGHT, SHARP/ BURNING DURING DAY, NOW WORSENING 8/ 10

• 7. Modifying/ Other Factors
• a. ICE/ HEAT/ NSAIDS TEMPORARY HELP, APPETITE,

HURTS WITH COUGH/ SNEEZE

Case #3 - Exam

• Observation: STANDING WHEN YOU ENTER ROOM
• Sitting: + SLUMP, 1+ S1 REFLEX,  SENSATION FIRST

WEBSPACE, LAT FOOT;  STRENGTH 4/ 5 L GREAT TOE EXTENSION, L ANKLE DF; 5-/ 5 L ANKLE PF

• Supine:

 + L SLR AT 45 DEG, L HIP FROM BUT PAIN W/ ER

• Prone:

 + TENDER L4-5 > L5-S1, L SI JOINT  NEG FEMORAL N STRETCH TEST  L HAM/ GLUT MAX 4+ / 5, ABSENT L L5 REFLEX

• Standing:

 ROM: PAINFUL FF TO 45 DEG; R SIDEBEND  ABLE TO TOE WALK; HARDER L HEEL WALK; 22 HEEL

RAISES ON R, 16 ON L; NO ATROPHY

Testing L5 Reflex

Disc and nerve root relationship

Disc and nerve root relationship

Imaging

Imaging

Dx – L4-5 disc herniation

Dx – L4-5 disc herniation

• Subspecialty referral for any weakness, loss of

reflexes

 Emergent care if loss of bowel/ bladder, saddle

anesthesia, increasing pain unresponsive to meds

• NSAID alternating with acetaminophen every 3 hrs

 E.g., 600 mg ibuprofen @ 0800, 1000 mg

acetaminophen @ 1100, 600 ibu @ 1400, etc.

• Other meds individualized

 E.g., prednisone, TCA, narcotics,

gabapentin

• Physical therapy
• Posture/ positions of comfort
• Weight loss

Lumbar intradiscal pressures

Sleeping Properly

 On your side  On your

abdomen

 On your

back

Case #4 - History

• 1. Age: 35 YO MALE PROGRAMMER TRAINING FOR SF

MARATHON

• 2. Date of injury/ symptom onset: GRADUAL X 1 MO
• 3. Injury Mechanism:
• a. Chronic/ Overuse: ? CAUSED BY INTERVALS
• 4. Swelling: NONE
• 5. Symptoms: Mechanical/ Other
• a. TIGHTNESS IN L HAM, L LOW BACK
• 6. Symptoms: Pain/ Numbness/ Tingling
• a. Location – L PROX HAM TENDON, BUTTOCKS
• b. Radiation – NO

c.

Type – INTERMITTENT, SHARP, ACHY, NO NIGHT PAIN, 0/ 10

• 7. Modifying/ Other Factors
• a. WORKING LONG HRS SEATED, LESS STRETCHING

Case #4 - Exam

• Observation: NO DISCOMFORT
• Sitting: NEG SLUMP, NL SENS/ STRENGTH/ REFLEXES
• Supine:

 NEG SLR, HIP FROM, NEG FABER  + THOMAS TEST ON RIGHT

• Prone:

 + TENDER L SI JOINT  NT OVER PROX HAM TENDON  NEG PAIN W/ PASSIVE HIP EXTENSION

• Standing:

 ROM: TIGHTNESS IN PROX HAM W/ FF  + GILLET’S TEST ON R (+ ANT ROTATION)  GAIT NL

Thomas Test

• Evaluate hip flexors, quads, ITB

Gillet Test

PSIS anterior rotated

Dx: Left SI Joint Dysfunction

• Anterior rotation

 Tight hip flexor, tight ITB  Weak glut  Excessive stretch on hamstring and adductors as

femur moves forward during sprinting but pelvis does not posteriorly rotate

• Posterior rotation

 Tight piriformis/ glutes  Weak hip flexor

• Rule out rheum d/ o if very tender over SI joint,

warm, AM pain/ stiffness, resolution with NSAID

• Physical Therapy

Case #5 - History

• 1. Age: 15 YO HS/ CLUB VB PLAYER, RHD
• 2. Date of injury/ symptom onset: GRADUAL X 2 MO
• 3. Injury Mechanism:
• a. Chronic/ Overuse: precipitating activity: SPIKING
• 4. Swelling: NONE VISIBLE
• 5. Symptoms: Mechanical/ Other: TIGHT
• 6. Symptoms: Pain/ Numbness/ Tingling
• a. Location – LOWER BACK, MORE L SIDED
• b. Radiation – NONE

c.

Type – DULL TO SHARP, MORE DURING AND AFTER ACTIVITY, HURTS AT NIGHT (SLEEPS ON STOMACH), 5-10/ 10 RANGE

• 7. Modifying/ Other Factors
• a. URINATING MORE FREQUENTLY, NSAIDS HELP, ONE

WEEK OFF HELPED

Case #5 - Exam

• Observation: MOVES EASILY
• Sitting: NEG SLUMP, NL REFLEXES, SENS, STRENGTH,

(-) CVAT

• Supine:

 NEG SLR, HIP FROM, HAM TIGHT BILAT  + THOMAS TEST BILAT FOR HIP FLEXORS

• Prone:

 + TENDER L5-S1 LEVEL, L> > R  + PAIN PASSIVE EXTENSION L HIP  + PAIN ACTIVE BACK EXTENSION

• Standing:

 ROM: PAIN W/ L SIDEBEND, L ROT, EXTENSION  PAIN 1-LEG EXTENSION L> > R

Case #5 - Exam

Radiographs

• AP/ Lateral

Additional Radiographs?

– Oblique views

• Can see

“Scottie Dog”

Additional Radiographs?

Imaging

• Bone Scan with

SPECT

– Localizes uptake

to posterior vertebral elements

– Hot vs. Cold

• Thin cut CT

– Assess age and

healing of fracture

• MRI
• STIRS

sequences

PROCEDURE

AVG ADULT RADI ATI ON DOSE

= TO NATURAL BACKGROUND RADI ATI ON

CXR 0.1 mSv 10 days Head CT 2 mSv 8 months XRay of extremity 0.001 mSv 3 hours XRay of Spine 1.5 mSv 6 months

Radiation Exposure

http: / / www.radiologyinfo.org/ en/ info.cfm?pg= safety-xray

Avg exposure 3 mSv/ year from nature 0.03 mSv/ year RT airplane flight

MRI vs CT

Spondylolysis - Tx

• Refer if imaging findings
• Treatment controversial
• Rest
• + / - Bracing
• Physical therapy
• Trunk stabilization and LE

flexibility

• Typical: hip flexors tight,

pelvis ant rotated, low back hyperextended

• RTP when pain free and

strong

• Complications
• Non-Union Chronic Pain
• Spondylolisthesis

Facet Joint Dysfunction

• Inflammation, sprain,

degeneration

• AROM = Active ROM

 Flexion = “opening”

and Extension = “closing”

 Lumbar facet joints

“open” on right side with left lateral flexion and left rotation

 Lumbar facet joints

“close” on right side with right lateral flexion and right rotation

Imaging



Facet Joint Dysfunction - Tx

• Can be associated

with nerve root impingement or inflammation

• Physical therapy

 Trunk stabilization

and LE flexibility

 Typical: hip flexors

tight, pelvis ant rotated, low back hyperextended

Spinal Stenosis

• Congenital or age-related

narrowing of spinal canal

 causes compression on spinal cord

and nerve roots

• Typically > 50 years old

 Severity increases with age

• Symptoms

 Pain in low back, difficulty

walking- especially downhill, progressive numbness/ weakness in legs, bladder/ bowel control issues

• Cause

 osteoarthritis, previous injury

• Treatment

 Meds, PT, referral for possible

injection

Piriformis Syndrome

• Muscle that runs on top
• f the sciatic nerve.

 When the muscle

tightens/ is in spasm, nerve gets compressed

• r inflamed, causing

burning or shock-like pain down leg

• Cause

 Prolonged sitting, car

accidents, falls

• Treatment

 Meds, PT, referral for

possible injection

Prevent Back Pain with a Healthy Lifestyle

• Exercise daily
• Practice correct posture
• Lift correctly
• Sleep properly
• Avoid prolonged position
• Achieve and maintain a healthy weight

There is usually not a quick fix

Be Creative and Goal-Oriented!

Tell me and I’ll forget; show me and I may remember; involve me and I’ll understand.

• Chinese proverb