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 Bilateral leg Progressive motor weakness Fever and chills or sensory deficit Prolonged steroid Unrelenting use, IV drug use severe pain with Major trauma rest Loss of bowel or Numbness in bladder function groin/ saddle
Guide to Lumbar Spine Conditions Sprain/Strain Dysfunction/ Derangement Postural ONSET Sudden, simple Gradual Sudden, simple move move; trauma; acute load PAIN Severe ache, Ache, Sharp, burning, diffuse, spasm intermittent Localized or Radiating MOBILITY Reduced; any Reduced b/c of Guarded flexion movement joint and CT & extension increases pain stiffness decreases pain; guarded in all ranges GOALS OF Decrease pain Decrease pain Decrease pain TX + spasm Increase ROM Stabilize spine Restore ROM Posture Posture Posture Strength/Flex Strength/Flex Strength/Flex Prevention
Bones and Joints
Intervertebral Discs
Nerves 31 prs of nerves C7 nerve exits b/ w 6 th and 7 th cervical vertebrae L4 nerve exits b/ w 4 th and 5 th 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
Muscles Superficial Thoracic group Abdominal group Erector Spinae group Spinalis Longissimus Iliocostalis Deep Transversospinal group Multifidus Rotatores Intertransversarius
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 once 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 On your back abdomen
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
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