Back Pain By Dr.Ammar P.s Thanks To Dr.Ammar for doing this on short notice

1. Ammar Al-Kashmiri, MDAmmar Al-Kashmiri, MD
Emergency PhysicianEmergency Physician
Khoula HospitalKhoula Hospital
Back Pain Made EZ!
Primary Health Care Physicians Wo

2. Epidemiology
Definitions/Classifiication
RED FLAGS +Interpretation
How to examine?
Testing
Specific conditions
Management
Overview

4. Epidemiology
Affects up to 90% of population at some point in
their lives
∼ 4% of emergency department visits
Highest economic burden after heart disease &
stroke
85% have no definite etiology
90% with nonspecific back pain symptoms resolve
within 1 month

5. Risk Factors
Increasing age
Heavy physical work (long periods of static work
postures, heavy lifting, twisting, and vibration)
Psychosocial factors (including work dissatisfaction
and monotonous work)
Depression
Obesity (BMI > 30)
Smoking
Drug abuse
History of headache

6. Definitions
Acute LBP = < 6 weeks
Subacute LBP = 6-12 weeks
Chronic LBP = > 12 weeks

7.  Nonspecific back pain (majority)
= localized
 Back pain + radiculopathy/sciatica
= radiating
 Back pain associated with another specific cause
= referred
Classification

8. Clinical Presentation
Ranges :
 mild (muscle spasm) → severe/unrelenting (epidural abscess)
NOT important → recognize a particular classic
presentation for various diseases
IMPORTANT → evaluate for the red flags
Identification of red flags will direct whether further
evaluation is required

10. Very Serious Pathology
Vascular
 AAA, Aortic Dissection (AD)
Malignancy
 Mets: breast, prostate, lung, kidney, thyroid
 Bone or spinal epidural metastasis (SEM)
Infectious Process
 Vertebral osteomyelitis ,Spinal epidural abscess
(SEA)
Spinal cord compressive syndromes (SCCS)
 Spinal epidural mets (SEM), central disc herniation,
SEA, spinal epidural hematoma

11. Less Serious Pathology
Spinal fractures
Spinal stenosis
Spondylolysis / spondylolisthesis
Regular disc herniations
 usually lateral and compress nerves on one side and
not the cord / cauda

12. Red Flags
History
Age <18,>50
>6 weeks
*Systemic complaints:
 fever/chills/night sweats
 undesired weight loss
 malaise
Trauma (minor in OP, elderly)
Cancer (0.7% → 9%)
Immunocompromise
IVDU

13. Red Flags

14. Red Flags
History
Think outside the box!
Resp- e.g. Pneumonia
GI- e.g. Pancreatitis
GU- e.g. Pyelonephritis
AAA

15. Historical Red Flags? What do
they mean?

16. Gradual onset of back pain
 Malignancy or infection usually progress over weeks to months
Age <18
 Congenital, spondylolysis/spondylolisthesis
Age >50
 AAA, malignancy, compression fracture
Thoracic back pain
 Aortic dissection, SEA, Vertebral osteomyelitis, malignancy
 Most common site of malignant spine lesions is thoracic spines
(accounts for 60% of cases)
History

17. History
Pain > 6 weeks
 Malignancy, infection, spinal stenosis, spondylolysis
Hx of trauma
 Fracture
 MVA in normal, fall in elderly/osteoporotic
Fever/chills/night sweats, weight loss
 Malignancy or infection
Pain worse when supine
 Malignancy or infection

18. History
Pain worse at night
 Malignancy or infection
Pain despite good analgesics
 Malignancy or infection
Hx of malignancy
 Hello? Can you guess?
Hx of immunosup (corticosteroids)
 Infection, osteoporosis

19. History
Recent procedure causing bacteremia
 Infection
 GU or GI procedures
Hx of IV drug abuse
 Infection
Bowel or bladder incontinence
 SCCS
Saddle numbness
 Cauda compression

20. Red Flags
Examination
General appearance
o lies still Vs writhes in pain
Vital signs
o BP : ↑,↓, R to L difference
o Fever
Pulsatile abdominal mass
Spinal process tenderness
Neurological deficits

21. Physical Exam Red Flags? What
do they mean?

22. Examination
Fever
 Infection BUT fever may not always be present
(especially vertebral osteomyelitis)
Hypotension
 Ruptured AAA
Extreme hypertension
 AD, especially if thoracic back pain
Pulsatile abdominal mass
 AAA

23. Examination
BP difference > 20 mm Hg in arms
 AD, but: BP difference > 20mm Hg in arms only
found in 40% of aortic dissections
- 20% of normals have this difference
Spinal process tenderness
 Fracture, osteomylelitis, SEA, malignancy
Focal neuro signs
 SCCS

24. Examination
Acute urinary incontinence
 SCCS / Cauda compression
 Actually is overflow incontinence
 Check for urinary residual > 150cc post void
Perianal numbness, loss of rectal tone
 SCCS / Cauda compression

25. Neurological Examination of the Back
Straight Leg Raise (SLR) Test
Motor
 L3-S1
Sensory
 L3-S1
 Rectal tone
 Perianal sensation
 Urinary retention

26. SLR

27. SLR
+ SLR ∼ 80% sensitive for herniated
disk at L4-L5/L5-S1 (95% of DH)
Leg passively elevated up to 7o°
+ test = new/worsening pain below
knee along path of a nerve root
between 30-70° of elevation
Reproduction of back pain or pain in
the hamstring is NOT a + test

28. + test can be verified by:
Ankle dorsiflexion
Internal rotation
Head flexion
Crossed SLR
SLR

30. Knee extension Foot inversionFoot inversion 1st
toe extension Foot eversion

31. A Word about S1
S1 radiculopathy cause weakness of plantar flexion,
but is difficult to detect until quite advanced
To illicit have the patient raise up on tip-toe three
times in a row, on one foot alone and then the other

33. Waddell Signs
≥3/5 signs more likely to have non-organic disease
 Excessive Tenderness
 Superficial: Widespread sensitivity to light touch of the
skin over a wide area of the lumbar skin
 Nonanatomic: felt over a wide area, not localized to one
structure, and often extends to the thoracic spine,
sacrum, or pelvis
 Stimulation
 Axial loading: ↑LBP with light pressure on skull while
standing
 Rotation: ↑LBP with passive rotation of shoulders and
pelvis in same plane, in standing position

34.  Distraction
 Inconsistent findings when patient is distracted, most
commonly seen when testing sitting versus supine SLR
 Regional Disturbance
 Motor: Generalized giving way or cogwheel resistance in
manual muscle
 Sensory: Glove or stocking, nondermatomal loss of sensation
 Overreaction
 Disproportionate verbalization or facial expression with
movement
 Assisted movement
 Rigid or slow movement
 Collapsing
Waddell Signs

35. Caution!
use in conjunction with entire presentation and not
as sole basis of discounting a patient’s symptoms
Waddell Signs

36. Diagnostic Studies
When is a diagnostic work-up required?
 When there are no red flags, a good history and physical
examination suffice
 When red flags are elucidated, further evaluation is
warranted

37. Laboratory Tests
Complete blood count (CBC)
Erythrocyte sedimentation rate (ESR)

38. Plain Radiography
There is a sense among many patients that they should receive
x-rays as part of their evaluation!
Plain radiographs rarely add helpful information in
establishing the diagnosis
X-ray early in the course of LBP do not improve outcomes or
reduce costs of care
They add cost, time and unnecessary radiation
Normal plain films do not exclude malignancy or infection in
patients with a suspicious history

39. Radiation Risks
Gonadal radiation from a two view x-ray of the
lumbar spine = radiation exposure from a CXR taken
daily for > 1 year!!
Oblique views substantially increase risks of
radiation and add little diagnostic information

40. Indications for Back X-rays
Age ≤18 years or ≥50 years
Constitutional symptoms
Pain > 6 weeks
History of traumatic onset
History of malignancy
Osteoporosis
Infectious risk (e.g. IVDU,
immunosuppression, indwelling
urinary catheter, steroids, skin
infection or UTI, recent procedures)
Progressive focal neurologic deficit

41. MRI
Gold standard for evaluation for
 epidural compression
syndromes
 spinal infection (osteomyelitis
and epidural abscess)
 spinal cord injury
 intervertebral disk herniation
(may be delayed 4-6 weeks)
*MRI evaluation to provide reassurance does not
lead to better prognosis

42. Management
Nonspecific back pain (∅radiculopathy/∅ red flags)
 important to educate patients that they will
respond to conservative management over 4-6
weeks (many respond well after several days)
 Approach to treatment is focused:
 analgesic medications (combination therapy)
 activity modification
 physical modalities

43. Analgesics
Paracetamol
Excellent analgesic
Proven efficacy comparable to NSAIDs
inexpensive
Small side effect profile in comparison to
NSAIDs
Recommended in the treatment for all
patients

44. NSAIDs
Most are equally efficacious
Lowest dose needed to reach pain reduction should
be attempted
COX-2 inhibitors should be used sparingly and only
after discussion with the patient about the risks
Analgesics

45. The most common recommended approach is to use
a combination of Paracetamol and NSAIDs
One suggested regimen =
Paracetamol 500-1000 mg QID
+/-
Ibuprofen 400-800 mg TID
or Naproxen 250-500 mg BID
Analgesics

46. Analgesics
Opiates
Liberal use recommended for patients with
moderate-severe pain
Allows patients to break pain cycle
Gives stronger option when exacerbations of pain
occur
Only for short period (7-10 days) to ↓ development
of dependence
Warn patients of problems of driving

47. Muscle Relaxants
e.g. Diazepam
Cause sedation + addiction with chronic use
May be useful if patient demonstrates significant
muscle spasm of the paraspinal musculature
Exert benefit only in first 4 days when muscular
spasm is at its peak (rarely a significant component
of symptoms after 1st
week of injury)
Analgesics

48. Activity Modification/Physical Modalities
Continue routine activities as tolerated + use pain as guide for
activity modification
Bed rest has no benefit and may ultimately be harmful in the
recovery (not even 2 days!)
Active exercise/back strengthening exercises not beneficial
during acute crisis
Moderate stretching and strengthening of abdominal muscles
and back muscles beneficial when acute pain subsides
Thermal and ice therapy ?marginally effective

49. Other Modalities
None of the following treatments has shown
significant improvement in the recovery rate from
acute LBP:
 Traction
 Diathermy
 Cutaneous laser therapy
 Ultrasound
 Corsets & Lumbar braces
 Homeopathy
 Acupuncture
 Massage
 TENS

50. Management directed at restoring function and
supporting adaptive techniques:
Exercise
Reduction in body weight
Improving cardiovascular fitness
Smoking cessation
Massage- beneficial when combined with exercise
Acupuncture-may be beneficial
TENS-no benefit
Spinal manipulation-no benefit
Subacute/Chronic LBP

51. Subacute/Chronic LBP
Activity Modification

53. Medications
Paracetamol/NSAID
Avoid opiates & muscle relaxants
Antidepressants- cyclic
antidepressants
Subacute/Chronic LBP

54. LBP with Sciatica
1% -4% of individuals with LBP
Young = herniated disc, Older = spinal stenosis
Herniated disk
 50% recover in 6 weeks
 5-10% ultimately require surgery
 Surgery beneficial only in first 2 years
 No difference in symptoms at 4 and 10 years post
operatively

55. Management similar to patient with uncomplicated
LBP
Analgesics- Paracetamol, NSAIDs, short-term opiates
Activity- routine, use pain as limiting factor
Epidural steroid injection- mild-moderate pain
reduction
Must be diligent to detect progressive neurological
function
Patient should be educated to return earlier if the
symptoms are worsening
LBP with Sciatica

56. Indications for Referral
 Cauda equina syndrome – bowel and bladder dysfunction, saddle
anesthesia, bilateral leg weakness and numbness = surgical
emergency
 Suspected spinal cord compression – acute neurologic deficits in a
patient with cancer and risk of spinal metastases
 Progressive or severe neurologic deficit
 Neuromotor deficit that persists after 4-6 weeks of conservative
therapy
 Persistent sciatica, sensory deficit, or reflex loss after 4-6 weeks in a
patient with positive SLR , consistent clinical findings
 Fractures

57. Conclusions
Back pain is a costly and common problem
Evaluation done best by categorizing into 3 categories:
nonspecific back pain/back pain with radiculopathy/back
pain with specific cause
Systematic approach is key. Know your red flags well!
Remember radiation risk and x-ray only when indicated
Chronic back pain is complex and needs comprehensive
approach

59. Thank
You!