Lumbar Spine Conditions · 2019-11-26 · Lumbar Spine Conditions Evidence-Based Approach to Diagnosis and Triage Anthony J. Lisi, DC Chiropractic Program Director, Department of

Lumbar Spine Conditions Evidence-Based Approach to Diagnosis and Triage

Anthony J. Lisi, DC

Chiropractic Program Director, Department of Veterans AffairsAssociate Research Scientist, Yale Center for Medical Informatics

Acute LBP

Serious Pathology

• Cancer• Infection• Acute CES

Fracture

• Trauma• Bone

weakening

Inflammatory

• Anklyosingspondylitis

Radiculopathy

• Herniated disc

• Spinal stenosis

Non-specific

• Mechanical

<1% ~1% ~1.4% ~10% >85%

Prevalence

Diagnostic Certainty

EB management approach

Serious Pathology

• Cancer• Infection• Acute CES

Fracture

• Trauma• Bone

weakening

Inflammatory

• Anklyosingspondylitis

Radiculopathy

• Herniated disc

• Spinal stenosis

Non-specific

• Mechanical

<1% ~1% ~1.4% ~10% >85%

Prevalence

Rule out serious/clearly treatable pathology

• Appropriate referral as indicated

Identify radiculopathy or non-specific LBP

• Reassure patients• Consider management options

EB diagnostic approach• Strategies

• Not over-testing those with benign pathology• Not missing those with serious/treatable disease

Chou R et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91.

Diagnostic approach

Risk factors for cancer ActionWeak Age >50

orHistory of cancer

Conservative tx trial and monitor

Significant History of cancerand any 1 of

Unexplained weight lossAge >50No improvement after 1 mo

Xray and ESR

High Positive xray/ESRand/or

High clinical suspicion

MRI w/contrast*

*Need recent creatinine to calculate eGFR

Diagnostic approach

Risk factors for infection ActionFeverIVDURecent infection/procedure

MRI w/contrastESR

Diagnostic approach

Risk factors for cauda equina syndrome ActionUrinary retentionBowel/bladder incontinenceSaddle anesthesiaMultilevel motor deficits

MRI

Diagnostic approach

Risk factors for vertebral fracture ActionAny age Significant trauma X-ray

Older adults Known osteoporosisCorticosteroid use

X-ray

Diagnostic approach

Risk factors for AS ActionYounger patients

Morning stiffnessBetter with exerciseAlternating buttock painPain awakens during later stage of sleep

X-ray

ESR / CRPHLA-B27

Diagnostic approach

Risk factors for lumbar radiculopathy ActionHerniated disc LBP with Radicular leg pain

(L4, L5, S1)+ SLR and/or +WLR

Conservativetreatment trial

If candidate for ESI or surgery MRI(EMG/NCV?)

Spinal stenosis Radiating leg painOlder agePseudo-claudication

Conservativetreatment trial

If candidate for ESI or surgery MRI(EMG/NCV?)

Non-specific LBP (~85%)• Likely reflects a spectrum

• Physical pain generators• Accurate diagnosis not often possible• Frustration for patients and providers

• Varying degrees of psychosocial factors

0%

20%

40%

60%

80%

100%

Patient 1 Patient 2 Patient 3

Bio

Bio Bio

Psycho

Psycho

Psycho

Social Social

Social

Patient Suffering

Biopsychosocial model

Non-specific LBP• After other causes ruled out:

• Reassurance• Avoid over-medicalization

• Consider EB treatment options

Recommendations

Acute/subacute (0–12 weeks)

Chronic(>12 weeks)

• Superficial heat• Spinal manipulation, massage,

acupuncture

• Exercise, yoga, tai chi• Spinal manipulation, massage,

acupuncture, low-level laser• Cognitive behavioral therapy,

operant therapy• Mindfulness-based stress

reduction, progressive relaxation

• If above inadequate, consider ibuprofen or skeletal muscle relaxant

• If above inadequate, consider 1) ibuprofen, then 2) tramadol or duloxetine

Qaseem et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14.

CHIROPRACTIC ADJUSTMENT

Chiropractic adjustment

Cavitation based

• HVLA thrust techniques

Non-cavitation based

• Mobilization techniques• Impulse instrument

techniques• Positional techniques

Spinal Manipulation

Spinal manipulation effects in-vivo• Lumbar intradiscal pressure

• Lisi AJ et al. Measurement of in vivo lumbar intervertebral disc pressure during spinal manipulation: a feasibility study. J Appl Biomech. 2006 Aug;22(3):234-9.

• Lumbar apparent diffusion coefficient• Wong et al. Differential patient responses to spinal manipulative therapy and their relation to spinal degeneration

and post-treatment changes in disc diffusion. Eur Spine J. 2019 Feb;28(2):259-269.

Mechanism

• Facet gapping• ↑ ROM• ↓ stiffness

• Mechanoreceptor response• Analgesia• Muscle tone

• Disc effects• Physiological pressures• Increased ADC

PSYCHOSOCIAL

Variable presentations

0%

20%

40%

60%

80%

100%

Patient 1 Patient 2 Patient 3

Bio

Bio Bio

Psycho

Psycho

Psycho

Social Social

Social

Patient Suffering

Chief complaint, clinical, imaging and lab findings identical

Considerations for MSK Providers

Patient

Do psychosocial factors play a

prominent role?

Can I address adequately in my

clinic?

When (and how) to refer to specialists?

Does the patient suffer from mental

illness?When (and how) to refer to specialists?

Approaches to psychosocial factors• In-office

• Goal-setting• Motivational Interviewing

• Specialist referral• Cognitive Behavioral Therapy for Chronic Pain

SMART Goal Format

•Specific•Measurable•Action Oriented•Realistic•Time-bound

Goals

Generic

• “I want to be more physically active”• “I should help more around the

house”• “I want to get my stress under

control”

SMART

• “I will go for a walk at least twice a week”

• “I will cook dinner every other day”• “I will practice the meditation tape

every night”

Resource LNI.WA.GOV

SUPPLEMENTARY MATERIALVA Chiropractic Program

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