Clinical assessment of backpain cmc

CLINICAL ASSESSMENT CLINICAL ASSESSMENT OF BACKPAINOF BACKPAIN

Dr. Anupam MahajanDr. Anupam Mahajan

LecturerLecturer

Department of OrthopaedicsDepartment of Orthopaedics

““Back Pain is an Illness Back Pain is an Illness in search of a Disease”in search of a Disease”

Williams ME, Haddler NM. N Engl J Med 1983;308:1357-Williams ME, Haddler NM. N Engl J Med 1983;308:1357-6060

Fact or Fiction

The work I do is the main cause of my bad back

FICTION

.

• Physical demands of work are a risk fact in the onset of back pain BUT overall the non work, individual and unidentified factors are more important.

Fact or Fiction

I have back pain I will get worse and may ultimately have to have an operation !

FICTION

•Most adults (60-80%) experience back pain at some time and it frequently reoccurs, but acute attacks are usually brief and self limiting.

Fact or FictionIf I hurt my back I should go to bed

and rest until I feel better ( I should rest and let pain be my guide!)

FICTION

• Prolonged resting weakens the muscles which support the back and can hinder recovery. Bed rest for 2-7 days is worse than no treatment

Fact or FictionFact or FictionThe way I feel about my bad back will determine The way I feel about my bad back will determine

how likely it is to get worse !how likely it is to get worse !

FACT

• If you think of yourself as a victim of the work you do you are more likely to get worse. Being positive about getting back to normal helps you to recover.

Fact or Fiction

X Rays and scans will not always show up the causes of back pain.

FACT

• In patients with non specific low back pain X ray and MRI findings do not match well with symptoms or work capacity

ANATOMY Anterior Column

-- anterior disc and vertebra, ant. long. ligament

Middle column-- posterior disc and vertebra, post. long. ligament

Posterior column-- bones: facet joints, pedicles, transverse processes, laminae, spinous processes-- ligaments: lig. flavum, interspinous, others

ANATOMY

Definitions

Acute LBP: <6 weeksSubacute LBP: >6 weeks but <3

months Chronic LBP: >3 monthsRecurrent LBP: Acute LBP in a patient

who has had previous episodes of LBP from a similar location, with asymptomatic intervening intervals.

Epidemiology – quick stats

90% of people experience back pain in their 90% of people experience back pain in their lifetime, and at least 50% have a recurrent lifetime, and at least 50% have a recurrent episodeepisode

80% of people seek care at some point for ALBP80% of people seek care at some point for ALBP

fifth most common reason to visit a physician fifth most common reason to visit a physician

50% of working persons have back pain every year

number one cause of disability under 45yrs

85% have no definitive diagnosisDeyo et al. JAMA 1992;268:760

<2% have disc herniation, <1% have malignancy

Causes of low back pain of low back pain

Why do we want to know the cause?

Guide our treatmentPatients want to know whyWe want to know why

Pain sensitive structures

Muscles & ligaments

Vertebral body periosteum

Dura Facet Joints Discs - AF Nerves Epidural veins

Common Sources of LBP

Disc 1. posteriorly - sinu vertebral nn. 2. laterally - gray rami communicantes a. branches of ventral rami 3. various types of nerve endings up to ½ annulus depth

Targets for dorsal primary ramus 1. facet joints

2. interspinous ligaments

3. back muscles

VPR

DPR

GRCSVN

Acute Back PainAcute Back Pain

Differential Differential Diagnosis

Mechanical Low Back or Leg Pain 97%

Nonmechanical Spinal Conditions 1%

Visceral Diseases 2%

Mechanical Low Back or Leg Pain (97%)

Lumbar strain/sprain Lumbar strain/sprain 70% 70% Degenerative process Degenerative process 10%10%Herniated discsHerniated discs 4% 4%Spinal stenosisSpinal stenosis 3% 3%Compression fxCompression fx 4% 4%SpondylolisthesisSpondylolisthesis 2% 2%Traumatic fracture Traumatic fracture <1%<1%Congenital Congenital <1%<1%SpondylolysisSpondylolysis Internal disc disruptionInternal disc disruption

Nonmechanical Spinal Conditions (1%)

Neoplasia 0.7%Neoplasia 0.7% multiple myelomamultiple myeloma metsmets lymphoma/leukemialymphoma/leukemia spinal cord tumorsspinal cord tumors retroperitoneal tumorsretroperitoneal tumors primary vert. Tumorsprimary vert. Tumors

Infection 0.01%Infection 0.01% osteomyelitisosteomyelitis septic diskitisseptic diskitis paraspinous abscessparaspinous abscess shinglesshingles

Inflammatory arthritis Inflammatory arthritis 0.3%0.3% ankylosing spondylitisankylosing spondylitis psoriatic spondylitispsoriatic spondylitis Reiter’s syndromeReiter’s syndrome Inflammatory bowel Inflammatory bowel

diseasedisease Paget’s disease Paget’s disease Scheuermann’s Scheuermann’s

diseasedisease

Visceral Disease (2%)Visceral Disease (2%)

Disease of pelvic Disease of pelvic organsorgans prostatitisprostatitis endometriosisendometriosis chronic PIDchronic PID

Renal diseaseRenal disease nephrolithiasisnephrolithiasis pyelonephritispyelonephritis perinephric abscessperinephric abscess

Aortic aneurysmsAortic aneurysms Gastrointestinal Gastrointestinal

diseasesdiseases pancreatitispancreatitis cholecystitischolecystitis penetrating ulcerpenetrating ulcer

Causes of low back painCauses of low back pain

Things that need:Things that need:

URGENT workupURGENT workupURGENT referralURGENT referralURGENT treatmentURGENT treatment

““Red Flag”Red Flag” signs signs

Watch out forWatch out for

History of traumaHistory of traumaWeight loss, malaise, feverWeight loss, malaise, feverNumbness, weakness,Numbness, weakness, incontinenceincontinence

Fracture

Tumor,infection

Cauda equina

HISTORY HISTORY • Onset, Duration, ProgressionOnset, Duration, Progression• LocationLocation• CharacterCharacter• Exacerbating and relieving factorsExacerbating and relieving factors• RadiationRadiation

• Previous episodes (course, treatment)Previous episodes (course, treatment)• Any other joint inv, morning stiffnessAny other joint inv, morning stiffness• Medical history (CA, osteoporosis, infections, Medical history (CA, osteoporosis, infections,

etc…)etc…)• Drugs/medications (IVDU, steroids)Drugs/medications (IVDU, steroids)• Systemic symptoms (fever, sweats, wt. loss, etc…)Systemic symptoms (fever, sweats, wt. loss, etc…)• Function (ability to work, care for self)Function (ability to work, care for self)

RED FLAGS – HISTORYRED FLAGS – HISTORY

BB – bowel/bladder – bowel/bladder AA – awakening (night-time), accident (trauma) – awakening (night-time), accident (trauma) CC – cancer, constitutional symptoms – cancer, constitutional symptoms KK – chronic disease – chronic disease

PP – parasthesia, pharmacy (steroids, IVDU) – parasthesia, pharmacy (steroids, IVDU) AA – age >55 or <20 – age >55 or <20 II -- infection, inactivity (worse at rest) -- infection, inactivity (worse at rest) NN – neurologic deficit – neurologic deficit SS – subacute (lasting >6wks), surgery (previous) – subacute (lasting >6wks), surgery (previous)

PHYSICAL EXAMPHYSICAL EXAM1. Inspection1. Inspection2. ROM2. ROM3. Palpation3. Palpation4. Motor4. Motor5. Sensation5. Sensation6. Reflexes6. Reflexes7. Straight leg raise7. Straight leg raise8. Abdominal exam8. Abdominal exam9. Vascular exam9. Vascular exam10. Other (as guided by above e.g. chest 10. Other (as guided by above e.g. chest

expansion)expansion)

INSPECTIONINSPECTION

GaitGait

PosturePosture-- head/shoulders, -- head/shoulders, listing, flxn/extn, pelvic listing, flxn/extn, pelvic tilt tilt

Muscle balance, Muscle balance, HabitusHabitus

AlignmentAlignment

Appley’s Textbook of Orthopaedics, 8th edn

PALPATION AND PERCUSSIONPALPATION AND PERCUSSION

Bones Bones -- tenderness or deformity over -- tenderness or deformity over spinous processesspinous processes

JointsJoints

-- facet and sacroiliac joint -- facet and sacroiliac joint tendernesstenderness

MusclesMuscles

-- paraspinal tension and -- paraspinal tension and trigger pointstrigger points

RANGE OF MOTIONRANGE OF MOTION

often very limited globally often very limited globally secondary to pain -- secondary to pain -- perform slowly with perform slowly with physical supportphysical support

FlexionFlexion (normal = 90 (normal = 90 degrees , >5 cm by degrees , >5 cm by Modified Schober’s Modified Schober’s method)method)

Lateral bendingLateral bending (normal = 45 degrees, (normal = 45 degrees, hand to knee) hand to knee)

RotationRotation (normal = (normal = 90 degrees, stabilize 90 degrees, stabilize hips)hips)

RANGE OF MOTIONRANGE OF MOTION ExtensionExtension (normal = 30 degrees) (normal = 30 degrees)

-- narrows canal, loads facet joints-- narrows canal, loads facet joints

CombinationsCombinations

-- extension + rotation loads ipsilateral facet-- extension + rotation loads ipsilateral facet

Hip ROM should also be assessedHip ROM should also be assessed

-- to r/o articular disorders, identify muscular -- to r/o articular disorders, identify muscular problems (e.g. flexion contracture may problems (e.g. flexion contracture may increase disc pressure)increase disc pressure)

NEUROLOGIC TESTINGNEUROLOGIC TESTING Motor examMotor exam (screen = squat, heel/toe (screen = squat, heel/toe

walks)walks)

Sensory examSensory exam (screen = light touch of foot, (screen = light touch of foot, knee)knee)

ReflexesReflexes (ankle, patellar, Babinski)(ankle, patellar, Babinski)

SLRSLR (sensitive but not specific for (sensitive but not specific for herniation of disc herniation of disc

+/- Others+/- Others (e.g. femoral stretch, auton, etc )(e.g. femoral stretch, auton, etc )

Straight Leg Raise -- SLRStraight Leg Raise -- SLR

positive SLR produces positive SLR produces radicular radicular painpain that radiates below one or that radiates below one or both knees, both knees, notnot pain in the pain in the buttock, thigh or backbuttock, thigh or back

improved by decreasing improved by decreasing elevation, and worsened by elevation, and worsened by ankle dorsiflexionankle dorsiflexion

crossed SLR) is much more crossed SLR) is much more specific (but not sensitive) for specific (but not sensitive) for disc herniationdisc herniation

Motor examMotor exam Bulk and ToneBulk and Tone

Power (1 to 5)Power (1 to 5)-- squat (L3,-- squat (L3,44), heel walk (L4,), heel walk (L4,55), toe walk (S1), ), toe walk (S1), -- more detailed testing if any neurologic deficit:-- more detailed testing if any neurologic deficit:no motor at L1no motor at L1hip addn (L2)hip addn (L2)hip flexn (L2,3) hip flexn (L2,3) knee extn (L3,4)knee extn (L3,4)ankle dorsiflexn (L4,5)ankle dorsiflexn (L4,5)hallucis extn (L5)hallucis extn (L5)hip extn (S1)hip extn (S1)ankle extn (S1,2)ankle extn (S1,2)

Sensory examSensory exam

light touch to light touch to medial foot (L4), medial foot (L4), first web space (L5) first web space (L5)

and and lateral foot (S1) lateral foot (S1)

will detect most clinically will detect most clinically significant deficits significant deficits

UMN vs. LMNUMN vs. LMNUpper Motor NeuronUpper Motor Neuron

increased toneincreased tone hyper-reflexiahyper-reflexia up going Babinskiup going Babinski diffuse weakness diffuse weakness

no fasciculationsno fasciculations normal bulknormal bulk

Lower Motor NeuronLower Motor Neuron

decreased tonedecreased tone decreased reflexesdecreased reflexes down going Babinskidown going Babinski focal weaknessfocal weakness

fasciculations fasciculations muscle atrophymuscle atrophy

Red Flags – Physical findingsRed Flags – Physical findings(things that make you go hmmm….)(things that make you go hmmm….)

feverfever saddle anaesthesiasaddle anaesthesia urinary retention or loss of rectal tone urinary retention or loss of rectal tone positive Babinski, other UMN signs positive Babinski, other UMN signs

bilateral, severe, progressive, or persistent (<1mo.) bilateral, severe, progressive, or persistent (<1mo.) neurologic deficitsneurologic deficits

bony tenderness to palpation or percussionbony tenderness to palpation or percussion abnormal abdominal or respiratory examabnormal abdominal or respiratory exam

Tests for SI Joint Tests for SI Joint

FABER test

Pelvic rock/ Compression test

Distraction test

Pump Handle test

Ganslens test

Other testsOther testsMilgram test- hold heels 2 in. off

table for 30 sec., if can hold intrathecal pathology ruled out

Tests for MalingeringPhlip’s testAird’s TestMagnuson TestHoover test

Signs of Non-organic Pain (Waddell)Signs of Non-organic Pain (Waddell)

1. Superficial tenderness (e.g. skin rolling)1. Superficial tenderness (e.g. skin rolling)

2. Pain with simulated testing (e.g. axial 2. Pain with simulated testing (e.g. axial loading)loading)

3. Inconsistent responses with distraction (e.g. 3. Inconsistent responses with distraction (e.g. clenched fist) clenched fist)

4. Non-anatomic neurologic deficits4. Non-anatomic neurologic deficits

5. Over-reaction and “pain behaviours”5. Over-reaction and “pain behaviours”

3 of 5 criteria present is suggestive of non-3 of 5 criteria present is suggestive of non-organic painorganic pain

Approach to DiagnosisApproach to DiagnosisBack pain

Localised to back Radiation Red Flag

Primarily back pain Referred

transient intermitent

claudication

Strain /sprainHip path

Facet jointIVD

<20 listhesis

20-40 Disc prol

Elderly Comp #

OA

Spinal stenosis

Constitutional symp

Trauma Neuro+ bowel bladder

Tumorinfection

fracture Cauda equina

Relieved by rest Not relieved by restRelieved by exercise

AS

Criteria for Radiographs (A/P, lateral)Criteria for Radiographs (A/P, lateral)

basically, basically, any red flags on history or any red flags on history or physicalphysical::

loss of lumbar lordosisloss of lumbar lordosis

scoliosis / kyphosis/ listhesis/ lysisscoliosis / kyphosis/ listhesis/ lysis

osteopenia / bone destruction osteopenia / bone destruction (30%)(30%)

disc spacedisc space

pediclespedicles

Blood WorkBlood Work

Blood work (with red flags only… be specific)Blood work (with red flags only… be specific)CBC, ESR CBC, ESR Blood cultures (+/- Montoux)Blood cultures (+/- Montoux)Alkaline Phosphatase, calcium, Phos, TP, albuminAlkaline Phosphatase, calcium, Phos, TP, albuminSerum protein electrophoresis, PSASerum protein electrophoresis, PSAHLA-B27HLA-B27

Other non-MSK-related tests as indicatedOther non-MSK-related tests as indicated

Initial Investigations -- findingsInitial Investigations -- findings

ConditionCondition RadiographsRadiographs Blood WorkBlood Work

Disc Disc

HerniationHerniation

narrowed disc space(s)narrowed disc space(s)

(not an acute change)(not an acute change)

NilNil

OsteoarthritisOsteoarthritis narrow joint space, cysts narrow joint space, cysts osteophytes, erosionsosteophytes, erosions

Nil (normal ESR)Nil (normal ESR)

SpondylolisthesisSpondylolisthesis Abnormal movement on Abnormal movement on flexion/extension viewsflexion/extension views

NilNil

Initial Investigations -- findingsInitial Investigations -- findings

ConditionCondition RadiographsRadiographs Blood WorkBlood Work

InfectionInfection often normal often normal

+/- changes at 10-14days +/- changes at 10-14days

CBC (WBC), ESR CBC (WBC), ESR

blood culture (60-80%)blood culture (60-80%)

TumourTumour erosions or blastic lesions,erosions or blastic lesions,

mets may invade pediclesmets may invade pedicles

(winking owl sign on AP)(winking owl sign on AP)

CBC (anemia), ESRCBC (anemia), ESR

PSA, electrophoresis, PSA, electrophoresis, alkaline phosphatasealkaline phosphatase

AnkylosingAnkylosing

SpondylitisSpondylitis

sacroiliac joints sacroiliac joints

(sclerosis, narrowing),(sclerosis, narrowing),

bamboo spine (squared)bamboo spine (squared)

ESRESR

HLA-B27 (90% +)HLA-B27 (90% +)

Criteria for CT/MRICriteria for CT/MRI

Significant neurologic findingsSignificant neurologic findings Unstable fracture or otherwise suspicious XRUnstable fracture or otherwise suspicious XR Significant red flags (despite normal XR, blood Significant red flags (despite normal XR, blood

work)work) No improvement after 6wksNo improvement after 6wks

CT better for bone, +/- tumour,CT better for bone, +/- tumour, MRI better for restMRI better for rest

Criteria for Bone ScanCriteria for Bone Scan

11.. MalignancyMalignancy

-- find early lesions (especially blastic)-- find early lesions (especially blastic)

2.2. InfectionInfection

-- Gallium scan most specific (pos. early)-- Gallium scan most specific (pos. early)

3. Occult fracture3. Occult fracture

Other InvestigationsOther Investigations

DensitometryDensitometryosteoporosisosteoporosis

ElectromyographyElectromyographysubtle, persistent neurologic symptoms e.g. subtle, persistent neurologic symptoms e.g.

spinal stenosis or spinal cord myelopathyspinal stenosis or spinal cord myelopathysuspected peripheral nerve lesion suspected peripheral nerve lesion sx of myopathysx of myopathy

EmergenciesEmergencies

Cauda Equina Syndrome / Spinal Cord Cauda Equina Syndrome / Spinal Cord CompressionCompression

only difference between the two is level affectedonly difference between the two is level affected

Etiology:Etiology: tumour, hematoma, abscess, fracture, tumour, hematoma, abscess, fracture, trauma, Spondylolisthesis, trauma, Spondylolisthesis,

HistoryHistory: : back pain is usually mild/mod.back pain is usually mild/mod.Numbness, paresthesiasNumbness, paresthesias fecal/urinary retention/incontinencefecal/urinary retention/incontinence

Cauda Equina Syndrome / Spinal Cord Cauda Equina Syndrome / Spinal Cord CompressionCompression

Physical examPhysical exam: : gait changes, gait changes, significant bilateral motor/sensory loss (e.g. saddle significant bilateral motor/sensory loss (e.g. saddle

anesthesia), anesthesia), Ankle areflexiaAnkle areflexialong tract signs, long tract signs, diminished rectal tone (60-80%), diminished rectal tone (60-80%), large post void residual (negative predictive value 99.99%)large post void residual (negative predictive value 99.99%)

Management:Management: XR, full spine MRI, XR, full spine MRI,

+/- steroids, surgery+/- steroids, surgery

Abdominal Aortic Aneurysm (AAA)Abdominal Aortic Aneurysm (AAA)

uncommon, but potentially lethal uncommon, but potentially lethal

RF: elderly, FHx, PVD (i.e.atherosclerosis)RF: elderly, FHx, PVD (i.e.atherosclerosis)

palpation for pulsatile mass is surprisingly palpation for pulsatile mass is surprisingly sensitive and specific, +/- bruit sensitive and specific, +/- bruit

Mechanical and Mechanical and Musculoligamentous Musculoligamentous

Back PainBack Pain

Diagnosis -- HistoryDiagnosis -- History

Disc Disc FacetFacet RootRoot StenosisStenosis

OnsetOnset (hrs—days)(hrs—days) (min--hrs)(min--hrs) (seconds)(seconds) (minutes)(minutes)

PainPain Back Back (radiates to (radiates to posterior posterior thigh(s))thigh(s))

Back Back (radiates to (radiates to buttock(s), buttock(s), lateral leg)lateral leg)

LegLeg

(unilateral, (unilateral, dermatome)dermatome)

Legs Legs

(bilateral)(bilateral)

DurationDuration wks—monthswks—months days--wksdays--wks sec-- minsec-- min minutesminutes

Activity Activity which which worsensworsens

bending, bending, lifting, lifting, ValsalvaValsalva

standing, standing, walkingwalking

as with discas with disc exercise, exercise, standingstanding

Diagnosis – physical examDiagnosis – physical exam

Disc Disc FacetFacet Root Root StenosisStenosis

ROMROM flexn hurts, flexn hurts, poor hip flexpoor hip flex

extn hurts, extn hurts, esp. with rotn esp. with rotn

flexn hurtsflexn hurts extn hurtsextn hurts

PalpnPalpn truncal tilt, truncal tilt, fxnl scoliosisfxnl scoliosis

pain over pain over facet jointfacet joint

pain with pain with nerve press.nerve press.

NilNil

NeuroNeuro NilNil NilNil dermatomaldermatomal

(sens/motor, (sens/motor, decr. reflex)decr. reflex)

(+ SLR)(+ SLR)

only if acute only if acute or v. severe or v. severe (UMN signs)(UMN signs)

PATHOPHYSIOLOGY OF DDDPATHOPHYSIOLOGY OF DDD

discs degenerate discs degenerate

compress the nerve root (compress the nerve root (sciaticasciatica) or spinal cord) or spinal cord

fissures and cracks occur in the annulus, and herniations of nucleusfissures and cracks occur in the annulus, and herniations of nucleus

reactive reactive osteophytesosteophytes

spinal stenosisspinal stenosis

spondylolisthesisspondylolisthesis

DISC HERNIATIONDISC HERNIATION 95% of disc herniations occur 95% of disc herniations occur

at L4/5 or L5/S1 because at L4/5 or L5/S1 because pressure is greatest therepressure is greatest there

disc most commonly herniate disc most commonly herniate posterolaterally, impinging on posterolaterally, impinging on the motor and sensory rami the motor and sensory rami (LMN signs) (LMN signs)

disc may also (rarely) herniate disc may also (rarely) herniate centrally, impinging on the centrally, impinging on the spinal cord itself (UMN signs)spinal cord itself (UMN signs)

DEGENERATIVE DISC DEGENERATIVE DISC DISEASEDISEASE

pain frompain from: : 1. disc damage (variable btw individuals) or 1. disc damage (variable btw individuals) or

2. root irritation by herniated discs2. root irritation by herniated discs

3. muscular inflammation/spasm3. muscular inflammation/spasm

therapy aimed at therapy aimed at pain controlpain control and and gentle ROMgentle ROM to to promote healing and prevent stiffness/weakeningpromote healing and prevent stiffness/weakening

secondary preventionsecondary prevention (improved flexibility, muscle (improved flexibility, muscle stabilizing, avoiding precipitating events, etc…) stabilizing, avoiding precipitating events, etc…)

FACET DISEASEFACET DISEASE

pain frompain from:1. pinching of synovium :1. pinching of synovium

2. underlying OA 2. underlying OA

3. secondary muscular 3. secondary muscular inflammation/spasminflammation/spasm

responds well to responds well to physical therapiesphysical therapies (stretch/relax (stretch/relax muscle spasm and move joint to allow realignment) muscle spasm and move joint to allow realignment)

secondary preventionsecondary prevention (prevent misalignment) (prevent misalignment)

SPONDYLOLISTHESISSPONDYLOLISTHESIS

Six typesSix types:: congenital /dysplasticcongenital /dysplastic 20%20% Lytic / isthmicLytic / isthmic 50%50% DegenerativeDegenerative 25%25% Post-traumaticPost-traumatic PathologicalPathological Post-opPost-op

SxSx: local pain : local pain oror radiculopathy radiculopathy oror cord compression (rare)cord compression (rare)

Spinal StenosisSpinal StenosisEtiology:Etiology:

DDD (i.e. typically elderly patients), DDD (i.e. typically elderly patients), trauma, trauma, congenital defectscongenital defectsfacet joint arthropathyfacet joint arthropathybony or lig thickening bony or lig thickening

History:History: most patients have hx of chronic back most patients have hx of chronic back

painpain 90% have predominantly leg 90% have predominantly leg

symptoms symptoms claudication (pain with exercise) claudication (pain with exercise) Must distinguish from vascular Must distinguish from vascular

Physical:Physical: signs are unreliable – may signs are unreliable – may

have thigh pain with sustained lumbar have thigh pain with sustained lumbar extension (>30 sec)extension (>30 sec)

Vascular Vs. Neurogenic Vascular Vs. Neurogenic ClaudicationClaudication

NeurogenicNeurogenic

ppt’d by extensionppt’d by extension onset variable with onset variable with

walkingwalking relief after 2-10 relief after 2-10

minutesminutes bilateral parasthesia bilateral parasthesia

+/- neuro deficit+/- neuro deficit

VascularVascular

no positional effectno positional effect onset after set onset after set

distancedistance relief under 2 minutesrelief under 2 minutes muscular cramping, muscular cramping,

often lateralizesoften lateralizes

OSTEOPOROSISOSTEOPOROSIS

Etiology: Etiology: primary (post-menopausal or elderly)primary (post-menopausal or elderly) secondary secondary

drugs—steroids, anticonvulsants; drugs—steroids, anticonvulsants; endocrine– thyroid/parathyroid xs,hypoestrogenism; endocrine– thyroid/parathyroid xs,hypoestrogenism; hepatic or renal disease; hepatic or renal disease; MalabsorptionMalabsorption rheumatoidrheumatoid

History: History: acute or chronic back pain (ache) with or without fracture acute or chronic back pain (ache) with or without fracture

or traumaor trauma may have history of other fractures (long bones)may have history of other fractures (long bones)

OsteoporosisOsteoporosis

Physical examn: loss of height, kyphosis loss of height, kyphosis

and/or scoliosis and/or scoliosis +/- bony tenderness or +/- bony tenderness or

neurologic sx neurologic sx

Investigations: plain XR (look for fracture, or plain XR (look for fracture, or

late changes)late changes) Densitometry (1-2 = Densitometry (1-2 =

osteopenia, >2.0 = osteopenia, >2.0 = osteoporosis)osteoporosis)

FracturesFractures

Etiology: Etiology: trauma, tumour, osteomalacia, trauma, tumour, osteomalacia, osteoporosisosteoporosis

History: History: sudden/localized pain +/- radicular sx, sudden/localized pain +/- radicular sx, trauma, old age, hx CA, steroid use or other RF trauma, old age, hx CA, steroid use or other RF for osteoporosis for osteoporosis

PhysicalPhysical: bony tenderness +/- neurologic deficit: bony tenderness +/- neurologic deficit

InvestigationsInvestigations: plain films, +/- CT, +/- bone scan: plain films, +/- CT, +/- bone scan

TuberculosisTuberculosis 50% of skeletal 50% of skeletal

tuberculosistuberculosis Mostly affects the dorsal Mostly affects the dorsal

and dorsolumbar spineand dorsolumbar spine Children and adolescentsChildren and adolescents Constitutional symptomsConstitutional symptoms Paradiscal most commonParadiscal most common

X-ray – loss of disc spaceX-ray – loss of disc space MRI- cord inv, abscesses MRI- cord inv, abscesses

OsteomyelitisOsteomyelitis Etiology:Etiology: usu. usu. hematogenous spread -- S.aureus hematogenous spread -- S.aureus

and gram negatives most common in vertebrae and gram negatives most common in vertebrae

HistoryHistory: : usually oldusually old immunocompromised (DM, steroids, chemotherapy, HIV, immunocompromised (DM, steroids, chemotherapy, HIV,

transplant, etc… )transplant, etc… ) pain aching, constant, varying severity, usu. pain aching, constant, varying severity, usu. SubacuteSubacute +/- constitutional symptoms +/- constitutional symptoms +/- history of recent infection (skin, UTI, bacteremia)+/- history of recent infection (skin, UTI, bacteremia)

OsteomyelitisOsteomyelitisPhysical:Physical: bony tenderness, painful bony tenderness, painful

ROM, fever (only 30%)ROM, fever (only 30%)

Diagnosis:Diagnosis:Gallium scanGallium scan positive earlier than XR (by positive earlier than XR (by

2-3days?) 2-3days?) blood cultureblood culture positive 60-80% positive 60-80% XRXR findings late – osteopenia, disc findings late – osteopenia, disc

space loss, soft tissue shadowsspace loss, soft tissue shadows

TumoursTumours Back pain may result fromBack pain may result from

tumours in the bony spine tumours in the bony spine or the adjacent soft tissues (fracture or pressure)or the adjacent soft tissues (fracture or pressure)

Primary MalignancyPrimary Malignancy-- sarcoma more common in children/young adults -- sarcoma more common in children/young adults -- multiple myeloma more common in adults (anemia, -- multiple myeloma more common in adults (anemia, renal failure, bone pain, constitutional sx) renal failure, bone pain, constitutional sx)

MetastasisMetastasis-- much more common than primary malignancy-- much more common than primary malignancy-- -- prostateprostate, thyroid, , thyroid, breastbreast, lung, kidney, lung, kidney

TumoursTumours

risk factors for malignancyrisk factors for malignancy (identify virtually all (identify virtually all pts): pts):

-- age over 50 (80%) -- age over 50 (80%) -- previous hx CA (33%) -- previous hx CA (33%) -- constitutional sx-- constitutional sx -- no relief with bed rest -- no relief with bed rest -- duration greater than one month-- duration greater than one month

TumoursTumours

x raysx rays

CTCT

Bone ScanBone Scan

Investigations for primaryInvestigations for primary

SpondyloarthropathiesSpondyloarthropathies

seronegative rheumatic diseasesseronegative rheumatic diseases may cause may cause sacroilitissacroilitis or or spondylitisspondylitis as well as peripheral arthritis as well as peripheral arthritis and enthesopathyand enthesopathy

extra-articular featuresextra-articular features – incl. – incl. iritisiritis, conjuctivitis, , conjuctivitis, apthous ulcers, aortitis, resp/kidney involvement, apthous ulcers, aortitis, resp/kidney involvement, etc…) etc…)

Ankylosing spondylitisAnkylosing spondylitis >> Reiter’s syndrome > >> Reiter’s syndrome > Inflammatory Bowel Disease > Reactive arthritis > Inflammatory Bowel Disease > Reactive arthritis > Psoriatic arthritisPsoriatic arthritis

Ankylosing SpondylitisAnkylosing Spondylitis History:History:

insidious onset back/buttock pain at insidious onset back/buttock pain at rest (better with activity), rest (better with activity),

prolonged am stiffness (hours), prolonged am stiffness (hours), peripheral arthritis (20-30%), peripheral arthritis (20-30%), extra-articular features, extra-articular features, FHxFHx

Physical:Physical: decreased back ROM (all directions), decreased back ROM (all directions), loss of lumbar lordosis, loss of lumbar lordosis, decreased chest expansion decreased chest expansion sacroiliac joint tendernesssacroiliac joint tenderness

Diagnosis:Diagnosis: plain XR, plain XR, HLA-B27 (90%)HLA-B27 (90%)

MUSCULOLIGAMENTOUS PAINMUSCULOLIGAMENTOUS PAIN

may mimic mechanical back pain or occur may mimic mechanical back pain or occur along with italong with it

may perpetuate mechanical pathology, may perpetuate mechanical pathology,

lifestyle measureslifestyle measures especially important in especially important in secondary preventionsecondary prevention

Musculoligamentous PainMusculoligamentous Pain

MYOFASCIAL SYNDROMESMYOFASCIAL SYNDROMEScharacterized clinically by restricted characterized clinically by restricted

ROM, muscle tenderness, and trigger ROM, muscle tenderness, and trigger pointspoints

e.g. Piriformis, Gluteal, Iliopsoas, e.g. Piriformis, Gluteal, Iliopsoas, Quadratus lumborumQuadratus lumborum

Trigger PointsTrigger Points

taut bands/knots of muscle fibrestaut bands/knots of muscle fibres that that referrefer pain pain along the sensory nerve innervating the musclealong the sensory nerve innervating the muscle

result of result of primaryprimary muscle strain or muscle strain or secondarysecondary to an adjacent bony or soft tissue to an adjacent bony or soft tissue

inflammation/injury (i.e. non-specific)inflammation/injury (i.e. non-specific)

pressure may be a pressure may be a diagnostic and therapeuticdiagnostic and therapeutic* * maneuver (30 – 60 sec)maneuver (30 – 60 sec)

TREATMENT STRATEGIESTREATMENT STRATEGIES1. Activity

2. Stretching, ROM

3. Heat and cold

4. Analgesia +/- anti-inflammatory

5. Consider physiotherapy referral

6. Patient education

7. Put in a plug for prevention -- including smoking cessation, weight loss loss

Activity

Bed rest longer than 48hrs is contraindicated Avoiding irritating activities may shorten

episode

-- minimize lifting

-- avoid prolonged sitting if it aggravates (soft support in small of back while sitting to minimize)

-- change position often

Stretching and ROM ExercisesStretching and ROM Exercises

speed recovery and prevent recurrence

specific examples include:

-- gentle ROM in all directions

-- “cat” stretch (20-30x), esp. in am, lubricates facet jts

-- pelvic tilt exercises

-- “scissors” stretch for paraspinals, hamstrings

-- “rocker” stretch to lengthen iliopsoas muscles

Heat/ColdHeat/Cold

Cold in first 48 hrs -- 10 min on/off, or 20-30 min q2h-- analgesia and limits edema

Heat after 48hrs-- similar application as above-- analgesia, improves spasm/exercise

tolerance

contraindicated in circulatory or cognitive compromise

AcetaminophenAcetaminophen

first line therapy for ALBP (along with NSAID)

fewer side effects than other analgesics

equal analgesia to NSAIDS, but no anti-inflammatory

analgesia with NSAIDS is cumulative

NSAIDS

first line agents

excellent for analgesia +/- anti-inflammatory

side effects are relatively common (GI, renal, others)

regularity needed for anti-inflammatory effect

NSAIDSNSAIDS ibuprofen

indomethicin more potent, but also more toxic

ketorolac is $$, toxic, over-rated for non-colicky pain

naproxen is fairly $$, but has a longer half-life (12-24hrs) allowing for BID dosing

cox-2 inhibitors reasonable, less studied, less costly

Narcotics

analgesia may be no better than with NSAIDS

dependence/abuse

constipation

drowsiness, clouded judgment, decr. reaction time may limit use

Muscle Relaxants

some benefit if used as monotherapy acutely,

not for extended use, not first line

primary side effect is drowsiness (often BDZ, anti-H)

dependence may occur

Physiotherapy

modest benefit during acute episode of LBP

significant benefit in chronic LBP (decreases need for surgery) and in the prevention of ALBP

not indicated for patients with neurologic deficits

Chiropracty

some benefit in the management of acute mechanical back pain without radiculopathy or red flags

no proven benefit in chronic pain

Surgery

evidence of significant spinal cord compression

persistent neurologic deficit after 1 month of conservative therapy, plus CT/MRI pathology

severe, limiting spinal stenosis

success depends on selection – if above criteria strictly applied, long-term benefit in 70-80%

Other therapies

traction, traction, transcutaneous electrical nerve stimulation,transcutaneous electrical nerve stimulation, biofeedback, biofeedback, diathermy, diathermy, ultrasound, ultrasound, acupuncture, acupuncture, facet joint injectionsfacet joint injections trigger point injectionstrigger point injections

PreventionPrevention

Weight loss, Smoking cessationWeight loss, Smoking cessation Aerobic exerciseAerobic exercise

Postural change (neck/shoulders back, pelvic tilt)Postural change (neck/shoulders back, pelvic tilt) Back and hip stretchingBack and hip stretching Strengthening abdominal, back musculatureStrengthening abdominal, back musculature

Workplace ergonomicsWorkplace ergonomics Avoid precipitating activities (e.g. heavy lifting, Avoid precipitating activities (e.g. heavy lifting,

especially while bending, reaching, or twisting)especially while bending, reaching, or twisting)

History, exam, risk fs for RED FLAG

FU at 2 wksReturn to normal activity

No diag. testsReassurance

Patient educationPain relief necessary?

Symp trearment optionsEarly return to usual activityActivity alterationsNSAIDsShort- ms relaxant/opoidsBed rest optional- <2 dSpinal manipulation/physical therapy optional

Resume normal activity

Yes

No

No

Yes

No

FU at 2 weeksReturn to activity tolerance?

No Yes

Review response to initial treatmentReview risk factorsModify symptomatic treratment

Resume normal activity

FU at 2 weeksReturn to normal activity?

Yes

No

Acute back pain >4 weeks

NoYes

EMG/MCV radiculopathy?Imaging study [MRI,CT, myelography]Are imaging and neurologic evaluations concordant?

Specialist FU; nerve root, plexus or CNS problem?

Appropiate intervention

Consult specialistNeurological exam.

Clear nerve root level?

Consult spinal surgeon

Yes

No

No

Yes Yes

Yes

Risk factor for serious etiology present

Rapidly progresive neurological deficit

Immediate consutlation specialist

Spine fracture Cancer Infection

Plain X ray

Fracture + Fracture-

CBC, ESRCBC, ESR, DLC, UA

Other labHigh suspicion after 10 days

– MRI, bone scan

Evidence of serious disease?

SummarySummary

ALBP is extremely prevalent and preventableALBP is extremely prevalent and preventable

A good history and physical exam are highly A good history and physical exam are highly sensitivesensitive

While uncommon, serious etiologies must be While uncommon, serious etiologies must be identified (red flags) and investigatedidentified (red flags) and investigated

Most ALBP is secondary to soft tissue injury and is Most ALBP is secondary to soft tissue injury and is amenable to conservative physical therapiesamenable to conservative physical therapies

Chronic BackpainChronic Backpain

When it become chronicWhen it become chronic

More psychological disturbanceMore psychological disturbanceMore social consequencesMore social consequencesMore behavioral changesMore behavioral changes

More difficult to treatMore difficult to treat

Watch out for…Watch out for…

Mood problemsMood problems

DepressionDepressionAnxietyAnxietyPost-traumatic stressPost-traumatic stressSuicidal riskSuicidal risk

Watch out for…Watch out for…

Thought problemsThought problems

Mal-adaptative ideasMal-adaptative ideasBlaming themselves / othersBlaming themselves / othersWrong (even no) coping skillsWrong (even no) coping skills

Watch out for…Watch out for…

Behavioral problemsBehavioral problems

Interaction with othersInteraction with others

Compensation issuesCompensation issues

Watch out for…Watch out for…

Substance use problemsSubstance use problems

AlcoholAlcoholSedativesSedativesOpioidsOpioids

Pain can be a withdrawal symptomPain can be a withdrawal symptom

When it become chronicWhen it become chronic

Established treatment: multi-Established treatment: multi-modalitymodality

‘‘golden standard’golden standard’1 + 1 = 31 + 1 = 3ExpensiveExpensive

Applicable for all sorts of chronic painApplicable for all sorts of chronic pain

PhysiotherapyPhysiotherapy

Established treatmentEstablished treatment

Aerobic exerciseAerobic exerciseStrengthening exerciseStrengthening exerciseStretching exerciseStretching exercise

Some exercise is better than nothingSome exercise is better than nothing

Epidural steroidEpidural steroid

RadiculopathyRadiculopathy

Good previous responseGood previous response

Relatively simple and safeRelatively simple and safe

Spine surgerySpine surgery

Presence of pathologyPresence of pathology

Correlate with painCorrelate with pain

Neurological symptomsNeurological symptoms

Works well in selected casesWorks well in selected cases

Facet joint injectionFacet joint injectionDiagnostic criteriaDiagnostic criteria

Use of steroidUse of steroid

Joint v.s. nerve injectionJoint v.s. nerve injection

Technical difficultiesTechnical difficulties

No consensus in its roleNo consensus in its role

Trigger point injectionTrigger point injectionShort lastingShort lasting

Simple and safeSimple and safe

BotoxBotox

No consensus in its roleNo consensus in its role

AntidepressantsAntidepressants

Better pain reliefBetter pain reliefCan treat depressionCan treat depressionFunctionally unchangedFunctionally unchangedMore side effectsMore side effects

Can try, but watch out for side Can try, but watch out for side effectseffects

Behavioral therapyBehavioral therapy

Better than nothingBetter than nothingTime consumingTime consumingNeed expertiseNeed expertise

Limited availabilityLimited availability

ChymopapainChymopapain

SimpleSimpleConflicting outcome dataConflicting outcome dataCatastrophic side effectsCatastrophic side effects

Only for selected cases (and in good Only for selected cases (and in good hands)hands)

AccupunctureAccupuncture

Patients believe in itPatients believe in itDoctors’ blind spotDoctors’ blind spotNo outcome dataNo outcome data

As good (and expensive) as anything As good (and expensive) as anything elseelse

ChiropracticsChiropractics

Doubtful treatment:Doubtful treatment:Patients like itPatients like itDoctor’s don’t like itDoctor’s don’t like itSimpleSimple

No better than conventional therapyNo better than conventional therapy

Useless treatment:Useless treatment:

MagnetMagnet Can TV games treat low Can TV games treat low

back pain?back pain?

AromatherapyAromatherapy Can Dior treat low back Can Dior treat low back

pain?pain?

Useless treatment can cause harmUseless treatment can cause harm

ExpensiveExpensiveDefeating experienceDefeating experienceEnhance mal-adaptive behaviour eg: Enhance mal-adaptive behaviour eg:

doctor shopping, fixation on physical doctor shopping, fixation on physical causecause

Special casesSpecial cases

Failed back surgeryFailed back surgery

Avoid further surgeryAvoid further surgeryEpidural SteroidEpidural SteroidSpinal Cord StimulatorSpinal Cord Stimulator

Strict patient selection for better Strict patient selection for better outcomeoutcome

ConclusionsConclusions

We know too little about itWe know too little about itTreatment remained empiricalTreatment remained empiricalSimple is beautifulSimple is beautiful

Don’t work too hard (try it on your Don’t work too hard (try it on your boss)boss)