Suggests that optimal approach is unsure

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Trevor Goodwin
5 years ago
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2 An Important Issue One of the most common reasons for seeking medical attention, second only to respiratory issues 84% of adults will have low back pain at some point Wide variety of approaches for treatment Suggests that optimal approach is unsure Most episodes are self-limited Some suffer from chronic or recurrent courses, with substantial impact on quality of life

3 Epidemiology Almost any structure in the back can cause pain, including ligaments, joints, periosteum, musculature, blood vessels, annulus fibrosusand nerves Intervertebral discs and facet joints most commonly affected 85% of those with isolated low back pain do not have a clear localization Usually called strain or sprain no histopathology, no anatomical location Men and women equally affected Age of onset years

4 Epidemiology Leading cause of work disability in those < 45 years Most expensive cause of work disability in terms of worker s compensation Multiple known risk factors: Heavy lifting, twisting, vibration, obesity, poor conditioning

5 Common Pathoanatomical Conditions of the Lumbar Spine

6 History Any evidence of systemic disease? Age (especially >50), hx of cancer, unexplained weight loss, IVDU, chronic infection Duration Presence of nocturnal pain Response to therapy Many patients with infection or malignancy will not have relief when lying down Note for arthritis patients young age, nocturnal pain and worsening with rest are common in AS

7 History Any evidence of neurologic compromise? Cauda equina syndrome is a medical emergency Usually due to tumor or massive herniation compressing the nerves of the cauda equina Urinary retention with overflow, saddle anesthesia, bilateral sciatica, leg weakness, fecal incontinence Sciatica caused by nerve root irritation Sharp/burning pain down posterior or lateral leg to foot or ankle; can be associated with numbness/tingling If due to disc herniation often worsens with cough, sneeze or performing the Valsalva

8 History Any evidence of neurologic compromise? Spinal stenosis is caused by narrowing of the spinal canal, nerve root canals, or intervertebral foramina Most commonly due to bony hypertrophic changes in facet joints and thickening of the ligamentum flavum Disc bulging or spondylolisthesis may also cause Back pain, transient leg tingling, pain in calf and lower extremity that is triggered by ambulation and improved with rest Can differentiate from vascular claudication through detection of normal arterial pulses on exam

www.rheumtcxt.com. Hochberg et al (eds) O www.

I loch berg et al (eds) Failure of the aortic

blood into the left ventricle Progressive

9 Hochberg et al (eds) O I loch berg et al (eds) Failure of the aortic valve to close tightly causes back flow of blood into the left ventricle Progressive deformity due to AS over a period of 36 years -L.. 41ADAM. lne - J L Sw'nson DR. CNct5hanUL4m JA 197e;00:2ii!LZ65. Reprod'uc:ed with :lie pesmis:s.ai c; Cahnef's "ub- ing Co

10 Physical Examination Inspection of back and posture (ie. Scoliosis, kyphosis) Range of motion Palpation of the spine (vertebral tenderness sensitive for infection) If high suspicion of malignancy, do a breast/prostate/lymph node exam Peripheral pulses to distinguish from vascular claudication

11 Physical Examination Straight leg raise: for those with sciatica or spinal stenosis symptoms Patient supine, examiner holds patient s leg straight Elevation of less than 60 degrees abnormal and suggests compression or irritation of nerve roots Reproduces sciatica symptoms (NOT just hamstring) Ipsilateral straight leg raise sensitive but not specific for herniated disk Crossed straight leg raise (symptoms of sciatica reproduced when opposite leg is raised) insensitive byt highly specific

12 Physical examination Neurologic examination L5: ankle and great toe dorsiflexion S1: plantar flexion, ankle reflex Dermatomal sensory loss L5: numbness medial foot and web space between 1 st and 2 nd toes S1: lateral foot/ankle

13 Nerve root L4 LS Sl Pain Numbness. Motor weakness Extension of q111adriceps Dorsifle:xi on of Plantar flexlon gr-eat toe of gre:at toe rand foot and foot Screening.Squat alftd ris.e Heel walking walking on examination toes Reflexes Kne.,e jerk dimenlshtid None NI iablc Ankle jerk diminished

14 Imaging AP and lateral L-spine if no clinical improvement after 4-6 weeks Guidelines for American College of Physicians and American Pain Society: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain Do perform x-rays if: fever, unexplained weight loss, hx of cancer, neurologic deficits, IVDU, age <18 or >50, trauma, immunosuppression, prolonged steroid use, skin/urinary infection, indwelling catheter

15 Imaging CT and MRI More sensitive for detection of infection and cancer than plain films Also able to image herniated discs and spinal stenosis, which cannot be appreciated on plain films Beware: herniated/bulging discs often found in asymptomatic volunteers may lead to overdiagnosis/overtreatment MRI better than CT for detection of infection, metastases, rare neural tumours

16 Low back pain + Pre5ence of 50iatica? {oo:.aslorially without back pairi) Simple b<1r;;k pillin {60 percent) Age 1mder 50 No signs of sx or systematic disease No hx of ea rice, (Ukellhood of musculoskefetaj C.jLJSe -0.99) + CQmplicillted back pii!in without radiculopathy (37 percent) Age ove:r 50 [ Not improved I Systemic signs, sx, or risk factors: fever, weight loss, hx of prior ca1ncer, hematurla, adenopathy, injection a ug use (Probabilft.y of 5Y temlc disease Is 1 to 10 percent, depending on the findings. Most patients stllj have muscujcjigame11tous pain {95 percent].) I STOP I I Plain fil rn and ESR * I,, 1 Radlculopathy (3 percent) Signs and sx of r.idio.llopathy, w/o bladder or bilateral findings May also have systemic signs, sx, or risk factors notecl In compllcatecl back pain Plain fllm ESR * If risks for osteomyelius IF normal, conservative care for 4 to 6 week:5 unles5 r1eurologic defi it is progressive Urgent situations ( <1 percen,t) Acute radiculopathy with urinary retentiori, saddle anesthesia, bilateral ne.urologic sx or bilateral exam fim!ings Progressive met.or we..ikness, May have s.ystemlc signs., sx, or risk factors. I Urgent consultatlori aml CT or MRI to evaluate for cord or cauda egulna compressjori If either abnormal, consider CTor MRI, Have high dinlcal suspicion In patierit with known caricer and new back pain; or patient with mur, fever and back pain Close follow-up Is warranted -- I STOP I Noncontrast CT or MRI, choice depends on loc-01 avallablllty If 12 week railure, meets criteria For subacute low back pain

17 Natural History Most recover rapidly 90% of patients seen within 3 days of symptom onset recovered within 2 weeks Recurrences are common Most have chronic disease with intermittent exacerbations Spinal stenosis is the exception usually gets progressively worse with time

18 Therapy Non-specific low back pain Few RCTs; methodology of studies generally poor quality NSAIDs and muscle relaxants good for symptomatic relief Try giving regular rather than prn Spinal manipulation (ie. chiropractic) of limited utility in studies Should recommend rapid return to normal activities with neither bed rest nor exercise in the acute period Bed rest found to not improve and may delay recovery Exercises not useful in acute phase; use in chronic

19 Therapy Nonspecific low back pain Traction, facet joint injections, TENS ineffective or minimally effective Systematic reviews of acupunture have shown little benefit? Massage therapy some promising results Surgery only effective for sciatica, spinal stenosis or spondylolisthesis

20 Therapy Herniated intervertebral discs Nonsurgical treatment for at least a month Exceptions: cauda equina syndrome, progressive neurologic deficits Early treatment same as for nonspecific low back pain, but may need short courses of narcotics for pain control Bed rest not useful Some patients benefit from epidural corticosteroid injections If severe pain, neurologic defecits MRI and consider surgery

21 Therapy Spinal stenosis Physiotherapy to reduce risk of falls Analgesics, NSAIDs, epidural corticosteroids (no clinical trials) Decompressive laminecotomy Spinal fusion + decompression if there is additional spondylolisthesis Symptoms often recur, even after successful surgery

22 Therapy Chronic low back pain Intensive exercise improves function and reduces pain, but is difficult to adhere to Anti-depressants: many with chronic low back pain are also depressed? Maybe for those without depression (tricyclics) Opiates Small RCT showed better effect on pain and mood than NSAIDs No improvement in actity Significant side effects: drowsiness, constipation, nausea

23 Therapy Chronic low back pain Referral to multidisciplinary pain center Cognitive-behavioural therapy, education, exercise, selective nerve blocks Surgical procedures rarely helpful

24 Treatment Physiotherapy for all Maintains good posture Maintains chest expansion Minimizes deformities

25 Treatment NSAIDs Good for mild symptoms Potentially disease modifying Indomethacin seems to work the best Beware of side effects, especially gastrointestinal disease

26 Treatment DMARDs Sulfasalazine mg bid Seems to be the most effective for spinal symptoms Methotrexate mg weekly For patients with prominent peripheral arthritis Doesn t work very well for spinal symptoms

27 Treatment Steroids Not very effective at all in AS Local injections for enthesitis or peripheral arthritis Anti-TNFα agents Remicade (infliximab), Enbrel (etanercept) and Humira (adalimumab) Very useful for treating symptoms, improving ROM, improving fatigue Hopefully disease-modifying...

28 Any questions?

Lumbar Disc Prolapse. Dr. Ahmed Salah Eldin Hassan. Professor of Neurosurgery & Consultant spinal surgeon

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