Paul Allan Regional Clinical Lead - South. Lumbar Spine. Assessment & Differential Diagnosis

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1 Paul Allan Regional Clinical Lead - South Lumbar Spine Assessment & Differential Diagnosis

2 Aims Refresh lumbar spine anatomy Red flags Discuss common pathologies seen in general practice Subjective and objective assessment Review of management strategies

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5 What Do You Need to Know? 5

6 Red Flags Red flags are a list of prognostic variables for serious pathology such as: Tumour Infection Fracture Cauda Equina Syndrome (Greenhalgh & Selfe 2010) Serious spinal pathology is rare <1% cases

7 Hierarchical List of Red Flags Age <10 & >51 Medical history of: Cancer, TB, HIV/AIDS, IV drug abuse Weight loss (>10% body weight in 3-6 months) Severe night pain Constant progressive pain Band-like pain Positive plantar response CES symptoms: loss of sphincter tone, altered S4 sensation, bladder retention, bowel incontinence Disturbed gait Systemically unwell Bilateral P/Ns in hands +/or feet Clinician gut feeling (Greenhalgh & Selfe 2010)

8 Some facts about back pain: Around 20% of people with low back pain (that is, 1 in 5 of the population) will consult their GP 85% of the population will experience low back pain in their lifetime For individuals younger than 45 years, mechanical LBP represents the most common cause of disability and is generally associated with a work-related injury. For individuals older than 45 years, mechanical LBP is the third most common cause of disability. Most cases resolve within 2-4 weeks

9 NICE Back Pain Guidelines in practice Do not offer X-ray For mechanical LBP MRI indicated if suspicions of malignancy, fracture, infection, inflammatory conditions only, or if for Ortho opinion on fusion surgery Provide advice on self- help, pain management, exercise Physiotherapy referral Pharmacological management paracetamol, NSAIDs and weak opiods initial choices

10 Case Study 1 55 year old male, IT professional presented with central LBP for a week. Sudden onset, started after shovelling snow. Describes it as a constant ache without radiation/referral to the buttock or lower limb. Worse with prolonged sitting, forward bending and lifting weights, 7/10 Eases with lying on the side and prone.

11 Case Study 1 O/E- Loss of lumbar lordosis in standing without any sciatic list Minimal tenderness over L4, L5, centrally along with spasm of the paraspinal muscles Restricted lumbar flexion and side flexion bilaterally to half range with pain at the end range. SLR and slump test is negative Neurology examination is unremarkable

12 Case Study 1 Management- Why not get imaging studies for non-specific LBP: Can be misleading- Many abnormalities as common in pain-free individuals as in those with back pain. If under age 60 Unexpected x-ray findings in only 1 of 2,500 patients with back pain Bulging disk in 1 of 3 Herniated disks in 1 of 5 pain-free individual If over age 60 and pain free Herniated disk in 1 of 3 Bulging disk in 80% All have age-related disk degeneration Spinal stenosis in 1 of 5 cases

13 Case Study 1 Management Stratify/Assess Risk i.e. StartBack Analgesics to permit activity Remain active- less likely to develop chronic pain Patient education regarding correct posture, ergonomics Home exercises- (specific and general aerobic) to improve mobility, strength and endurance.

14 Case Study 1 The same patient presents again after 2 years and reports that he got over that last attack in less than a 3 weeks but has had low back pain ever since Been under emotional stress due to situations at work and home (High StartBack score) Stopped doing regular exercises and playing tennis. He now complains of another attack of acute back pain after chopping wood 3 days ago. No radiation of symptoms in lower limbs.

15 Case Study 1 O/E: Paraspinal muscle spasm present and lumbar ROM was limited in all directions to half range, with pain at the end of range Tenderness on palpation- L4-S1 centrally and laterally SLR negative and normal neurology exam. Management: As before- remain active, analgesics, specific exercises etc. Consider psychosocial factors for persistent pain, yellow flags Patient education regarding nature of persistent pain, physiology Multi-modal management- multidisciplinary pain management programme

16 Case Study 2 45 year old carpenter presents with sudden onset pain in the low back radiating to the right buttock, posterior aspect of the right thigh and leg for the past 3 weeks Constant strong ache, intermittent shooting pain in the right lower limb; 8/10 on NPRS Paraesthesia and numbness in the right foot Prolonged sitting, bending forwards and squatting aggravates pain and side lying on the left eases it. Regular night pain but denies any bladder retention/incontinence or saddle anaesthesia. Tried resting it and been off work but not helped symptoms.

17 Case Study 2 Lumbar flexion and left side flexion limited to half range, radiating pain at end of range. Lumbar extension is nearly full with back pain at the end range SLR positive on right at 60 degrees, slump positive No sensory or motor loss Depressed ankle jerk on the left, normal knee jerk Plantars downgoing and clonus absent

18 Case Study 2 Management- Patient education regarding symptoms- can take up to 12 weeks for neurogenic pain to ease Postural and ergonomic advice Pharmacological management for pain Specific exercises to reduce neural mechanosensitivity MRI if worsening neurology/other red flags Epidural injections if no improvement in weeks may be considered Surgery- long term effects are same as conservative.

19 Case Study 2 Same patient presents 4 weeks later and reports no significant improvement in symptoms. He complains of heaviness and weakness in both legs and also intermittent retention of urine and saddle anaesthesia. O/E- Lumbar ROM has slightly improved. Crossed SLR is positive and he is unable to walk on his tip-toes Gross motor weakness is noted in S1/S2 myotomes and ankle jerks are absent bilaterally.

20 Case Study 2 Management Referral to A&E department for urgent screening/mri scan as best outcome of surgical decompression is within 48 hours of onset of symptoms. Insufficient evidence to draw firm conclusions regarding the appropriate time frame for management and prognosis. Prognosis of incomplete CES is better than complete CES

21 Case Study 3 65 year old retired lorry driver presents with 20 year history of low back pain,12/12 history of bilateral LL numbness knees-feet and 6/12 history of right leg pain. Worse with prolonged standing, walking and eases with sitting. Denies any weakness in legs/falls or B/B symptoms, SA, weight loss PMH- R TKR and hypertension; was a smoker for 30 years Co-codamol helps

22 Case Study 3 O/E- Forward stooped posture with loss of lumbar lordosis No lumbar spine tenderness Full lumbar spine flexion, restricted and painful extension to ½ range Altered sensations right L5 dermatome No motor deficit Positive SLR on right at 60 degrees, negative slump Ankle and knee jerks are normal with downgoing plantars Normal peripheral pulses and capillary return.

23 Case Study 3 Management- Pain relief- pharmacological management Advice on posture- avoid prolonged extended positions Specific exercises- flexion, neural gliding, improve spinal mobility Epidural injections Consider referral for surgical intervention if failure of conservative management or progressive neurology deficit.

24 Case Study 4 A 32-year-old salesman complains of severe low back pain of gradual onset over the past few years. Worse in the morning (8/10) with stiffness and gradually decreases during the day. Denies fever or weight loss but does feel fatigued O/E: Loss of lumbar lordosis but no focal tenderness or muscle spasm. Lumbar ROM restricted in all directions to half range with minimal pain end of range. Lumbar excursion on Schober test is 2 cm and limited lung expansion on deep breathing No neurologic deficit

25 Case Study 4 Diagnosis of inflammatory back disease- Insidious onset, duration >3 months Symptoms begin before age 40 Morning stiffness >1 hour Activity improves symptoms Systemic features: Skin, eye, GI, and GU symptoms Peripheral joint involvement Infections Management: Mobility and strengthening exercises Conditioning exercises- aerobics Pharmacological- immunosuppresants/biologics

26 Case Study 5 A 60 year old man complains of the insidious onset of constant low back pain that worsens when he lies supine, so he sleeps in a recliner. There is a remote history of back injury many years ago. He has lost 10kg in the past 6 months O/E- Generalised tenderness over lower thoracic and lumbar spine. Lumbar ROM is minimally restricted but painful on terminal flexion and extension. No neurologic deficit Bloods- Hb 9 mg%, WBC 9,000, ESR 110 mm/h, monoclonal spike on serum protein electrophoresis

27 Subjective history Pain- type of pain (ache, burning, shooting), duration (constant, intermittent) Location of pain- central, unilateral, referred to buttock/thigh/leg, associated paraesthesia and numbness- distribution Onset- acute, chronic, insidious Mechanism of injury- flexion, hyperextension, direct trauma Aggravating and easing factors (helps clinical reasoning in differentiating tissue pathology) Severity on NPRS/VAS Red flags as discussed including CES questions Functional limitations

28 Objective examination Observation Palpation Bony Soft Tissue Range of Motion Neurologic Examination Special Tests

29 Objective examination Observation- Erythema (infection) Posture- level of shoulders, iliac crests, any scoliosis (structural/sciatic), increased or flattened lordosis Palpation- Spinous processes Soft tissues- paraspinal muscles, gluteal muscles, piriformis, anterior abdominal wall/inguinal area

30 Objective examination Range of Motion- Flexion Extension Side Flexion Rotation Neurologic Assessment-

31 Objective examination

32 Objective examination

33 Objective examination Reflexes- Knee jerk- L3/L4 Ankle jerk- S1 Plantar reflex/babinski s sign- Normal down-going or no response Positive- extension of big toe and fanning of other toes Clonus- positive in UMN lesions

34 Objective examination Neurodynamics- Neural tension tests SLR Crossed SLR Slump Femoral nerve tension test (prone) Femoral slump

35 Any Questions?