Patient Chart Quotes. Spine Mythology and Evidence- Based Management of Back Pain. Patient Chart Quotes. Patient Chart Quotes

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1 Spine Mythology and Evidence- Based Management of Back Pain John Engstrom, MD Professor of Neurology August 11, 2009 Patient Chart Quotes The patient was in his usual state of good health until his airplane ran out of gas and crashed. Patient Chart Quotes Patient Chart Quotes The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately. The patient has been depressed ever since she began seeing me in

2 Medical Approach to the Initial Evaluation of Back Pain and Spine Diseases: Objectives -Know the risk factors by history and examination for serious causes of acute low back pain (ALBP) -Be able to use a simple, practical algorithm for evaluating patients with acute back pain Evaluation of Back Pain/Spine Diseases- Spine Mythology -Non-radiologists know how to interpret spine neuroradiology reports -Spine neuroimaging findings are adequate to define the source of back pain -Know the reflex, motor, sensory findings for L4- S1 radiculopathy (the common lumbar radiculopathies) Patient - Back and Leg Pain 55 yo man with low back pain and intermittent, posterior left leg and calf pain for two months Hx - no trauma, nocturnal pain, chronic infection, intravenous drug use, steroid use General exam - Positive left straight-leg raise No fever. Stable weight. No spine tenderness. Normal abdominal/rectal exam Absent Patrick s/heel percussion signs ALBP-Natural History/Treatment 85-90% of patients are back to their functional baseline after 12 weeks Treat symptoms NSAIDs or acetaminophen for pain Limited (2-3 days maximum) bed rest; progressive ambulation Muscle relaxants if pain interferes with sleep Reassurance! 2

3 Acute LBP: Use of History and Examination Serious vs. benign source Rational approach to patient management Patient-Question 1 A recognized risk factor for a serious cause of acute low back pain is patient age > 50 years. 53% 1. True 2. False 47% True False Acute LBP: Risk Factors for Serious Cause - History Pain worse at rest or at night Prior history of cancer History of chronic infection History of trauma Age > 50 years Intravenous drug use Corticosteroid use History of rapidly progressive neurologic deficit Acute LBP: Risk Factors for Serious Cause - Examination Unexplained fever Unexplained, documented weight loss Percussion tenderness over spine Abdominal, rectal, or pelvic mass Patrick s sign or heel percussion sign Straight-leg or reverse straight-leg raising signs Rapidly progressive focal neurologic deficit 3

4 Low Back/Buttock Pain: Patrick s/heel Percussion Signs Patrick s Sign - Hip or buttock pain elicited by internal rotation of the hip with the knee in flexion Heel percussion - Leg fully extended, heel percussion elicits hip/buttock pain Patient- Back and Leg Pain 55 yo man with low back, left posterior leg and calf pain for two months. Risks for serious cause: History risks patient age General exam left straight-leg raising sign Neurologic exam diminished sensation over dorsum of left foot, weak left foot eversion, normal reflexes Patient-Question 2 LBP: Stretch Signs The straight-leg raising sign can be used to test for which one of the following: A. An L4 radiculopathy B. An L5 radiculopathy C. Femoral nerve irritation D. Hip or pelvis pathology 66% 22% 10% 2% Straight-leg raising Traction on the L5 or S1 roots, or sciatic nerve (all posterior to hip); reproduces patient s symptoms Reverse straight-leg raising Traction on the L2-L4 roots or femoral nerve (all anterior to hip); reproduces patient s symptoms An L4 radiculo... An L5 radiculo... Femoral nerve... Hip or pelvis... 4

5 LBP General Examination Abdomen Pelvis Rectum Costovertebral angles Hips Spine Patient-Question 3 Which of the following is an important cause of low back pain? A. Neoplasm B. Rapidly progressive neurologic deficit C. Fracture D. Infection E. All of the above Neoplasm 0% 0% Rapidly progre... Fracture 3% Infection 0% 97% All of the abo... Initial Approach to Acute LBP Algorithm 2 - Suspected Serious Etiology Risk factors present Acute LBP 1 Fracture Cancer Infection Rapidly progressive neurologic deficit Risks for Serious Source? Yes No Plain XR/CT ESR, CBC, consider consultation imaging, other lab Immediate consultation Consider infection, tumor, fracture Symptomatic Rx x 3 months No Diagnostic Tests 1 Pain < 3 months duration 5

6 Patient Exam- Back and Leg Pain 55 yo man with low back, left posterior leg and calf pain for two months. Risks for serious cause: History patient age General exam left straight-leg raising sign Neurologic exam diminished sensation over dorsum of left foot, weak left foot eversion, normal reflexes Patient-Question 4 The neurologic examination findings localize to which one of the following locations: 1. Peroneal nerve 2. L4 root 3. L5 root 4. S1 root 5. Tibial nerve 68% 23% 1% 5% 3% Peroneal nerve L4 root L5 root S1 root Tibial nerve Lumbosacral Radiculopathy - Neurologic Findings Root Motor Reflex Sensory loss Pain Distrib L4 Quadriceps Knee Medial calf Medial calf (knee extension) L5 Peronei None Lat calf, Posterolat thigh (foot eversion) dorsal foot dorsal foot S1 Abductor hallucis Ankle Sole foot Posterior thigh (toe flexors) calf 6

7 Herniated Disc Patient Back and Leg Pain L-S disc herniations: ~95% L4-5 or L5-S1 levels. L4 nerve root exits between L4-5 verterbras. Thus, we would think that an L4-5 level disc hernation would compromise the L4 nerve root -55 yo man with back and left leg pain for two months -Neurologic exam suggests left L5 root injury -Imaging confirms lateral left L5-S1 disk herniation -Patient opted for medical management and recovered full power; he did have a small residual patch of numbness over the dorsal left foot Patient-Question 5 Which one of the following is not, by itself, an indication for surgical diskectomy: 1. Cauda equina syndrome 2. Spinal cord compression 3. Severe radicular pain 4. Progressive focal motor weakness Cauda equina s... 11% Spinal cord co... 11% 71% Severe radicul... 7% Progressive fo... Spine Mythology #1 The non-radiologist is trained to properly interpret spine neuroimaging reports The neuroanatomic abnormalities reported by spine neuroimaging are easily applied to clinical management 7

8 Causes of Intervertebral Foramen Narrowing Lateral disc herniation Uncovertebral hypertrophy Loss of disc height Lateral recess stenosis Facet joint hypertrophy Osteophytes Listhesis Mass lesions (eg-trauma, infection, neoplasm) Uncovertebral / Uncinate Hypertrophy uncinate hypertrophy and oteophytosis of adjacent facet joints. 8

9 Spondylolysis and Spondylolisthesis Spondylolysis-multiple microfractures in the pedicles of either L4 or L5 Congenital predisposition Common in teenage athletes-back pain in a teenager is a different entity Spondylolisthesis-Slippage of one vert body on another; max with flexion or extension Spine Mythology #2 The origin of limb and back pain is easy to determine from spine imaging studies The most prominent anatomic spine abnormality is the likely source of the pain The location of the pain easily predicts the segmental origin of the pain Referred Pain 1893 Described by Sir Henry Head Saline injection into interspinous ligaments may result in pain remote from injection site Referred pain abolished by injection of local anesthetic at the site of the original injection Sclerotomal pain 9

10 Pain Referred to the Back LBP: Abdominal Aortic Aneurysm Kidney: Infection, inflammatory, neoplasm, renal artery/vein thrombosis, ureteral obstruction Colon: Ulcerative colitis, diverticulitis, neoplasm Prostate: Chronic prostatitis Uterosacral ligaments: endmetriosis, carcinoma, malposition Pancreas: Pancreatitis, pseudocysts, tumors Retroperitoneal: Hemorrhage, tumor, abscess Gallbladder: Pain induced by fatty foods Back pain, abdominal pain, shock; back pain only in 20% Misdiagnoses non-specific back pain, diverticulitis, renal colic, myocardial infarction Pulsatile abdominal mass on exam in 50-75% LBP/Radiculopathy: Pain-Sensitive Spine Structures Vertebral bodies Periosteum Dura Facet joints Annulus fibrosis Epidural veins Posterior longitudinal ligament LBP-Patient Education Goal: Validate the impact of the patient s pain on their life (e.g.-let the patient save face) Not all back and leg pain is due to nerve tissue injury (e.g.-the appendicitis analogy) Referred pain from the spine is common Unless the source of the pain is correctly identified, surgery doesn t help 10

Medical Approach to the Initial Evaluation of Acute Back Pain: Conclusions Use a directed history and examination to

serious cause Use a simple algorithm for acute LBP and modify with new evidence and clinical experience Initial

narrowing, spondylolysis, and spondylolisthesis Do not assume the most prominent spine neuroimaging abnormality is the

11 Medical Approach to the Initial Evaluation of Acute Back Pain: Conclusions Use a directed history and examination to inform patient management and rational ordering of tests Determine if the pain is more or less likely to be from a serious cause Use a simple algorithm for acute LBP and modify with new evidence and clinical experience Initial Medical Approach to Evaluation of Back Pain: Spine Mythology Know the practical significance of the terms foramenal narrowing, spondylolysis, and spondylolisthesis Do not assume the most prominent spine neuroimaging abnormality is the cause of the patients back and/or leg pain; referred pain from the back to the legs, not related to nerve root injury, is common 11

Back Pain. John W. Engstrom, MD December 16, Disclosures. A Clinical Approach to the Evaluation of Back Pain and Lumbar Radiculopathy

Back Pain. John W. Engstrom, MD December 16, Disclosures. A Clinical Approach to the Evaluation of Back Pain and Lumbar Radiculopathy Disclosures Nothing to declare --- or --- Significant ownership interests Speaker bureaus, honorarium, grants A Clinical Approach to the Evaluation of and Lumbar Radiculopathy John Engstrom, MD Acute Low