Back Pain Update. Steven Andersen, MD Providence Physiatry Clinic PDF Free Download

Back Pain Update Steven Andersen, MD Providence Physiatry Clinic 2016

Back Pain is Very Common Lifetime prevalence 80% 12 month prevalence 40% Point prevalence 20% Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2010 Summary Tables. Atlanta, GA: Centers for Disease Control and Prevention; 2011. Accessed at www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf on 10 April 2014. D. Hoy et al The Epidemiology of low back pain Best Practice & Research: Clinical Rheumatology, 2010-12-01, Volume 24, Issue 6, Pages 769-781

Increasing proportion of health care costs Without evidence of corresponding improvement Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingworth W, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299:656-64. [PMID: 18270354]

Back Pain Remission & Recurrence Episode remission in 1 year 54-90% Recurrence at one year 24-80% Activity limiting back pain becomes recurrent D. Hoy et al The Epidemiology of low back pain Best Practice & Research: Clinical Rheumatology, 2010-12-01, Volume 24, Issue 6, Pages 769-781

Diagnosis Overview The majority presenting in primary care will have nonspecific low back pain Identify specific cause, if present, like radiculopathy or potentially serious underlying condition Classify as acute, subacute or chronic, identify psychosocial factors associated with chronicity Reserve imaging for Suspected radiculopathy or spinal stenosis when surgery is an option Suspected serious systemic illness, fracture, cord compression Consider EMG when relationship between leg symptoms and imaging findings is unclear

Three Low Back Pain Categories Nonspecific Low Back Pain Radiculopathy & Spinal Stenosis Specific Systemic or Spinal Cause Cancer Infection

Frequency of presentation in primary care Nonspecific Low Back Pain 85% 9% 6% 5% Radiculopathy & Spinal Stenosis Specific Systemic or Spinal Cause Cancer 1% 0.10% Infection

Low Back Pain Imaging Guideline Immediate imaging Radiography + ESR if major risk for cancer New LBP + cancer history Multiple cancer risk factors MRI if radiography negative MRI +/- ESR for suspected spinal infection New LBP + fever and IVDA or recent infection MRI for suspected cauda equina syndrome New urine retention, fecal incontinence, saddle anesthesia MRI for severe neurologic deficit Progressive or multilevel motor weakness

Imaging Useful if H&P suggests specific underlying cause Anatomic abnormalities pain source Herniated or bulging discs, spinal stenosis, annular tears, disk degeneration common in asymptomatic people Routine imaging increased cost and likelihood of invasive procedure without increased benefit

Similarities in disc degeneration in MZ twins with discordant load exposures Spine, Battié et al., 2004[48]

Nonspecific Low Back Pain approx. 85% Nonspecific Low Back Pain Radiculopathy & Spinal Stenosis Specific Systemic or Spinal Cause Cancer Infection

Nonspecific Low Back Pain Regional backache: Back pain experienced by people who are otherwise well (Hadler, NEJM, 1986) Synonyms Nonspecific back pain Mechanical back pain

Nonspecific Low Back Pain 0.80 x 0.85 = 70% adult population Spontaneous recovery >50% by 4 weeks >90% by 6 weeks No treatment scientifically proven to speed recovery for NLBP

Chronic nonspecific low back pain > 12 weeks if resolves tends to recur Psychosocial factors and emotional distress are strongest predictors of duration and severity

STarT Back RCT Useful to predict risk for chronicity Intervention (stratified care) (n=568) Control (non-stratified ) (n=283) Primary outcome: Roland Morris Disability Questionaire Stratified care associated with greater improvement in RMDQ scores In use at Providence Rehabilitation Services

Behavioral treatment of chronic low back pain In the intermediate- to long-term, there is little or no difference between behavioral therapy and group exercises for pain or depressive symptoms. 30 randomized trials Henschke, Cochrane Database Syst Rev 2010

Reducing disability in chronic nonspecific low back pain Encourage movement and activity even if pain is present Exercise offers slight benefits in pain and function meta-analysis of 43 RCTs, Hayden, Ann Internal Med 2005 Yoga associated with reduced pain and disability meta-analysis of 10 RCTs, Cramer, Clin J Pain 2013

Acetaminophen Review of RCTs acetaminophen vs placebo (n=1825) does not produce better outcomes than placebo for people with acute LBP, and it is uncertain if it has any effect on chronic LBP. Saragiotto, Cochrane Database, 2016

NSAIDs Review of 65 randomized and double-blind controlled trials (n=11,237) NSAIDs effective for short-term relief with acute and chronic low-back pain without sciatica but effect sizes small No specific type of NSAID clearly more effective than others. COX-2 inhibitors associated with increased cardiovascular risks in specific patient populations. Pepjin, Cochrane 2008

Opioids short-term benefits for moderate to severe pain (prescribe < 3 day supply ) Scientific evidence is lacking for benefits to treat chronic pain (CDC. 2016) Best approach to chronic pain patients already on opioids who seem at low risk for misuse?

Muscle relaxants insufficient evidence to determine whether effective for subacute or chronic low back pain more effective than placebo for patients with ACUTE low back pain on short-term pain relief adverse effects require that they be used with caution Benzodiazepines and non-benzodiazepines included in review vantulder, Spine 2003

Antidepressants Conflicting results from meta-analyses TCAs and duloxetine may have small effects Duloxetine approved by FDA in 2012 for low back pain. Side effects: drowsiness, dry mouth, diszziness SSRIs ineffective Depressions common in patients with CLBP and should be addressed

Anticonvulsants Gabapentin, pregabalin, carbamazepine May be effective for radiculopathy pain Lack of evidence for back pain w/o radiculopathy Topiramate 10-week, randomized, double-blind, placebo-controlled study (n=96) McGill Pain, Oswestry Low Back Pain, SF-36 improved

Facet joint injection Glucocorticoid facet joint injection not shown to be effective for reducing low back pain Chou, Spine 2009

Complimentary & alternative treatments probably some temporary benefit Manipulation (Rubenstein, Spine 2011) Massage (Furlan, Spine 2009) Acupuncture (Lam, Spine 2013) Sham acupuncture ( needles placed in nonacupuncture points) as effective as true acupuncture in some studies. Placebo? Needling effect? Insufficient evidence Glucosamine, willow bark extract

Other nonsurgical interventions Spinal cord stim moderately effective for failed back surgery syndrome with persistent radiculopathy, device complications common Not effective: prolotherapy, facet injection, intradiscal steroid or thermocoagulation APS Clinical Practice Guideline 2010

Nonspecific Low Back Pain Treatment Summary Pain resolves in 6 weeks with or w/o treatment in 90% of cases No treatment shortens duration or prevents recurrence Encourage normal activity despite pain STarT Back tool useful at predicting chronicity Pain persists in 10% after 6 weeks Goal: reduce pain and activity intolerance

Identify and treat depression Psychological therapies (cognitive behavioral therapy), guided exercise therapies and yoga modestly effective at reducing pain & activity intolerance Consider short courses of NSAIDs, manipulation, massage, acupuncture for temporary relief. Limit opioids to 3 days; consider tapering patients on long term opioids Consider TCA, duloxetine

Prevention Correct lifting technique training: no evidence this works Verbeek JH, Martimo KP, Kuijer PP, Karppinen J, Viikari-Juntura E, Takala EP. Proper manual handling techniques to prevent low back pain, a Cochrane systematic review. Work. 2012;41 Suppl 1:2299-301. [PMID: 22317058] Back brace: ineffective van Duijvenbode IC, Jellema P, van Poppel MN, van Tulder MW. Lumbar supports for prevention and treatment of low back pain. Cochrane Database Syst Rev. 2008:CD001823. [PMID: 18425875]

Radiculopathy & Spinal Stenosis Nonspecific Low Back Pain Radiculopathy & Spinal Stenosis Specific Systemic or Spinal Cause Cancer Infection

Radiculopathy Sciatic pain (distal to knee) Straight leg raising test Passive lifting of affected leg less than 60 deg reproduces pain radiating distal to knee Ankle dorsiflexor, toe extensor, plantarflexor weakness Dermatomal sensory loss Reflex impairment Therapy trial before MRI MRI if candidate for surgery or ESI Immediate MRI for CES /severe neuro deficit

Radiculopathy

Epidural Steroid Injection Systematic review of 30 placebo controlled trials for radiculopathy: immediate small temporary improvements in pain and function 8 trial for spinal stenosis: not effective Chou, Ann Intern Med 2015 No role in low back pain without radiculopathy

Lumbosacral radiculopathy treatment summary High likelihood of spontaneous recovery Temporary activity restriction, NSAIDs, short course opioids selectively No PT 1 st 2 weeks, consider PT after 2 weeks Systemic or epidural steroid options for temporary relief of persistent symptoms Consider discectomy for persistent symptoms or progressive neurologic deficit

Spinal Stenosis Symptoms/risk factors Older age, uncommon <50 Pseudoclaudication thigh pain after 30 sec lumbar extention Sensory loss, leg weakness Neuro exam often normal Rarely progresses to cauda equina syndrome Therapy trial, MRI later if surgical candidate

Deferred MRI After Therapy Trial Candidate for surgery/esi and: Radiculopathy symptoms/signs Back + leg pain Positive SLR test Spinal stenosis symptoms/risk factors Older age, uncommon <50 Pseudoclaudication, thigh pain after 30 sec lumbar extention

Lumbar spinal stenosis treatment summary Benign prognosis, neurologic disability rare PT, NSAIDs, short course opioids in select cases, PT Epidural injections not supported by evidence Surgery for Progressive neurologic deficit Disabled by symptoms + inadequate response to conservative treatment Urgent surgery referral for cauda equina syndrome

Surgery Immediate referral for suspected cord or cauda equina compression or spinal infection Spinal stenosis or radiculopathy with unacceptable pain after conservative trial or worsening neurologic status fusion not more effective than nonsurgical treatment for CLBP; crossover problems Mirza & Deyo, Spine 2007

Vertebral Osteomyelitis Nonspecific Low Back Pain Radiculopathy & Spinal Stenosis Specific Systemic or Spinal Cause Cancer Infection

Vertebral Osteomyelitis Indwelling devices Recent instrumentation Injection drug use Fever (52%) New localized back / neck pain, tenderness Immediate MRI w contrast +/- ESR

Cancer Nonspecific Low Back Pain Radiculopathy & Spinal Stenosis Specific Systemic or Spinal Cause Cancer Infection

Cancer History of cancer Unexplained weight loss No relief with bedrest Pain > 1 month Age Radiography + ESR if major risk for cancer New LBP + cancer history Multiple cancer risk factors MRI if radiography negative

Systemic or Spinal Causes Nonspecific Low Back Pain Radiculopathy & Spinal Stenosis Specific Systemic or Spinal Cause Cancer Infection

Compression fracture Increased age Trauma Prolonged corticosteroids

Deferred Radiography +/- ESR After Therapy Trial Weaker cancer risk factors (unexplained weight loss, age > 50) Compression fracture (age >65 female or >75 male, osteoporosis, corticosteroids, trauma) Ankylosing spondylitis risk factors/signs (age 20-40, AM stiffness, improvement with exercise, alternating buttock pain, awakening with back pain 2 nd half of night)

Summary The majority presenting in primary care will have nonspecific low back pain Identify specific cause, if present, like radiculopathy or potentially serious underlying condition Classify as acute, subacute or chronic, identify psychosocial factors associated with chronicity Reserve imaging for Suspected radiculopathy or spinal stenosis when surgery is an option Suspected serious systemic illness, fracture, cord compression Consider EMG when relationship between leg symptoms and imaging findings is unclear

Back Pain Update. Steven Andersen, MD Providence Physiatry Clinic 2016