Table of contents
Approach to Back Pain
- Xrays: Poor test, but done anyways
- spinal metastasis (60% sensitivity, 17% specificity)
- steomyelitis (82% sens, 57% spec)
- CT/MRI
- Study found herniated disks in 25% of asymptomatic ppl. (most asymptomatic)
- Does not correlate well with clinical symptoms
- MRI: better for soft tissue (herniated disks, tumors)
- CT: better for bone (osteoarthritis)
RED Flags of Back Pain
(I like to group them by diagnoses)
- Non-Specific
- Constitutional Symptoms (Fever, wt loss)
- Epidural Abscess, osteomyelitis
- IV Drug Use
- Immunocompromized
- Cancer
- Pain worse at night
- History of cancer
- Cauda Equina
- Saddle parasthesia or anesthesia
- Neuro Deficits
- Epidural Hematoma
- Anticoagulant use or bleeding disorder
- Recent spinal procedure
Cauda Equina Syndrome
- Acute loss of function of the lumbar plexus due to compression, trauma, or other damage.
- Triad:
- Urine Retention / Fecal incontinence
- Saddle anesthesia
- Ataxia
- Any patient with suspected cauda equina needs post-void residual (positive if volume >200cc). A negative post-void residual essentially rules out cauda equina.
- NEED MRI IF SUSPECTED
- CT does not have enough sensitivity/specificity for cord compression syndromes (only bony).
- CT myelogram is an option if MRI not available
Causes
- Mechanical Pain (97%)
- Lumbosacral Strain (MOST COMMON)
- Herniated Disk (4%) - leg pain often worse than back pain, radiates below knee
- Spondylolisthesis (2%)
- Degenerative
- Degenerative Disk or Facet (10%) - older, similar findings to lumbosacral strain
- Spinal Stenosis (3%) - pain better when spine flexed or seated (open post. comp.), worse walking downhill
- Osteoporotic Fractures (4%) - spine tenderness, hx of trauma
- Nonmechanical Spinal Conditions (1%)
- Neoplasia
- Inflammatory
- Infection
Physical Exam
- .Screening for herniated disk: ask for sciatica (if pain radiates below knee)
- (95% of herniated disks have sciatica)
HERNIATION | NERVE ROOT AFFECTED | SENSORY LOSS | MOTOR WEAKNESS | SCREENING EXAMINATION | REFLEX |
---|---|---|---|---|---|
L3-L4 disk | L4 | Medial foot | Knee extension | Squat and rise | Patellar |
L4-L5 disk | L5 | Dorsal foot | Dorsiflexion ankle/great toe | Heel walking | None |
L5-S1 disk | S1 | Lateral foot | Plantarflexion ankle/toes | Walking on toes | Achilles |
Lumbosacral Strain & Disc Herniation
- Continue daily activities as tolerated, use pain as limiting factor.
- No bed rest (only a bit if needed), shown to prolongue recovery.
- Tylenol, NSAID, opioid analgesics.
- Spinal traction, massage, diathermy (electrically induced current producing heat), ultrasound, biofeedback, acupuncture no proven benefit.
- Follow-up in 4-6wks with primary care.
- Return if RED FLAGS.
Treatments/Outcomes
- Education
- Natural history of back pain is favourable overall
- 30-60% improve in one week
- 60-90% recover in six weeks
- 95% recover in 12 weeks.
- Relapses common.
- Natural history of back pain is favourable overall
- Drugs:
- Tylenol
- NSAIDs at antiinflammatory doses. (use H2 antagonist or misoprostol)
- Narcotics (short term narcotic is acceptable, if needs long term - re-evaluate cause of pain).
- Early mobility + Early return to work. (LBP correlates to low job satisfaction)
- Surgery
- No benefit, unless Red Flags.
Cervical Radiculopathy
- Nerve root compression at cervical spine
- Nerve roots exit above the level of the corresponding pedicle (unlike Lumbar spine).
- Mechanisms:
- Herniated disk. (soft disk herniation)
- Encrouachment by surrounding degenerative or hypertrophic bony elements (hard disk pathology)
- Associated inflammation, vascular response, and intraneural edema contribute to pain.
- Pain:
- Patterns:
- Soft disk herniation: acute presentation, with or without radiating extremity sx.
- Spondylosis: Chronic bilateral axial neck and radiating arm pain.
- Can have many sources, but notably:
- Degenerative disk
- Facet joints
- Classically pain radiates from neck or upper back down the arm, past the elbow. (absence of radiating extremity pain does not precloude root compression)
- Patterns:
- Specific Exam:
- Myelopathy vs Radiculopathy
- Myelopathic symptoms: difficulty manual dexterity, gait disturbance, upper motor neuron signs (Hoffman sign, Babinski, hyperreflexia, clonus)
- Imaging:
- Xrays:
- Antero-posterior open-mouth.
- Anteroposterior lower cervical
- Neutral lateral.
- If unclear if radiculopathy or entrapment syndrome in upper limb do electromyography.
- MRI if persistent symptoms (do CT if has steel cervical hardware)
- Xrays:
- Tx:
- Non-operative:
- Non-operative is suggested, use multimodal approach
- 1. Immobilization (Cervical collar):
- A short course (one week) may reduce symptoms in inflammatory phase.
- Not proven to alter course or intensity of pain.
- 2. Traction (Cervical traction unit)
- In theory: Distracts neural foramen and decompresses nerve root.
- 12lb applied on angle of 24 degrees at 15-20minute intervals.
- Only beneficial when muscular pain subsided, do not use in myelopathy.
- Recent systematic review: (2012) insufficient evidence for management of chronic symptoms.
- 3. Pharmacotherapy
- No proven benefit for cervical radiculopathy. (but positive results in lumbar and low back pain sugest potential role).
- NSAIDs: show to be effective for low-back pain, often considered first-line.
- May add narcotics, muscle relaxants, antidepressants, or anticonvulsants.
- Opioids may be effective in neuropathic pain of up to 8wks duration. (insufficient evidence beyond 2 months).
- Muscle relaxants (Cyclobenzaprine [Flexeril]) may help acute neck pain by reducing tension.
- Tricyclic Antidepressants and Venlafaxine (Effexor): may produce moderate relief in chronic neuropathic pain.
- Tramadol may provide significant relief of neuropathic pain.
- Oral Steroids: widely used for radicular pain, but no evidence they alter the course.
- 4. Physiotherapy
- Beneficial in restoring ROM and conditioning of neck muscles.
- Principles:
- In first 6 weeks: gentle ROM + stretching exercises
- Supplement w/ massage, heat, ice, electrical stimulation
- When pain better: isometric strengthening and increased ROM exercises.
- Spinal Manipulation: no evidence. May cause harm (worsen).
- 5. Steroid injections
- Perineural steroid injections (trans-laminar, transforaminal epidural, selective nerve root blocks).
- Do only if confirmed pathology on CT/MRI.
- One study: significant pain relief at 14 days and 6mo F/U after a series of blocks.
- Another study: 21 pts awaiting surgery: Improved pain + reduced need for surgery.
- Another study: no difference.
- Complications are rare:
- 1.66% or minor, and <1% for major (spinal/brainstem damage)
- Another study: epidural Corticosteroids may give short-term improvement of radicular symptoms.
- Non-operative:
- Indications for Surgery:
- Intractable pain.
- Sensory deficit
- Objective weakness
- Prognosis:
- 31% had recurrence
- 26% needed surgery for intractable pain, sensory deficit, objective weakness.
- Natural history study: 51 pts followed for 2-19 yrs. At 2 months:
- 43% no symptoms
- 29% mild or intermittent symptoms.
- 27% disabling pain.
- NONE progressed to myelopathy
- Overall: 90% asymptomatic.
Reference: AAFP article
Comments