Back Pain

    Approach to Back Pain

    BackPainApproach.png

    • 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.
    • 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)
    • Specific Exam:
      • Symptoms exacerbated by Spurling Sign (extension and rotation of neck)
        • afp20100101p33-f1.jpg
        • Holding arm above head (Shoulder abduction sign) decompresses nerve root - helps symptoms.
    • 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)
    • 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.
    • 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

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