M. Andrew Greganti, MD
Back Pain
 Accounts for 2.5% of medical visits – second most common
reason for office visits in US
 Prevalence varies widely – 1.2 to 43%
 Risk factors:
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Obesity
Smoking
Female gender
Physically strenuous or sedentary work – lifting over 25 lbs
Low educational level
Job dissatisfaction
Somatization disorder, anxiety, depression
Workers’ Compensation Insurance
Genetic background
Cultural differences
Prognosis
 Generally good, especially if expectation is to improve
– most do get better with no intervention
 Less than 5% have serious underlying pathology
 A cause can be found only in a minority of patients
 Chronicity seems to correlate with:
 Female gender
 Increasing age
 Pre-existing psychosocial factors
Clinical Evaluation
 Key concepts:
 Most patients have mechanical low back pain – no
infectious, inflammatory, or neoplastic cause.
 Degenerative disc disease plays a substantial role but
exactly how much of one is unclear. Many patients
without pain have discs on MRI.
 Muscular and ligamentous sources of pain are
probably equally important.
 Tender fibro-fatty nodules (back mice) may play some
role but correlation with back pain remains in question.
History
 Consider 3 major concerns:
 Evidence for a systemic process – hx of cancer, age
over 50, weight loss, nocturnal pain, unresponsiveness
to Rx
 Evidence for neurologic compromise – cauda equina
syndrome, radiation of pain below the knee,
pseudoclaudication as in spinal stenosis, focal weakness
 Social or psychological distress contributing to
chronic, disabling pain
Physical Examination
 Check for spinal curvature – kyphosis, scoliosis, etc.
 Check for spinal tenderness
 Straight leg raising and crossed straight leg raising
 Evaluate for deficits in L4, L5, and S1 distributions.
 Lymph node, breast, and prostate exams if neoplasia is
suspect
 Check peripheral pulses
Diagnostic Imaging
 Imaging is essential in these situations:
 Progression of neurological findings
 History of trauma
 History of neoplasia
 Age <18 or >50
 Special situations:
 Injection drug use
 Immunosuppression
 Indwelling Foley catheter or recent GU procedure
 Concomitant steroid use
Plain Films, MRI, CT
 If symptoms persist for 4 to 6 wks with no
improvement, order two views of plain films
without obliques
 Implications of spondylosis, spondylolisthesis,
spondylolysis
 Order MRI or CT to evaluate progressive
neurologic deficits, to evaluate for cancer, or to
evaluate patients with refractory symptoms –
greater than 12 wks of persistent pain
Treatment of Back Pain
 Bed rest is not indicated – may actually delay
recovery
 NSAIDS and narcotics have similar efficacy – use of
NSAIDS should be limited to 2 to 4 wks
 Adverse effects more common in older patients
 Acetaminophen is probably as good as NSAIDS.
 Muscle relaxers are more effective than placebo for
short-term relief
 NSAIDS + muscle relaxants may be better - based
on observational data.
Treatment of Back Pain
 Opioids are effective in acute back pain but
obviously have multiple side effects and are
addicting
 Tramadol is a non-opioid and works on the opioid
receptor – is worth a trial.
 Oral glucocorticoids probably are not beneficial for
acute pain.
 Lidocaine patches, anticonvulsants, antidepressants
are of limited effectiveness in acute pain.
Treatment of Back Pain
 Epidural injection:
 Efficacy remains unclear – conflicting results from
controlled trials
 Probably best in radiculopathy secondary to HNP – has
short-term (at 6 wks) but no long-term benefit at 3 , 6, or 12
months
 Not of proven benefit in spinal stenosis and nonspecific
pain
 No difference in translaminar, transforaminal, and caudal
approaches
 2 of 7 trials found epidural injection vs placebo associated
with lower rates of subsequent surgery.
 Adverse events: dural puncture, bleeding, infection
Treatment of Back Pain
 Local or trigger point injection rarely works
 Facet joint steroid injection doesn’t help at 1 and 3
months
 Medial branch of dorsal ramus nerve blocks are of
unknown efficacy
 Sacroiliac joint steroid injection was more
effective than anesthetic injection in one small
trial
 Probably does work for spondyloarthropathies
 Rx effectiveness of piriformis syndrome using injected
steroids remains unclear
Treatment of Back Pain
 Chemonucleolysis for HNP should only be used in
patients who do not want surgery – not often done in
US
 Paravertebral botulinum toxin injection was
superior to placebo at 3 and 8 weeks
 Evidence for the efficacy of radiofrequency nerve
ablation remains inconsistent – would only
consider in the most refractory situations
 Prolotherapy should not be used
Treatment of Back Pain
 Exercise is not good for acute pain in contrast to more
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chronic pain.
Encourage mobilization as soon as possible.
Physical therapy is, in general, very helpful but no
difference in heat/cold, ultrasound, electrical stimulation
TENS effectiveness is very questionable at best.
Spine manipulation by chiropractors may be helpful.
Accupuncture is probably equivalent to NSAIDS.
Traction does not help lumbar pain.
Hip Pain
 Basic issues:
 The major dilemma is to differentiate among gluteus
medius superficial and deep bursitis and osteoarthritis
 The hip is “fixed” by the pelvic girdle, making it more difficult
to differentiate pain originating in the lumbar spine and knee
from hip pain.
 The gluteus medius and gluteus minimus muscles
abduct the hip and attach at the greater trochanter.
 The gluteus maximus extends the hip and attaches just
distal to the greater trochanter
 The iliopsoas muscle, the major hip flexor, attaches at the
lesser trochanter.
Clinical Presentation of Hip Pain
 Hip pain with weight bearing and improvement
with rest is most compatible with DJD.
 Constant pain and pain while supine are more
likely with infectious, inflammatory, and
neoplastic processes.
 Lateral hip pain is often from the joint or from the
greater trochanteric bursa, especially if there is point
tenderness.
 Hip joint pain is more often anterior
 Lateral paresthesias raise the possibility of meralgia
paresthetica.
Clinical Presentation of Hip Pain
 Anterior hip or groin pain is most often seen in
DJD of the hip joint.
 Important to differentiate DJD from osteonecrosis
 If not worse with repetitive hip flexion, have to consider
inguinal hernia and intraabdominal process.
 Anterior thigh pain just above the knee presents the
most difficulty
 Posterior hip pain is not usually from the hip.
More commonly is secondary to lumbar disc,
sacroiliac disease, facet joint disease.
Clinical Presentation of Hip Pain
 Trochanteric bursitis is caused by exaggerrated
movement of the gluteus medius tendon and tensor fascia
lata over the lateral femur.
 More likely to develop with leg length discrepancy, knee
arthritis, ankle sprain, LS spine stiffness
 Point tenderness over trochanteric bursa
 Hip DJD presents with groin pain worse with
movement, limited internal rotation (<15 º), limited
flexion (<115 º)
 Osteonecrosis presents in the groin, thigh, or buttock
 Rest pain is common as is nocturnal pain
Hip Examination
 Observe patient’s gait - ? antalgic, short leg limp,
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Trendelenburg gait
Passive internal and external rotation - ? endpoint
stiffness – endpoint pain raises osteonecrosis, occult
fracture, acute synovitis, metastatic disease
Fabere or Patrick test
Straight leg raising to evaluate lumbar origin
Check sensation lateral thigh - ? meralgia
Evaluate L4, L5, and S1 nerve root distribution
Check for tenderness over the sacroiliac joint
Check leg pulses
Evaluation of Hip Pain
 AP of pelvis and hip films
 MRI if occult hip or pelvic fracture is suspected – also
to evaluate early osteonecrosis
 Local anesthetic blocks of sacroiliac joint,
trochanteric area below gluteus medius tendon, lateral
femoral cutaneous nerve
Treatment of Hip Pain
 Very similar to Rx of back pain
 Acetaminaphen, tramadol, NSAIDS
 Physical therapy
 Joint replacement