Diagnosing Low
Back Pain
Eden Wheeler, M.D.
Physical Medicine and Rehabilitation
Rockhill Orthopaedics, P.C.
1
I. History:
2
• Mechanism of injury
• Associated symptoms:
•
•
•
•
•
•
•
•
Bladder / bowel function
Fevers / chills
Sleep disturbance
Numbness / tingling
Prior injuries, treatment and outcomes
Medications
Family history
Social history:
•
•
•
•
Vocational
Education
Tobacco / ETOH / Illicit drugs
Function: ADLs & Mobility
• Litigation
3
Pain Specifics:
•
•
Quality: sharp, dull, shooting, burning, etc.
Location / Distribution:
• Radicular: Dermatomal distribution, dysesthesias
• Radiating: Nondermatomal
•
Onset:
• Gradual: DDD
• Acute: Disc abnormality, strain, compression fractures
•
•
•
•
•
Severity / Intensity
Frequency: Constant vs. Intermittent
Duration
Exacerbating and Alleviating Factors
Time of Day: If nocturnal, consider malignancy
4
Red Flags:
•
•
•
•
Significant trauma history, or minor in older adults
Nocturnal pain in supine position with history of cancer
Bladder or bowel incontinence or dysfunction
Constitutional symptoms:
• Fever / chills
• Weight loss
• Lymph node enlargement
• Risk factors for spinal infection
• Recent infection
• IV drug use
• Immunosuppression
• Major motor weakness
5
II. Examination:
6
A. Physical:
• Posture:
• Splinting
• Body language
• Gait:
• Antalgia
• Heel / Toe pattern
• Trendelenberg
• Musculoskeletal:
•
•
•
•
ROM
Leg length
Vascular
Atrophy
7
• Abdomen:
• Presence of masses
• Back:
•
•
•
•
Inspection
Palpation
ROM
Scoliosis
• Neurological:
• Sensation
• Motor
• DTRs
• Rectal if indicated:
• Evaluation of sphincter tone
8
B. Symptom Magnification
Examination:
• Waddell signs: Presence of nonorganic signs
suggesting symptom magnification and
psychological distress
–
–
–
–
–
Superficial or nonanatomic distribution of tenderness
Nonanatomic or regional disturbance of motor or sensory impairment
Inconsistency on positional SLR
Inappropriate/excessive verbalization of pain or gesturing
Pain with axial loading or rotation of spine
• Give-away weakness: Inconsistent effort on manual
motor testing with “ratcheting” rather than smooth
resistance
9
C. Pathological Examination:
• Spurling’s maneuver: Lateral rotation and extension of spine resulting
in neuroforaminal narrowing and nerve root encroachment, clinically
reproducing extremity pain, usually in dermatomal distribution
• Straight-leg raise (SLR): Elevation of lower extremity, seated or
standing, resulting in neural tension at S1 nerve root with extremity pain
• Patrick’s maneuver: Crossed leg with unilateral pain indicative of
sacro-iliac (SI) joint dysfunction
• Femoral stretch: Hip extension stretch with heel pushed to buttock in
lateral supine or prone position resulting in anterior thigh pain
10
III. Low Back Pain:
11
A. Epidemiology:
• Incidence of LBP:
• 60-90 % lifetime incidence
• 5 % annual incidence
• 90 % of cases of LBP resolve without treatment within 6-12
weeks
• 40-50 % LBP cases resolve without treatment in 1 week
• 75 % of cases with nerve root involvement can resolve in 6
months
• LBP and lumbar surgery are:
• 2nd and 3rd highest reasons for physician visits
• 5th leading cause for hospitalization
• 3rd leading cause for surgery
12
B. Disability:
• Age and LBP:
• Leading cause of disability of adults < 45 years old
• Third cause of disability in those > 45 years old
• Prevalence rate:
• Increased 140 % from 1970 to 1981 with only
125 % population growth
• Nearly 5 million people in the U.S. are on
disability for LBP
13
C. Lifetime Return to Work:
• Success of less than 50 % if off work greater
than 6 months
• 25 % success rate if off work greater than 1 year
• Nearly 0 % success if return to work has not
occurred in 2 years
14
D. Occupational Risk Factors:
•
•
•
•
•
•
Low job satisfaction
Monotonous or repetitious work
Educational level
Adverse employer-employee relations
Recent employment
Frequent lifting
• Especially exceeding 25 pounds
• Utilization of poor body mechanics in technique
15
E. Differential Diagnoses:
• Lumbar strain
• Disc bulge / protrusion / extrusion
producing radiculopathy
• Degenerative disc disease
• Spinal stenosis
• Spondyloarthropathy
• Spondylosis
• Spondylolisthesis
• Sacro-iliac dysfunction
16
F. Diagnostic Tools:
• 1. Laboratory:
•
Performed primarily to screen for other disease etiologies
• Infection
• Cancer
• Spondyloarthropathies
• No evidence to support value in first 7 weeks unless with red flags
• Specifics:
• WBC
• ESR or CRP
• HLA-B27
• Tumor markers:
Kidney
Breast
Lung
Thyroid
Prostate
17
• 2. Radiographs:
• Pre-existing DJD is most common diagnosis
• Usually 3 views adequate with obliques only if equivocal findings
• Indications:
• History of trauma with continued pain
• Less than 20 years or greater than 55 years with severe or
persistent pain
• Noted spinal deformity on exam
• Signs / symptoms suggestive of spondyloarthropathy
• Suspicion for infection or tumor
18
• 3. EMG / NCV ( Electrodiagnostics):
• Can demonstrate radiculopathy or peripheral nerve
entrapment, but may not be positive in the extremities
for the first 3-6 weeks and paraspinals for the first 2 weeks
• Would not be appropriate in clinically obvious radiculopathy
• 4. Bone scan:
• Very sensitive but nonspecific
• Useful for:
• Malignancy screening
• Detection for early infection
• Detection for early or occult fracture
19
• 5. Myelogram:
• Procedure of injecting contrast material into the spinal canal
with imaging via plain radiographs versus CT
• In past, considered the gold standard for evaluation of the spinal
canal and neurological compression
• With potential complications, as well as advent of MRI and CT,
is less utilized:
• More common: Headache, nausea / vomiting
• Less common: Seizure, pain, neurological change, anaphylaxis
• Myelogram alone is rarely indicated
• Hitselberger study 1968 Journal of Neurosurgery:
• 24 % of asymptomatic subjects with defects
20
• 6. CT with myelogram:
• Can demonstrate much better anatomical detail than
myelogram alone
• Utilized for:
• Demonstrating anatomical detail in multi-level disease in preoperative state
• Determining nerve root compression etiology of disc versus
osteophyte
• Surgical screening tool if equivocal MRI or CT
21
• 7. CT:
• Best for bony changes of spinal or foraminal stenosis
• Also best for bony detail to determine:
• Fracture
• DJD
• Malignancy
• SW Wiesel study 1984 Spine:
• 36 % of asymptomatic subjects had “HNP” at L4-L5
and L5-S1 levels
22
• 8. Discography (Diagnostic disc injection):
• Less utilized as initial diagnostic tool due to high incidence of
false positives as well as advent of MRI
• Utilizations:
• Diagnose internal disc derangement with normal MRI / myelo
• Determine symptomatic level in multi-level disease
• Criteria for response:
• Volume of contrast material accepted by the disc, with normals of 0.5 to
1.5 cc
• Resistance of disc to injection
• Production of pain---MOST SIGNIFICANT
• Usually followed by CT to evaluate internal architecture, but
also may utilize MRI
• As outcome predictor (Coulhoun study 1988 JBJS):
• 89 % of those with pain response received benefit from surgery
• 52 % of those with structural change received surgical benefit
23
• 9. MRI:
• Best diagnostic tool for:
• Soft tissue abnormalities:
• Infection
• Bone marrow changes
• Spinal canal and neural foraminal contents
• Emergent screening:
•
•
•
•
Cauda equina syndrome
Spinal cored injury
Vascular occlusion
Radiculopathy
• Benign vs. malignant compression fractures
• Osteomyelitis evaluation
• Evaluation with prior spinal surgery
24
• Has essentially replaced CT and myelograms for initial
evaluations
• Boden study 1990 JBJS:
• 20 % of asymptomatic population less than 60 years with “HNP”
• 36 % of asymptomatic population of 60 years
• Jensen study 1995 NEJM:
• 52 % of asymptomatic patients with disc bulge at
one or more levels
• 27 % of asymptomatic patients with disc protrusion
• 1 % of asymptomatic patients with disc extrusion
25
• MRI with Gadolinium contrast:
• Gadolinium is contrast material allowing enhancement of
intrathecal nerve roots
• Utilization:
• Assessment of post-operative spine---most frequent use
• Identifying tumors / infection within / surrounding spinal cord
• Diagnosis of radiculitis
• Post-operatively can take 2-6 months for reduction of mass
effect on posterior disc and anterior epidural soft
tissues which can resemble pre-operative studies
• Only indications in immediate post-operative period:
• Hemorrhage
• Disc infection
26
• 10. Psychological tools:
• Utilized in case scenarios where psychological or emotional
overlay of pain is suspected
• Symptom magnification
• Grossly abnormal pain drawing
• Non-responsive to conservative interventions but with essentially
normal diagnostic studies
• Includes:
• Pain Assessment Report, which combines:
• McGill Pain Questionnaire
• Mooney Pain Drawing Test
• MMPI
• Middlesex Hospital Questionnaire
• Cornell Medical Index
• Eysenck Personality Inventory
27
MRI Nomenclature:
• Anular fissure:
(PER NASS)
Focal disruption of anular fibers in concentric, radial or
transverse distribution
• Disc bulge:
Circumferential, diffuse, symmetric extension of anulus beyond
the adjacent vertebral end plates by 3 or more mm, usually due to weakened or lax
anular fibers
• Disc protrusion:
Focal, asymmetric extension of disc segment beyond
margin of vertebral end plates into the spinal canal with most of anular fibers intact
• Disc extrusion:
Focal, asymmetric extension of disc segment and / or nucleus
pulposis through the anular containment into the epidural space
• Disc sequestration: Extruded disc segment that is detached from original
with migration into the canal
• Disc degeneration:
Irreversible structural and histiological changes in
nucleus seen on MRI T2WI images (commonly associated with bulge)
28
Specificity / Sensitivity
Diagnosis
Test
Sensitivity
Specificity
Disc
“Herniation”
CT
0.90
0.70
MRI
0.90
0.70
CT Myelo
0.90
0.70
CT
0.90
0.80-0.95
MRI
0.90
0.75-0.95
Myelogram
0.77
0.70
Spinal
Stenosis
29
G. Treatment
• Medications
• NSAIDS
• Membrane stabilizers
• TCA / Neurontin
• re-establish sleep pain
• reduce radicular dysesthesias
• Muscle relaxers:
• re-establish sleep patterns
• more useful in myofascial/muscular pain
• Narcotics: rarely indicated
• Steroids: more useful for radiculitis
• Non-narcotic analgesics: Ultram
30
• Physical therapy
•
•
•
•
•
•
•
•
Modalities
electrical stimulation/TENS
Postural education / body mechanics
Massage / mobilization / myofascial release
Stretching / body work
Exercise / strengthening
Traction
Pre-conditioning / work-conditioning
• Injections
•
•
•
•
•
Epidural blocks
Facet blocks
Trigger point
SNRB
SI joint
31
• Surgery:
•
•
•
•
Laminectomy
Fusion
Discectomy
Percutaneous Lumbar Discectomy
– Success rate variable 50 -85 %
– Low rate of complications:
• Infection
• Peripheral nerve injury
– Benefits:
•
•
•
•
•
Outpatient procedure
Minimal to no epidural scarring
No general anesthesia
Spine stability preservation
Decreased cost
32
• Chemonucleolysis
• IDET: Intradiscal Electrotherapy or Spine CATH
• Alternative:
• Chiropractic:
• Clinical studies show benefit only in first 3 weeks of symptoms
• Acupuncture
• Biofeedback
33
IV. Specific Disorder
Considerations
34
A. Sacroiliitis:
• History:
•
•
•
•
Trauma is very common
Repetitive LS motion--lumbar rotation or axial loading
No specific correlation with exacerbating activities
Commonly have leg length discrepancy or condition contributing
• Biomechanics:
• Movement of the SIJ is involuntary, usually from muscle imbalances
• Can occur at multiple levels: lower extremities, hip, LS spine
• Motion is complex and not single-axis based
35
• Differential Diagnosis:
a. Fracture
• Traumatic
• Insufficiency stress fractures: elderly patient with osteoporosis
without history of trauma
• Fatigue stress fractures: usually athletes / soldiers
b. Infection
• Hematogenous spread with predisposing history
• Usually unilateral symptoms present
c. Degenerative joint disease
d. Metabolic disease
e. Referred pain
36
f. Seronegative spondyloarthropathies
• RA--usually not until late in course of disease
• Ankylosing spondylitis
• Psoriatic arthritis
g. Primary SI tumor
• Rare and usually synovial villoadenomas
h. Iatrogenic instability
• Via pelvic tumor resection or bone graft site
i. Osteitis condensans ilii
• Prevalence of 2.2 %, primarily in multiparous women
• Usually self-limiting and bilateral
j. Reactive disease as sequellae of PID
37
• Diagnostic Tools:
• X-rays: Up to 25 % of asymptomatic adults over 50 years
can have abnormalities
• MRI / CT: Only if looking for tumor
• Bone scan: Good for fractures but less favorable for inflammation
• Treatment:
• Medications: NSAIDS
• Physical therapy
• Correct limb discrepancy
• Injection: Fluoroscopy-guided vs. local
• Surgical fusion: Few figures for efficacy
38
B. Cauda Equina Syndrome:
• History:
• Sudden, partial or complete loss of voluntary bladder function
due to massive disc impingement on spinal nerves
• Can include loss of sensation as well as sphincter tone
• Treatment:
• Urgent decompression is mandatory for prevention of
irreparable / irreversible bladder damage
• 12 hours is the maximum time prior to irreversible changes
39
C. DDD and Spondylosis:
• Clinical:
• Up to 75 % of involvement of the spine occurs at 2 levels:
L5-S1 and L4-L5
• Possible factors that contribute to development:
– Changes with maturation in:
• Nutrition
• Disc chemistry
• Hormones
– Occupational forces
• Progression of disc narrowing leads to degenerative changes of
bony structures, especially posterior components, leading
to spondylosis
40
• Treatment:
• Medications
• Physical therapy
• Lifestyle changes:
• Smoking cessation
• Weight loss
• Vocational changes
• Injections:
• Less helpful if pain is limited to central low back only
• Surgery:
• Laminectomy
• Fusion
41
D. Spinal Stenosis:
• Clinical:
• Results from narrowing of spinal canal and / or neural foramina
(CONGENITAL OR DEGENERATIVE)
• Most common complaint is leg pain limiting walking
• Neurogenic / Pseudoclaudication = pain in lower extremities with gait
• Relief can occur with:
– stopping activity
– sitting, stooping or bending forward
• Common are complaints of weakness and numbness of extremities
• Usually becomes symptomatic in 6th decade
42
• Diagnosis:
• CT and MRI may yield false-positive results, therefore EMG /
NCV can be helpful to confirm diagnosis
• Myelography also can be confirmatory and pre-surgical
screening tool
• Treatment:
•
•
•
•
•
Medications
Physical therapy
TENS
Epidural injections
Surgical decompression laminectomy
43
E. “HNP”:
• Clinical:
• Low back pain wit associated leg symptoms
• Positions can induce radicular symptoms
• Posterolateral disc pathology most common:
• Area where anular fibers least protected by PLL
• Greatest shear forces occur with forward or lateral bend
• Central disc pathology:
• Usually with LBP only without radicular symptoms, unless
a large defect is present
44
• Treatment:
• Conservative treatment:
– Saul and Saul study 1989 Spine:
• > 90 % success rate of symptom resolution with
non-operative management
– Bozzao study 1992 Radiology:
• 69 patients with “HNP” studied longitudinally with MRI
• 63 % with >30 % reduction with 48 % > 70 % reduction
over time
•
•
•
•
Medications
Physical therapy
Injections
Surgery
45
F. Pars Interarticularis Defects:
• Spondylolysis:
•
•
•
•
Anatomic defect in the bony pars interarticularis within the lamina
May uni- or bilateral
Can be congenital or induced
Usually without clinical symptoms with incidental findings on
radiographs
46
• Spondylolisthesis
• Progression of spondylolysis with separation
• Grades assigned I-IV for level of translation
• Most common levels are L5-S1 (70 %) and L4-L5 (25 %)
• May be asymptomatic, but can result in
• Spondylosis
• DDD
• Radiculopathy
• Treatment:
•
•
•
•
Medication
Physical Therapy
Injections
Surgery
47
V. Chronic Pain Issues
48
A. Pain Reinforcing Factors:
• Secondary gain: Support system allows passive / inactive role for
patient via catering to needs and hence fostering dependency
• Environmental: Inadequate opportunity or skills to compete in the
professional community
• Physician knowledge deficit: In areas of diagnosis and appropriate
treatment, can prolong symptoms and validate pain behavior
• Worker’s compensation: Laws have become counterproductive-financial compensation or open claim may discourage desire for return
work and impede recovery
• Litigation: Anticipation of large financial settlement can reinforce pain
behavior and develop into learned pain behavior
49
B. Risk Factors for Delayed
Recovery:
Occupational


Job availability
Patient perception of
work load
Psychosocial

Anger with “system”


Disabled spouse



Job dissatisfaction

Time off of work
Medical
Poor English
proficiency

History of narcotic or
substance abuse
Poor fitness
History of prior
injury
50
C. Discouraging Chronic Pain:
• Requiring employer to accommodate restrictions to allow
continued working during treatment and recovery
• Rapid abjudication of disability and compensation claims
• Physician education re: appropriate treatments and limiting use of
potentially addictive medications
• Ergonomic work environments
• Patient education re: disease process and treatment options
51
D. Considerations of
PM & R Treatment:
• Physical therapy is initially usually one of modalities with progression
into more active exercise
• Pre-conditioning therapy is more functional with transition into Work
Conditioning (Work Hardening) program
• Always consider return to work, whether modified duty with restrictions
or limiting hours worked
• If patients poorly tolerate standard therapy, consider pool therapy
intervention which allows elimination of gravity effects
• Functional Capacity Evaluations utilized if patients are not progressing
through therapy or if have reached a plateau and abilities as
well as restrictions need to be assessed
• Job site evaluations appropriate if concerns re: ergonomics
52
E. Final Thoughts:
• It is the patient, not the diagnostic test,
that is treated
• 80 % of patients will recover from acute
low back pain within 3 days to 3 weeks,
with or without treatment, with up to 90 %
resolved in 6-12 weeks
53