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Zafar Iqal
Abbasi Shaheed Hospital
Karachi
Acute Low Back Pain
Affects up to 90% of the US population at
some point in their life
It is second only to URI-s for symptom-
related visits to primary care physicians
It is the most common cause of work related
disability in persons under the age of 45 and
the second most common cause of temporary
disability for all ages
It costs over 60 billions annually
Acute Low Back Pain
It is a self-limiting condition that usually
resolves in up to six weeks
In approximate 80% of the cases no clear
etiology is ever determined
There is a small subset of patients in
whom LBP signals a life-threatening
disease or a disorder that require
immediate attention
Low Back Pain
Is defined as pain localized between the
lower rib cage and the gluteal folds often
extending or radiating into the thighs. It
can be subclassified as:
Acute if lasting less than 6 weeks
Subacute if lasts between 6 and 12 weeks
Chronic if duration of the pain is longer than
12 weeks
Low Back Pain Generators
1. Osseous: vertebral body, pedicles,
lamina, facets, spinous and transverse
processes of the vertebras
2. Neuroanatomic (frequent pain
generator)
3. Supporting structures:
• Intervertebral disc (most frequent pain gen.)
• Ligaments (ALL, PLL, L. flavum, facet
capsules, supraspinous, intraspinous)
Differential Diagnosis
Mechanical Low Back or Leg Pain
97%
Nonmechanical Spinal Conditions
1%
Visceral Diseases
Differential Dx: Mechanical
Low Back or Leg Pain (97%)
Lumbar strain/sprain Traumatic fracture
70% <1%
Degenerative process Congenital
10% disease:severe kyphosis
Herniated discs 4% or scoliosis, transitional
vertebrae <1%
Spinal stenosis 3%
Spondylolysis
Compression fx 4%
Internal disc disruption
Spondylolisthesis
2% Presumed instability
Differential Dx:Nonmechanical
Spinal Conditions (1%)
Neoplasia 0.7% Inflammatory arthritis
multiple myeloma 0.3%
mets ankylosing spondylitis
lymphoma/leukemia psoriatic spondylitis
spinal cord tumors Reiter’s syndrome
retroperitoneal tumors Inflammatory bowel
primary vert. Tumors disease
Infection 0.01%
Paget’s disease
osteomyelitis Scheuermann’s disease
septic diskitis
paraspinous abscess
shingles
Differential Dx: Visceral
Disease (2%)
Disease of pelvic Aortic aneurysms
organs Gastrointestinal
prostatitis
diseases
endometriosis
pancreatitis
chronic PID
cholecystitis
Renal disease
nephrolithiasis
penetrating ulcer
pyelonephritis
perinephric abscess
Red Flags in the History
Age – less than 18 or more than 50
Trauma – even minor if elderly/steroid rx
Cancer
Fever, chills, night sweats
Weight loss
IVDA
Recent GI/GU procedures
Severe and unremitting pain
Severe or progressive neurological deficit
Red Flags in the History
Benign back pain is usually dull,
achy pain which is exacerbated by
movement but improves with rest
Red flags for tumor or infection is
pain that is worsen at night and
awakes patient from sleep, not
improved by rest or is unrelenting
despite appropriate analgesics
Red Flags in the History
Pain that is worsen with prolonged
sitting, coughing and Valsalva
maneuver often occurs with disk
herniation
Patients with benign acute LBP
rarely have associated neurological
deficits. Any such complaint is a “red
flag”
Physical Examination -
Inspection
Vital signs – fever is a red flag for infection; is
present in 27% of TB OM, 50% of pyogenic OM and
in 87% of epidural abscesses
Patients with benign back pain prefer to remain still.
Severe pain should rise concerns for infection,
nephrolithiasis or aortic aneurysm
Observe patient’s gait and ability to heel walk
(testing dorsiflexion-L4 and L5 roots) and toe walk
(testing plantar flexion – S1 root)
Physical Examination -
Inspection
Back should be exposed and observed for
spasm, erythema and edema
Patients with anterior problems
(degenerated disk) usually have
extension preference; those with
posterior mechanical problems
(spondylosys or spondylolysthesis) have
flexion preference
Physical Examination -
Palpation
Spine and paraspinal structures should be palpated.
Point tenderness usually indicates ligamentous
disruption or local destruction by tumor or fracture
Straight leg test – a positive test reproduces
radicular pain below the knee and along the path of a
nerve root (L5, S1) at 30- to 70- degree elevation
from supine. Is approximate 80% sensitive for disk
herniation. Approximately 80-90% of all herniated
disks occur at the level of either L4-5 or L5-S1
Physical Examination –
Neurological Evaluation
Lower extremity strength and
sensation (dermatomal distribution)
Reflexes - Patellar (L3-L4)
- Achilles (S1)
- Babinski (upper motor)
Associated neurological deficits –
urinary and bowel retention or
incontinence
Red Flags in the Physical
Examination
Fever
Point tenderness on percussion
Anal sphincter laxity
Perianal sensory loss
Motor weakness
Positive straight leg raise test
Diagnostic Testing
When there are no red flags a good
history and physical exam should
suffice
Lab tests - if tumor or infection is
suspected a CBC, ESR, CRP should be
obtained
Radiography – are necessary only if there is
concern for fracture (history of trauma),
malignancy or rheumatologic disease. AP
and Lat views should suffice. If films are
negative but concern still exists MRI or CT
should be obtained
Diagnostic Testing - MRI
Is the gold standard test for compressive
lesions of the spinal cord or the cauda
equina, infections or disk herniation
Allows evaluation for disk degeneration
and nerve root entrapment
Excellent screening for bone marrow
replacement processes
If only disk herniation is suspected, it can
be delayed for 6 weeks
Diagnostic Testing – CT
Is the modality of choice to visualize bony
details especially subarticular region
Very useful in setting of trauma to
evaluate the stability of the spinal column
and integrity of the spinal canal
Useful for vertebral OM but can miss
epidural abscesses
Use of myelography prior to CAT scanning
will provide excellent intratechal detail
Diagnostic Testing
Bone Scan – can help identify
metastatic cancer, infectious
processes and stress fractures
Electromyography/Nerve Conduction
Velocity - can be useful to
investigate radiculopathy. Have little
use in nonradicular pain syndromes
Treatment of Benign Acute
LBP
About 80% of acute LBP sufferers will
completely recover in 4 weeks
Several studies found that patients who
resumed their activity recovered faster than
those who stayed in bed for 2 days
Active exercise has not been shown to be
beneficial during the acute stage of back pain
Patients should resume normal daily activities
but curtail those that exacerbate the pain
Analgesia
The mainstays of therapy are NSAIDs,
acetaminophen, and opiate analgesics
Acetaminophen has proven efficacy
comparable with NSAIDs with fewer side
effects. Usual dose is 650 to 1000mg Q 6
hrs
Most nonsteroidals are equally efficacious.
Lowest dose should be tried. If there is
concern about GI bleeding can be
combined with misoprostol or PPI
Analgesia
COX-2 inhibitors are effective, have
fewer side effects than regular NSAIDs
but the cost is very high
A common approach is a combination
of acetaminophen 650 to 1000 mg QID
with ibuprofen 800 mg TID or
naproxen 500 mg BID
Ketorolac has not been shown to be
superior to other oral NSAIDs
Analgesia
Opiate analgesics (codeine) should be
prescribed for more severe pain in
combination with acetaminophen or
NSAIDs
Oxycodone and hydrocodone should be
avoided because of higher dependency
potential
Should be prescribed only for a short
period of time
Analgesia
Muscle relaxants (methocarbamol,
cyclobenzaprine, diazepam) are especially
indicated in treating LBP associated with
spasm
Are more effective than placebo in treating
LBP but no better than NSAIDs
Can produce drowsiness
Does not seem to have a synergistic effect
with acetaminophen or NSAIDs
Back Manipulation
Is one of the most controversial
treatments for LBP
Most studies have found that while it may
have some limited short term benefit the
lasting results are unproven
A recent meta-analysis of 39 RCT-s did
not show back manipulation to be more
effective than conventional treatment
Other Physical Modalities
Other treatment modalities include
traction, ultrasound, cutaneus laser
therapy, massage, accupuncture and
electrical nerve stimulation. None of these
has been shown to improve recovery rate
from acute LBP
Heat and ice therapy is marginally
effective in reducing pain and is very
inexpensive
Preventive Measures
Start a program of regular exercises
beginning with low stress aerobic
exercises followed in a few weeks by
exercises to condition specific trunk
muscles
Loss of excess of weight
Regular walking and swimming
Avoidance of high impact exercises for at
least several months after the acute LBP
Epidural Compression
Syndrome
Includes spinal cord compression,
cauda equina syndrome and conus
medularis syndrome
Except for the level of the
neurological deficit, the presentation
of these syndromes is similar
The initial evaluation and
management is also similar
Epidural Compression
Syndrome
Is a medical emergency because of the
catastrophic neurological loss that can
develop
Is caused by pressure being exerted on
the cord or cauda equina from a space
occupying lesion – tumor, abscess, disk
herniation or traumatic compression
Epidural Compression
Syndrome
LBP might not be the dominating complaint
Leg pain is more frequent
Symptoms are usually bilateral and usually
a combination of motor, sensory and
autonomic dysfunctions
Patients can experience constipation or
incontinence of the bowel, retention or
incontinence of the urinary bladder
Epidural Compression
Syndrome
Saddle anesthesia
Major motor or sensory loss is often
noted
Patients with these symptoms
should be treated emergently and
should be assumed they have spinal
cord injury until proven otherwise
Epidural Compression
Syndrome
10 –100 mg of dexamethasone
should be administered iv because it
might reduce the progression of
deficits and alleviate pain
Emergent MRI of the region
according to the level of the
neurological deficits
Immediate specialist consultation
Epidural Compression
Syndrome
Outcomes depend on the neurologic
deficit at presentation
Patients paraplegic at presentation are
unlikely to walk again; those who were
too weak to walk alone but not paraplegic
had a 50% chance of walking again.
Those who were ambulatory remained so
Of the patients catheterized for
denervated bladder 80% did not recover
bladder function
Cancer
History sensitivity specificity
Age > 50 0.77 0.71
previous history 0.31
0.98 of cancer
failure to improve 0.31
0.90 in 1 mo. of therapy
no relief -bed rest >0.90 0.46
duration > 1 mo 0.50 0.81
age >50 or cancer hx or 1.00 0.60
unexplained wt loss or
failure of conservative tx.
Insidious onset
constitutional symptoms
Infection
Intravenous drug abuse, UTI, or skin
infection in 40%
also,
immune suppression
insidious onset
previous surgery
constitutional symptoms
Compression fracture
History sensitivity
specificity
age >500.84 0.61
age >70 0.22 0.96
trauma 0.30 0.85
corticosteroid use 0.06 0.995
Reverse
lies prone or on side and thigh is extended
one at a time; pain over involved nerve root
usually L3 or L4 irritation
PE -Lumbar disc herniation
Test sensitivity specificity
ipsilateral SLR 0.80 0.40
crossed SLR 0.25 0.90
impaired ankle reflex 0.50 0.60