Approach To Low Back Pain

Approach To Low Back Pain

Dr. Anmar AL-Dewachi Assistant Professor of Family Medicine M.B.Ch.B-MPH-JHSFM

Definition

LBP : Pain that occur posteriorly in the region between lower ribs margin and proximal thigh.

Types of LBP

According to its duration, LBP classified in to Acute → < 6 weeksSub-acute → 6-12 weeksChronic → >12 weeks

Epidemiology

One of the most common complaints seen in the general practice and orthopedic clinic.2nd commonest cause for visiting a physician in adults after URTI.The point prevalence of low back pain (LBP) in the United States is 5.6% Life time prevalence 60-70%.It occurs most often between the ages of 45 and 65 years. It affects men and women equally. The first episode usually occurs between 20 and 40 years of age. The majority of patients self-treat back pain and only 25%–30% of them seek medical care. However, back pain still ranks as one of the top reasons for visits to family physicians.

Natural history of LBP

The natural history of back pain is favorable overall with some studies showing that One-third of patients with LBP will be better in 1 week Two-thirds will be better in 7 weeks. However, relapses and recurrences are common in this condition, affecting about 40% of patients within 6 months .

Risk Factors

Main Risk Factors: Heavy lifting and twisting Old age. Lack of exercise Smoking Obesity Genetic factors. Low back pain is common even in people without these risk factors.

Differential diagnosis

Mechanical low back pain
97%
Mechanical implies an anatomic or functional abnormality without a malignant, infectious, or inflammatory etiology.
Lumbar Strain or Sprain/Idiopathic Low Back Pain
70%
Degenerative disc/facet process
10%

II. Non-mechanical spinal conditions

~1%

Infection

III. Non-spinal, visceral disease
2%

Evaluation

Medical history
It is important to evaluate three concerns in taking a history:Is there evidence of systemic disease?Is there evidence of neurologic involvement?Is there social or psychological distress that may contribute to chronic, disabling pain?Important points in HX.Patient's age Pain history ( site, severity, duration, precipitating and relieving factors ,associated symptom…….etc) A history of cancer Unexplained weight loss


Medical History
Chronic infection The presence of nighttime pain The response to previous therapy Hard physical labor Osteoporosis Physical inactivity Symptoms of systemic disease Symptoms of neurologic compromise Presence of social or psychological distress that may contribute to chronic, disabling pain


Clues that may suggest underlying systemic disease include: History of cancer Age over 50 years Unexplained weight loss Duration of pain greater than one month Nighttime pain Unresponsiveness to previous therapies

Sciatica A sharp or burning pain radiating down from the back to the posterior or lateral aspect of the leg, usually to the foot or ankle. Sciatic nerve pain is often associated with numbness or tingling. Sciatica due to disc herniation usually increases with coughing, sneezing, or performance of Valsalva maneuver.


Patient present with: LBP Saddle ansthesia Bowel or bladder dysfunction ( incontinence or retention) urinary retention with overflow incontinence is typically present. bilateral sciatica, and leg weakness.

Spinal stenosis

Symptoms of significant lumbar spinal stenosis include back pain, transient tingling in the legs, and walking-induced pain localized to the calf and distal lower extremity, resolving with rest. This pain with walking, referred to as"pseudoclaudication" or "neurogenic claudication", is clinically distinguished from vascular claudication by the presence of normal arterial pulses

Physical Examination

I. Gait and posture Observe the gait of the patient and check for scoliosis II. Range of motion Flexion, extension, lateral flexion, and lateral rotation of low back Pain increased by flexion reflects usually mechanical causes Pain precipitated by extension is indicative of spinal stenosis III. Palpation or percussion of the spine Point tenderness may indicate a fracture or infection Para-spinal tenderness indicates muscle spasm

Physical Examination

IV. Heel-toe walk, squat and rise Inability to walk heel-toe, squat and rise may indicate Cauda-Equina syndrome or neurologic compromise V. Straight leg raising

Straight Leg Raising

Straight leg raising is done with the patient supine. The examiner raises the patient's extended leg with the ankle dorsiflexed, being careful that the patient is not actively "helping" in lifting the leg. The test is considered positive when the sciatica is reproduced between 10 and 60 degrees of elevation.


Straight Leg Raising
A positive test is a test that reproduces the symptoms of sciatica, with pain that radiates below the knee, not only back or hamstring pain. Ipsilateral SLR is sensitive but not specific for a herniated disk. whereas crossed straight-leg raising CSLR (with the symptoms of sciatica reproduced when the opposite leg is raised) is insensitive but highly specific.

Red flags

Age > 50 years Major trauma. Night pain or pain at rest Progressive motor and sensory deficit Saddle anesthesia, bilateral sciatica or leg weakness, difficulty urinating, fecal incontinence Unexplained weight loss

Fever, chills, recent UTI or skin infection, wound near spine History of cancer metastatic to bone Osteoporosis Immunosuppression Chronic oral steroid IV drug use Substance abuse Failure to improve after conservative therapy

Findings that Prompt Immediate Action/Referral

Saddle anesthesia Loss of anal sphincter tone Major motor weakness in lower extremities Fever Vertebral tenderness Limited spinal range of motion Neurologic findings persisting beyond one month

Diagnostic testing

In the absence of red flag findings, there is no need for diagnostic tests. A period of 4-6 weeks of conservative care is safe and appropriateDiagnostic Tests that might be needed: Imaging studies ( plain radiography, CT scan and MRI):Imaging is not necessary during the first 4 to 6 weeks, unless the patient have the following criteria Age ≥50 yearsHistory of sever traumaHistory of malignancyProgressive neurological findingsConstitutional symptoms

Management

Management
Non-pharmacological treatment Pharmacological treatment.

Non-Pharmacologic Treatment

Bed rest : No benefit from complete bed rest. If necessary should be less than 2-3 days. The patient should be encouraged to return to work and their usual activities as soon as possible. Patient education: Advice patient to stay active but avoid heavy lifting, bending, twisting and setting for long time. Wear flat shoes or shoes with low heels (1 inch or lower). Exercise regularly (Inactive lifestyle contributes to lower back pain).


Maintain proper diet to prevent overweight or obesity. Quit smoking. Gentle range of motion and strengthening exercises are recommended for patients with non-sciatic back pain. Massage: Although there is no definitive evidence supporting the effectiveness of massage, many patients find it helpful. Stretching, ice, and heat are all effective

Pharmacological treatment

Pharmacological treatment
Non-steroidal anti-inflammatory (NSAID) and AcetaminophenAcetaminophen, NSAIDs, or a COX-2–inhibitor is 1.st line therapy for pain management.NSAIDs used to relieve mild to moderate pain.NSAIDs (Ibuprofen, diclofenac, naproxin ….etc) Opiate 2nd or 3rd line option for pain management for short period for moderate to sever pain Muscle relaxants: Muscle relaxants can be effective when there is significant muscle spasm present, but benefits must be balanced with their sedative properties.

Pharmacological treatment

Tricyclic antidepressants and anticonvulsants are effective in patients with underlying depression or a neuropathic pain. Steroids: No studies support their use in acute low back pain. Epidural steroid injection may be helpful in patients with radicular symptoms who do not respond to 2-6 weeks of conservative management

Algorithm: Evaluation of LBP

Low Back Pain
Presence of Sciatica
Simple Back Pain
Complicated Back Pain without radiculopathy
Radiculopathy
Urgent Situations
Conservative care and pain management for 4-6 weeks
Improved
Stop
Not improved
ESR and plain X-rays
Plain X-ray ESR if risks for osteomyelitis
Urgent consultation and MRI or CT
If normal, conservative care for at least 4-6 weeks unless neurologic deficit is progressive
Improved
Stop
Not improved
Non-contrast CT or MRI
If either abnormal, consider CT or MRI
* NO
YES