BACK to Basics: The Diagnosis and Management of Low Back Pain - PowerPoint PPT Presentation

2016 Annual Review in Family Medicine December 5, 2016 BACK to Basics: The Diagnosis and Management of Low Back Pain Cindy J. Chang M.D. UCSF Primary Care Sports Medicine Associate Clinical Professor of Orthopaedics and Family and Community Medicine

Disclosures I have nothing to disclose

Objective  Perform an effective problem-focused history and physical examination for evaluation of low back pain  Develop treatment plans for the most common causes of low back pain

Important Points  With a good history… you should arrive at the correct diagnosis 90% of the time Or at least a confident top 3 differential!   With a good history, and comfortable knowledge of basic anatomy… it will make your exam focused, quick and efficient  And give you more time to chart…  With a good history, and comfortable knowledge of basic anatomy, you will not need to palpate until the END of the exam…  Or you risk your patient not letting you finish the exam! Hampton JR et al, BMJ 1975

Exam Room Tips  Stock gowns/ sheets and paper shorts in the room  Be able to get to both sides of the exam table  Have a step stool handy

Low Back - History 1. Age, occupation, etc. 2. Date of injury/ symptom onset 3. Injury Mechanism: a. Acute: pop, ability to continue activity b. Chronic/ Overuse: precipitating activity 4. Swelling: location 5. Symptoms: Mechanical/ Other a. Locking, tightness, weakness, bowel/ bladder 6. Symptoms: Pain/ Numbness/ Tingling a. Location - Point to where it is b. Radiation - come from or go anywhere else c. Type - burning, sharp, dull, achy, constant, at night, w/ activity or position, Grade pain 7. Modifying/ Other Factors a. Better/ worse, previous injury/ surgery, red flags

Red Flag Symptoms  History of cancer  Bilateral leg  Progressive motor weakness  Fever and chills or sensory deficit  Prolonged steroid  Unrelenting use, IV drug use severe pain with  Major trauma rest  Loss of bowel or  Numbness in bladder function groin/ saddle

Guide to Lumbar Spine Conditions Sprain/Strain Dysfunction/ Derangement Postural ONSET Sudden, simple Gradual Sudden, simple move move; trauma; acute load PAIN Severe ache, Ache, Sharp, burning, diffuse, spasm intermittent Localized or Radiating MOBILITY Reduced; any Reduced b/c of Guarded flexion movement joint and CT & extension increases pain stiffness decreases pain; guarded in all ranges GOALS OF Decrease pain Decrease pain Decrease pain TX + spasm Increase ROM Stabilize spine Restore ROM Posture Posture Posture Strength/Flex Strength/Flex Strength/Flex Prevention

Bones and Joints

Intervertebral Discs

Nerves  31 prs of nerves  C7 nerve exits b/ w 6 th and 7 th cervical vertebrae  L4 nerve exits b/ w 4 th and 5 th lumbar vertebrae

Nerves  Dermatomes  Myotomes  L1/ L2 – Hip flexion  L3/ L4 – Knee extension  L4 – Ankle dorsiflexion  L5 – Great toe extension  S1 – Ankle plantarflexion

Nerves  Dermatomes Lee MWL et al, Clin Anat 2008

Muscles  Superficial  Thoracic group  Abdominal group  Erector Spinae group  Spinalis  Longissimus  Iliocostalis  Deep  Transversospinal group  Multifidus  Rotatores  Intertransversarius

Low Back – A systematic exam  Observation: abrasions, bruising, comfort, motion  Sitting: slump test, reflexes, sensation, strength  Supine:  SLR  Hip ROM / pain  Hamstring/ Hip flexor tightness  Prone:  Tenderness LS spine, SI joints  Femoral nerve stretch, passive extension hips/ spine  Hamstring/ glut max strength, L5 reflex  Standing:  ROM: flex, ext, sidebend, rot/ exten  One legged extension, Gillet test (pelvic motion)  Feet, gait, heel/ toe walk, functional testing

Low Back – A systematic exam

Case #1

Case #1- History 1. Age—22 professional soccer player 2. Date of injury/ symptom onset--ACUTE 3. Injury Mechanism: a. Acute: DIRECT BLOW; UNABLE TO CONTINUE PLAY 4. Swelling: AT SITE OF TRAUMA 5. Symptoms: Mechanical/ Other a. TIGHTNESS, NO LOSS OF BOWEL/ BLADDER 6. Symptoms: Pain/ Numbness/ Tingling a. Location – MID-LEFT LUMBAR SPINE b. Radiation – TO LEFT BUTTOCKS c. Type – CONSTANT, SHARP, WITH ANY CHANGE IN POSITION, 13/ 10 PAIN 7. Modifying Factors a. NO PREVIOUS INJURY/ SURG; BEST WHEN LYING STILL

Case #1 - Exam  Observation: DISCOMFORT, IN PAIN  Sitting: LOCAL PAIN WITH SLUMP TEST, NO RADIATION. NL REFLEXES, STRENGTH, SENSATION  Supine:  (-)SLR, FROM HIP NO PAIN  Prone:  + TENDER LEFT LUMBAR SPINE L3 AND L4 LEVELS  Standing:  ROM: + PAIN IN ALL RANGES  PAIN WITH WALKING

Case #1 - Exam

Dx: Left L3 Transverse Process Fracture

Transverse Process Fracture  Sudden extreme twisting or side-bending movement, or direct impact

Transverse Process Fracture  Majority treated conservatively, no surgery needed  A brace may be used  Gradual introduction of movement and PT/ rehab once pain decreased  Full return to activity expected

Case #2- History 1. Age, occupation, etc.: 50 YO OVERWT FEMALE, SELF- EMPLOYED AS CARPENTER 2. Date of injury/ symptom onset: 2 DAYS AGO 3. Injury Mechanism: a. Acute: WENT TO CATCH HAMMER THAT WAS FALLING OFF COUNTER 4. Swelling: NONE 5. Symptoms: STIFFNESS, BOWEL/ BLADDER OK 6. Symptoms: Pain/ Numbness/ Tingling a. Location – ENTIRE LOW BACK b. Radiation – NO c. Type – BURNING, NO NIGHT PAIN, W/ MOTION, 4/ 10 7. Modifying/ Other Factors a. BETTER WITH ICE, IBUPROFEN, KNEES TO CHEST, NO RED FLAGS

Case #2 - Exam  Observation: STIFFNESS  Sitting: NEG SLUMP, NL REFLEXES, SENS, STRENGTH  Supine:  NEG SLR, HIP FROM W/ O PAIN  Prone:  NO CENTRAL SPINE OR BONY PAIN  TENDER BILAT PARASPINAL MM ON PALP  NEG FEMORAL NERVE STRETCH, HAM/ GLUT MAX STRENGTH 5/ 5  Standing:  ROM: STIFF/ PAIN ESP FF W/ SPASM, PAIN WHEN RETURNING TO ERECT POSITION  SLOW GAIT, HEEL/ TOE WALK OK

Case #2 - Exam

Diagnosis – Muscle strain  Acute sudden movement or action  Overuse from poor posture, mm strength, endurance  Common and self-limiting  Treatment:  NSAIDS/ MM relaxers  Ice/ Heat  Proper posture and movement patterns  Physical Therapy if no resolution  Active daily exercise, e.g. walking in proper shoewear  Weight management

“ Your back went out because your front went out.”

Case #3- History 1. Age, occupation, etc.: 51 YO OVERWT CARPENTER 2. Date of injury/ symptom onset: 1 MONTH AGO 3. Injury Mechanism: a. ON A DEADLINE AND MOVING FASTER THAN USUAL; LIFTING MORE BOXES 4. Swelling: NONE 5. Symptoms: STIFF, WEAK, BOWEL/ BLADDER OK 6. Symptoms: Pain/ Numbness/ Tingling a. Location – LOW BACK, L BUTTOCKS b. Radiation – L LAT LEG TO ALL TOES c. Type – ACHY PAIN AT NIGHT, SHARP/ BURNING DURING DAY, NOW WORSENING 8/ 10 7. Modifying/ Other Factors a. ICE/ HEAT/ NSAIDS TEMPORARY HELP,  APPETITE, HURTS WITH COUGH/ SNEEZE

Case #3 - Exam  Observation: STANDING WHEN YOU ENTER ROOM  Sitting: + SLUMP, 1+ S1 REFLEX,  SENSATION FIRST WEBSPACE, LAT FOOT;  STRENGTH 4/ 5 L GREAT TOE EXTENSION, L ANKLE DF; 5-/ 5 L ANKLE PF  Supine:  + L SLR AT 45 DEG, L HIP FROM BUT PAIN W/ ER  Prone:  + TENDER L4-5 > L5-S1, L SI JOINT  NEG FEMORAL N STRETCH TEST  L HAM/ GLUT MAX 4+ / 5, ABSENT L L5 REFLEX  Standing:  ROM: PAINFUL FF TO 45 DEG; R SIDEBEND  ABLE TO TOE WALK; HARDER L HEEL WALK; 22 HEEL RAISES ON R, 16 ON L; NO ATROPHY

Testing L5 Reflex

Disc and nerve root relationship

Disc and nerve root relationship

Imaging

Imaging

Dx – L4-5 disc herniation

Dx – L4-5 disc herniation  Subspecialty referral for any weakness, loss of reflexes  Emergent care if loss of bowel/ bladder, saddle anesthesia, increasing pain unresponsive to meds  NSAID alternating with acetaminophen every 3 hrs  E.g., 600 mg ibuprofen @ 0800, 1000 mg acetaminophen @ 1100, 600 ibu @ 1400, etc.  Other meds individualized  E.g., prednisone, TCA, narcotics, gabapentin  Physical therapy  Posture/ positions of comfort  Weight loss

Lumbar intradiscal pressures

Sleeping Properly  On your side  On your  On your back abdomen

Case #4 - History 1. Age: 35 YO MALE PROGRAMMER TRAINING FOR SF MARATHON 2. Date of injury/ symptom onset: GRADUAL X 1 MO 3. Injury Mechanism: a. Chronic/ Overuse: ? CAUSED BY INTERVALS 4. Swelling : NONE 5. Symptoms: Mechanical/ Other a. TIGHTNESS IN L HAM, L LOW BACK 6. Symptoms: Pain/ Numbness/ Tingling a. Location – L PROX HAM TENDON, BUTTOCKS b. Radiation – NO c. Type – INTERMITTENT, SHARP, ACHY, NO NIGHT PAIN, 0/ 10 7. Modifying/ Other Factors a. WORKING LONG HRS SEATED, LESS STRETCHING

Case #4 - Exam  Observation: NO DISCOMFORT  Sitting: NEG SLUMP, NL SENS/ STRENGTH/ REFLEXES  Supine:  NEG SLR, HIP FROM, NEG FABER  + THOMAS TEST ON RIGHT  Prone:  + TENDER L SI JOINT  NT OVER PROX HAM TENDON  NEG PAIN W/ PASSIVE HIP EXTENSION  Standing:  ROM: TIGHTNESS IN PROX HAM W/ FF  + GILLET’S TEST ON R (+ ANT ROTATION)  GAIT NL

Thomas Test  Evaluate hip flexors, quads, ITB