modern management of back pain 2017.ppt - ucsf · pdf file– red flag signs for serious...
TRANSCRIPT
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A n t h o n y L u k eMD, MPH, CAQ (Sport Med)
University of California, San FranciscoPrimary Care Medicine: Update 2017
Modern Management of Back Pain
Disclosures
• Founder, RunSafe™
• Founder, SportZPeak Inc.
• Sanofi, Investigator initiated grant
Outline
• Assessment
• Imaging
• Treatment
– Conservative
– Surgical
Management Approach
• Sort patients into:– Simple low back pain (mechanical low back pain)
– Flexion vs Extension back pain
– Nerve root pain
– Red flag signs for serious spinal pathology
– Cauda equina syndrome
• Identify which patients may benefit from specialist treatment
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Examination Approach
Standing
Sitting
Supine
Prone
Posture
• Posteriorly
• Shoulders
• Inferior scapula – T8
• Iliac crests L4
• Dimples of venus – S1 T8
L4
Posture
• Lines: ear lobe‐acromion‐iliac crest
• Lordosis, kyphosis
• Pelvic inclination ‐ ASIS lower than PSIS
Examination Observation
Skin
• Café au Lait
• Spina Bifida
Gait
Shift
Repeated heel raises
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Examination ROM
• Pain flexion vs extension
Can check for:
• Flat back
• Scoliosis ‐ hump
• Rotation – stabilize the pelvis
• Lateral flexion
Examination ROM
Single leg extension
(Stork test)
Trendelenberg Test
Examination Sitting
Neurologic Exam
• Motor
• Sensory
• DTR’s
• Babinski/clonus
Examination Sitting ‐ Provocation
Indirect Straight Leg Raise
• Reproduces SLR in the sitting position
• May have “Sciatica” with sitting too long (i.e. driving)
Slump Test
• Fully flex patient’s neck chin to chest Examiner holds foot in dorsiflexion and passively extends leg
• Highly reliable (k=0.83‐0.89)
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Examination Supine ‐ Provocation
Lasegue’s Straight Leg Raise Test
• Tests primarily L5, S1‐2 sciatic nerve roots
• Passive hip flexion with leg in extension from 30‐70 degrees
• Sensitivity 0.85‐0.91, Spec 0.32‐0.52
Examination Supine ‐ Hip
• Hip Internal and External ROM
• Labral Impingement and Stress tests
• Thomas test – for hip flexor tightness
“FABER” Test
• For stressing anterior labrum
• Positive in 15/17
• Also SI joint
Examination Supine
• Popliteal Angle
• Check for Limb length discrepancy
– Measure ASIS to medial malleolus
• Perform Appropriate Abdominal Exam
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Examination Prone
• Palpate lumbar spine / pelvis
• Paravertebral muscles / Piriformis / gluteal areas
• Sacral thrust/ Sacral Apex Pressure/ Spring test
• +/‐ Rectal exam
Who? 35 year old female runner
What? Extension low back pain
When? Acute flare x 2 weeks since running, LBP on and off x 2 yrs, worse after pregnancy
How? Pain with activity, some numbness and tingling L leg
Where? Left sacroiliac joint pain with radiating pain into left hip
Case 1
Case 1
• LOOK 5’ 6”, 150 pounds– Swayback Posture (mild thoracic kyphosis, hyperlordosis lumbar spine)
• FEEL– Mild tenderness at L SI joint
• MOVE– ROM extension 30°mildly tender; Flexion 70°
• SPECIAL TESTS– Direct and indirect SLR negative– March/Gillet test slight asymmetry– L/E 5/5, Reflexes normal
What to do?
• Mechanical Low Back Pain
• Differential Dx – SI joint dysfunction, early OA, DDD, ligament, Muscle strain
• Flexion vs Extension LBP?
• Physical therapy or home exercise program
• Symptomatic treatment
• Education → address biomechanics
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Mechanical LBP
• 80% resolve within 2 weeks
• 90% resolve with in 6 weeks
• Consider POSTURE
• Improve core stability, conditioning
• Decrease stress
Posterior elements / Facet Joints
• Superior / inferior facet joints
• Pars interarticularis
• Allow flex/ext and side bending with minimal rotational motion due to direction of facets
• Usually NWB but can WB with extension
• Facet joint asymmetry may lead to disk degeneration
Does the Sacroiliac joint move ?
• Is a Diarthrodial Joint
• Synovial fluid
• Cartilage on both surfaces
• A joint capsule
• Ligamentous connections
• Articular connections allowing movement
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Hip Pain can be Confusing
Confounding Factors:
• 27‐90% of patients with groin pain have more than one coexisting injury
Morelli and Weaver, 2005
Femoral Acetabular Impingement(F.A.I.)
• Cam effect
• Protrusion of femoral head neck – “bump”
• Orientation of the acetabulum –acetabular version
• Increased stress on labrum
Examination Supine ‐ Hip
• Hip Internal and External ROM
• Labral Impingement and Stress tests
• Thomas test – for hip flexor tightness
Posterior Hip Pain
Piriformis syndrome
10% of population have sciatic nerve passing through the piriformis
Beaton et al. Anat Rec, 70, 1937.
Muscle strain vs sciatica
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“FABER” Test
• For stressing anterior labrum
• Positive in 15/17
• Also SI joint
Core Stability
• Center of gravity lies anterior to spine
• Erector spinae muscles, abdominal musculature, the lumbodorsal fascia and gluteus maximus resist the body weight
• Deep Muscle stabilizers (type 1 fibers) maintain core stability
• Multifidus, TA, pelvic floor and diaphragm ‐ affects posture
• If impairment, may get reflex inhibition due to other pain and can affect sports activity
“Usual” Non‐operative Care
• Education → address biomechanics andPOSTURE
• Active physical therapy ‐ Exercises to improve core stability, conditioning
• Symptomatic treatment
Activity modification
• Temporarily limit or avoid specific activities known to increase mechanical stress on spine (SE:D)
• Consider requirements of the job, non‐physical factors (SE:C)
• Limited bed rest, if recommended should be 2 days or less (SE: A)
• Aerobic exercise: avoid debilitation (SE: C)
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Red Flag – Spondyloarthropathy
Patients with chronic back pain duration (≥ 3 months) with back pain onset before 45 years of age should be referred to a rheumatologist if at least one of the following parameters is present:
•Inflammatory back pain
•Human leukocyte antigen – B27 positivity
•Sacroiliitis on imaging, if available (on x‐rays or MRI)
•Peripheral manifestations (in particular arthritis, enthesitis and/or dactylitis)
•Extra–articular manifestation(psoriasis, inflammatory bowel disease and/or uveitis)
•Positive family history for spondyloarthritis
•Good response to non‐steroidal anti‐inflammatory drugs
•Elevated acute phase reactantsPoddubbnyy D, van Tubergen A, Landawe et al. Ann Rheum Dis; 2015, 74: 1483‐1487.
Who? 16 year old quarterback
What? Extension low back pain
When? 2 months
How? No injury; has been lifting weights (dead lifts)
Where? Diffuse low back
Case 2
Case 2
LOOK 6’ 2”, 230 pounds
• Posture within normal limits
FEEL
• Minimal tenderness with patient in prone
MOVE
• ROM extension 30°mildly tender; Flexion 60°
SPECIAL TESTS
• 1 leg‐hyperextension test positive
• Neurological status normal
Want images?
• When in doubt
• Red flags
• Children, elderly
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Which X‐rays?
AP Lumbar Spine
Alignment
• Pedicles
• Spinous processes
Which X‐rays?
• Lateral
Alignment
• Disk spaces
• Spondylolisthesis
Which X‐rays?
• Obliques
Other ImagingBONE SPECT SCAN
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Staging Lesions by CT
• Early – focal bony absorption or a hair‐line defect
• Progressive – wide defect with small fragments
• Terminal – sclerotic change
Spondylolysis Healing
Other ImagingMRI or CT myelography
• Not recommended in the first 6 weeks in the absence of red flags
• MRI modality of choice in LBP symptoms not responding to conservative treatment or red flags of serious conditions (Tumor, infection etc.)
• MR Neurogram
• EMG and SEP– Useful in questionable nerve root symptoms +/‐ back pain >6 weeks
– Not recommended if the diagnosis of radiculopathy is obvious
What to do?
• Physical therapy
• Activity Modification / Rest
• Avoid aggravating activity
Controversial
• Modify activities only vs Bracing
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Lumbar Corset with Rigid Insert
What about BOB?The Boston Overlapping Brace
Causes of Back Pain(Micheli, Wood. Arch Pediatr Adolesc Med 1995; 149:15‐18)
Lesion Youth Adult P value
Discogenic 11 48 0.05
Spondylolytic lesion
47 5 0.05
Lumbosacral strain
6 27 0.05
Hyperlordotic mechanical back pain
26 0
Osteoarthritis 0 4
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Back Pain in Children
• No EXACT cause is identifiable in 90% of adult back pain
• Diagnosis of pain generator is more common in children’s back pain
• Work up more aggressively
Who? 30 year old female ICU nurse
What? Extension low back pain
When? LBP x 5 yrs, worse x 6 wks
How? Sitting >30 minutes causes numbness and tingling R leg
Where? Low back with radiating pain into right hip and numbness right foot
Case 3
Case 3
LOOK 5’ 5”, 155 pounds• Posture within normal limitsFEEL• Mild tenderness at L3‐L4; L4‐L5MOVE• ROM Extension 30°mildly tender; Flexion 70°SPECIAL TESTS• Direct and indirect SLR negative• 4+/5 strength over R EHL otherwise L/E 5/5• Reflexes normal
X‐ray
AP Lumbar Spine Lateral Lumbar Spine
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MRI
• L to R
• L3‐L4
• L4‐L5
• Moderate
stenosis
ivc
common iliac arteries
psoas
QL
psoas
QL
IL LL
m nerve roots
dural sac
L4 spinal nerve
L4 subpedicular
MRI Axial Views
L2‐L3
L3‐L4
L4‐L5
L5‐S1
dural nerve‐root sleeve
dorsal root ganglion
spinal nerve
ventral ramus
dural sac
dorsal root
ventral root
Intervertebral Disk
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Disk Herniation
Mechanism
• L5‐S1 most common 90%
• Compression of neural structures such as sciatic nerve causes radicular pain
Symptoms
• Acute herniation usually 30‐50 years
• Pain worse with flexion
• May have “Sciatica”– Pain with sitting too long (i.e. driving)
• Rule out bowel or bladder symptoms
Treatment• Education
• Activity modifications
• Physical Therapy
• Medications
– NSAIDs should be recommended (Strength: Strong)
– Opioids may be considered but should be avoided if possible (Strength: Weak)
– Antidepressants should not be routinely used (Strength: Strong)
White et al. Spine, 2011
Treatment
Medications
• Oral prednisone had a modest improvement in function at 3 weeks but not significant improvement in pain in patients with acute radiculopathy after 1 year
Goldberg H et al. JAMA. 2015
• Single trial of gabapentin shows symptom improvement (pain ‐26.6, ‐38.3 to ‐14.9) but only short term benefits
Pinto et al. BMJ, 2012
• Fluoroscopic guided epidural injections had strong evidence of short‐term benefit in relieving acute radicular pain for individuals for periods less than 6 months
Manchikanti L et al., Clin Orthop Relat Res., 2015
Surgery better than Non‐operative(SPORT) – Disk (SE: A)
• In patients with a herniated disk confirmed by imaging and leg symptoms persisting for at least six weeks, surgery was superior to non‐operative treatment in relieving symptoms (15.0 (95% C.I.’s, 11.8 ‐ 18.1)) and improving function (14.9 (95% C.I.’s, 12.0 ‐ 17.8))
• 4‐year rate of reoperation was 10%
Weinstein et al., Spine, 2008
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Muscle Relaxants and Benzodiazepines
• Muscle relaxants more effective than placebo for short term pain relief
• Side effects of drowsiness, dizziness and other side effects is high (RR 2.04; 95% CI; 1.23‐3.37)
Van Tulder et al., Cochrane Review, 2003
• Various muscle relaxants found to be similar in performance
• Carisoprodol (Soma), drug abuse and dependency• Short term use in acute exacerbations
– Metaxalone (skelazin) least sedating
• Sleep assistive medication– Baclofen or tizanidine (zanaflex)
Narcotics
CLASS III (LOW)
• Vicodin, Lortab, Lorcet, Norco (Hydrocodone + Acet)
• Darvon (propoxyphene)
CLASS II (MOD)
• Percocet, Oxycodone, OxyContin,
HIGH
• Morphine, Fentanyl
Who? 64 year old Vietnamese speaking female
What? Severe pain 12/10
When? Worse x 4 months, LBP x years
How? Worse with standing/extension, used to walk 1 mile now 1/2 blocks
Where? Left leg pain with walking
PHM – Diabetes, hypertension
Case 4
Case 4
LOOK 5’ 2”, 130 pounds
• Can’t lie down, gait antalgic
FEEL
• L3‐S1 tenderness with palpation
MOVE
• ROM extension 5° tender; Flexion 50°
SPECIAL TESTS
• Indirect SLR positive B
• Sensation intact to light touch B
• Reflexes +2, downgoing Babinski
• Weak Extensor hallucis longus L, weak plantarflexors
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Spinal Stenosis
• Degenerative spinal stenosis usually older than 40 years
• Extension biased pain
• Burning or aching pain in the lumbar region, buttocks, or lower extremities when in upright posture
• Associated with numbness, paresthesias, or subjective weakness with walking = Neurogenic claudication
TreatmentConservative
•Activity modification, physical therapy
•Pain control– NSAIDs or Acetaminophen
– Narcotics
– Neurogenic pain – anticonvulsant
– Antidepressants – Tricyclic antidepressants
•Topicals – Lidocaine 5% patches, diclofenac 1.3% patches
•Cognitive therapy, TENS, spinal cord stimulationChou et al., Spine, 2009
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Treatment
Conservative
• Physical therapy showed similar results as surgical decompression in RCT
• Another RCT found a benefit overall from epidural injection at 6 weeks but did not find a difference when patients received injections of corticosteroids plus lidocaine compared to lidocaine alone
Friedly JL et al., N Engl J Med. 2014.
Treatment
Surgical options:
• Spinal decompression (widening the spinal canal or laminectomy)
• Nerve root decompression (freeing a single nerve)
• Spinal fusion (joining the vertebra to eliminate motion and diminish pain from the arthritic joints)
• Randomized trial (SPORT) showed less benefit of surgery between 4 and 8 years
Lurie JD et al. Spine, 2015
Surgical Treatment
• Cauda equina needs emergency decompression
Surgical Indications
• Sufficient morbidity
• Failure of conservative treatment
• Anatomic lesion that can be corrected
• Complications usually neurologic
Surgical Indications
• Cancer
• Infection
• Deformity
• HNP w/neural involvement
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Surgery
• Adverse prognostic factors
– Litigation
– Previous surgery ‘failed back’
– Multi level disease
– Manual worker
– Young male
– Smoker
– Psychosocial factors
Surgery
• Complications– Pain
– Donor site pain
– Infection
– Neurological damage
– Non‐union
– Cutaneous nerve damage
– Implant failure
– Death
Surgical Considerations
• Patient selection is very important
• Should be performed v/very clear indications
• Pts should understand that surgery can improve their pain but is unlikely to abolish it
• Results are less good in patients w/adverse prognostic factors
• Abnormalities in scanning does not necessarily mean that surgery is indicated
• With a “normal”MRI, surgery is almost never indicated
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Spondylolisthesis
• Anterior displacement of the superior vertebra on the vertebra below
• Graded by percent slip
Surgery better than Non‐operative(SPORT) ‐ Spondylolisthesis
• LBP patients still improved significantly more with surgery than with nonoperative treatment (15.3 (95% C.I.’s, 11 ‐ 19.7) for bodily pain, 18.9 (95% C.I.’s, 14.8 to 23) for physical function
• Predominant leg pain patients improved significantly more with surgery than predominant LBP patients
Weinstein et al, J Bone Joint Surg Am, 2009
Management Approach
• Sort patients into:– Simple low back pain (mechanical low back pain)
– Flexion vs Extension back pain
– Nerve root vs peripheral pain
– Red flag signs for serious spinal pathology
– Cauda equina syndrome
• Identify which patients may benefit from specialist treatment
12th UCSF Primary Care Sports Medicine Conference
San Francisco, Dec 1-3, 2017
Hotel Intercontinental
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RED FLAGS
• Cancer
– Unexplained weight loss
– Age greater than 50
– Failure to improve w/treatment
– Pain for more than 4‐6 weeks
– Night/rest pain
– History of cancer
RED FLAGS Cancer
– Action to be taken:
• Imaging
• CBC, ESR and/or CRP
• Screening for possible primary– Breast in women
– Prostate in men
– Lung
– Kidney
– Thyroid
– Myeloma
• Referral to surgeon
RED FLAGS
• Infection
– Fever
– Hx of IVDU
– Recent infection (UTI, skin, pneumonia)
– Immunocompromise
– Rest pain
RED FLAGS Infection
– Action to be taken:
• Imaging (MRI) (Urgent)
• CBC, ESR and/or CRP
• Appropriate surgical consultation
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RED Flags
• Cauda equina syndrome
– Urinary retention or incontinence
– Saddle anesthesia
– Anal sphincter tone decrease/incontinence
– Bilateral LE weakness
– Progressive neurological deficit
RED FLAGSCauda equina syndrome
– Action to be taken:
• IMMEDIATE surgical consultation
RED FLAGS
• Fracture
– Use of corticosteroids
– Age over 70 of hx of osteoporosis
– Recent significant trauma
– Severe pain
RED FLAGS Fracture
– Action to be taken:
• Imaging (X‐rays and MRI)
• Appropriate surgical consultation
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RED FLAGS
• Acute abdominal aneursym
– Abdominal pulsating mass
– Other atherosclerotic vascular disease
– Resting or night pain
– Age over 60
RED FLAGSAcute abdominal aneursym
– Action to be taken:
• Appropriate imaging (US)
• Surgical consultation
Summary Management
• Diagnosis: Hx & Px, Investigations, Red flags
• Education
• Activity modification
• Progressive ROM and exercise
• Symptom control: Medications
• Injection therapy
• Surgical referral