approach to the patient with low back pain in primary care

Approach to the patient with Low

Back Pain in Primary Care

ObjectivesDifferentiate between concerning and non-

concerning causes for acute low back pain Identify historical red flags Identify examination red flags

Briefly review evidence-based treatment options for low back pain

Acute Low Back PainEasy Visit??? Frustrating Visit???

Acute Low Back PainEasy

Usually not serious Limited

management options

Often quick exam

Frustrating Difficult patients Limited

management options

Can feel unsatisfying

Differential Diagnosis:

30 seconds List differential diagnosis for Low back pain

30 seconds List differential diagnosis for “bad” causes of

Low back pain

Differential Diagnosis of Low Back Pain Mechanical low back pain (97%) Lumbar strain or sprain (≥ 70%) Diffuse pain in lumbar

muscles; some radiation to buttocks Degenerative disk or facet process (10%) Localized lumbar

pain; similar findings to lumbar strain Herniated disk (4%) Leg pain often worse than back pain;

pain radiating below knee Osteoporotic compression fracture (4%) Spine tenderness;

often history of trauma Spinal stenosis (3%) Pain better when spine is flexed or

when seated, aggravated by walking downhill more than uphill; symptoms often bilateral

Spondylolisthesis (2%) Pain with activity, usually better with rest; usually detected with imaging; controversial as cause of significant pain

Nonmechanical spinal conditions (1%)Neoplasia (0.7%) Spine tenderness; weight

lossInflammatory arthritis (0.3%) Morning

stiffness, improves with exerciseInfection (0.01%) Spine tenderness;

constitutional symptoms

Nonspinal/visceral disease (2%)Pelvic organs—prostatitis, pelvic inflammatory disease,endometriosisLower abdominal symptoms commonRenal organs—nephrolithiasis, pyelonephritis Usually

involves abdominal symptoms; abnormal urinalysisAortic aneurysm - Epigastric pain; pulsatile abdominal

massGastrointestinal system—pancreatitis, cholecystitis,

peptic ulcer Epigastric pain; nausea, vomitingShingles – (zona) Unilateral, dermatomal pain;

distinctive rash

Differential Take-Home 97% is mechanical

4% Herniated disc (95% L4-L5; L5-S1)

0.2% Cauda Equina2% Non-back sources1% Cancer and Infection

Our Job…In 15 minutes, differentiate benign from

serious causes of low back pain

We Need a Strategic TimelineGood history – 3-5 minutesFocused Exam – 2-4 minutesTreatment options and pt education – 4-5

minutes

The Case Begins:

87 yo M presents to clinic for back painLocated mid to low backStarted about 3-4 days ago

OutlineList essential components of a LBP history,

including Red flagsReview Physical Examination for LBP

Identify Red flagsReview proper indications for lab and

imagingDiscuss acute management options

General QuestionsOnsetLocationMechanism of InjuryRadiationPositional changeNumbness, tinglingWeakness

Red FlagsAge > 50IV drug useHx/o cancerProlonged steroid

useOsteoporosisDistal numbnessSaddle anestesia

Bowel or bladder loss

FeverTraumaUnexplained wt

lossPain at rest/nightWeakness

Diagnoses & Red FlagsCancer

Age > 50History of

CancerWeight lossUnrelenting

night painFailure to

improve

Infection IVDU Steroid use Fever Unrelenting night

pain Failure to improve

FractureAge >50Trauma Steroid useOsteoporosis

Cauda Equina SyndromeSaddle anesthesiaBowel/bladder

dysfunctionLoss of sphincter

controlMajor motor

weakness

Diagnoses & Red FlagsCancerAge > 50History of

CancerWeight lossUnrelenting

night painFailure to

improve

Infection IVDU Steroid use Fever Unrelenting night

pain Failure to improve

FractureAge >50Trauma Steroid useOsteoporosis

Cauda Equina SyndromeSaddle anesthesiaBowel/bladder

dysfunctionLoss of sphincter

controlMajor motor

weakness

Our caseRed flags

Age 87 Hx/o Non-Hodgkin’s

Remission for the past 4 years

Our CaseNo hx/o back problemsNo traumaNo radiationNo focal weaknessNo numbness or tinglingNo change in bowel or bladder function

OutlineList essential components of a LBP history,

including Red flagsReview Physical Examination for LBP

Identify Red flagsReview proper indications for lab and

imagingDiscuss acute management options

Physical ExamRule-out most concerning things

Concerning features Decreased strength Diminished reflexes Sensory loss

Reassuring features Paraspinal muscle

spasm Full strength No sensory deficits

Six-Point MSK ExamInspectionPalpationROMStrengthNeurovascularSpecial Tests

InspectionEnsure

No obvious deformitiesNo erythemaSkin lesions (Zoster)

PalpationSoft Tissue4 clinical zones

Paraspinal muscles Gluteal muscles Sciatic area Anterior

abdomen/abdominal wall

Bones Primarily palpating

spinous processes and facets

NeurologicTesting

SensationStrengthReflexes

Special TestsTests to stretch spinal cord or sciatic nerve

Tests to stress the sacroiliac joint

Straight leg raiseLooking for lumbar disk herniationPerformed supine for best sensitivityPositive when radiating pain observed at 30-

70 degress of hip flexionVery high sensitivity, but low specificityShould also do the crossed-leg straight leg

raise Positive when they have pain when you lift and

adduct the opposite leg

FABER test:FlexionA-BductionExternalRotation

TestsLab

Based on clinical picture Think Red Flags

Imaging XR CT MRI

Imaging GuidelinesChoice to do imaging based on:

Historical red flags Trauma, chronic steroid use = XRay Suspect abscess, cauda equina = MRI

Exam red flags New/severe sensory or strength loss = consider MRI

OutlineList essential components of a LBP history,

including Red flagsReview Physical Examination for LBP

Identify Red flagsReview proper indications for lab and

imagingDiscuss acute management options

Back pain treatmentNSAIDs (A)

Improve pain vs. placebo in controlled trials No difference between them NNT for 50% pain relief is 2-3

Muscle relaxants (A) Most beneficial in the first week Shown effective in trials Work best when combined w/ NSAIDs

TreatmentPain relievers

Both opioid and non-opioidSteroids

No benefit shown w/ orals Short-term benefit shown for epidural

Bed rest NO!!! Activity increases functional status and

decreases time missed from work and pain

TreatmentExercise plan

No benefit during the acute phase, but helpful afterwards for prevention in MSK back pain (although USPSTF is neither for nor against)

Massage Mixed evidence, but not harmful

Acupuncture Most good studies show no benefit, but overall

results are mixedIce/Heat (B)

Equivalent in a Cochrane review

Clinical recommendation and Evidence ratingIn the absence of “red flag” findings or signs

of cauda equina syndrome, four to six weeks of conservative care is appropriate for patients with acute low back pain. C

Nonsteroidal anti-inflammatory drugs, acetaminophen, and skeletal muscle relaxants are effective first-line medications in the treatment of acute, nonspecific low back pain. A

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, diseaseoriented evidence, usual practice, expert opinion, or case series.

Clinical recommendation and Evidence ratingBed rest for more than two or three days

in patients with acute low back pain is ineffective and may be harmful. Patients should be instructed to remain active. A

Education about activity, aggravating factors, natural history, and expected time course for improvement may speed recovery of patients with acute low back pain and prevent chronic back pain. C

Specific back exercises for patients with acute low back pain are not helpful. A

Clinical recommendation and Evidence ratingHeat therapy may be helpful in reducing pain

and increasing function in patients with acute low back pain. B

Spinal manipulative therapy for acute low back pain may offer some short-term benefits but probably is no more effective than usual medical care. B

ConclusionsHistory is very important

Don’t forget your red flagsLook for focal findings on examThere is evidence to help with treatmentPt’s w/ low back pain or sciatica w/o red flag

SYMPTOMS should try conservative management for about 6 wks prior to imaging or intervention

ReferencesEvaluation and Treatment of Acute Low Back

Pain. AAFP. 75(8), 2007.Acute Lumbar Disk Pain. AAFP. 78(7), 2008.When to Consider Osteopathic Manipulation.

JFP. 59(9), 2010.ACSM Primary Care Sports Medicine.Physical Exam of the Spine and Extremities.

Hoppenfeld, S. et al.

Questions???