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ECHO BOOT CAMP

Low Back Pain &

Lumbar Spinal Stenosis

Practical Evaluation &

Management Tips

Carlo Ammendolia DC, PhD

Assistant Professor, IHPME, University of Toronto

Associate Scientist/Chiropractor, Mount Sinai Hospital, Toronto

CCRF Professorship in Spine, Dept of Surgery, University of Toronto

Disclosures

No Relationships with Commercial Interests

Funding: Canadian Chiropractic Research

Foundation (CCRF)

and The Arthritis Society

Founder spinemobility Research & Resource

Centre- Not-for-Profit Organization

Objectives

Understand the epidemiology of low back pain and

lumbar spinal stenosis

Perform a systematic assessment of patients with

back pain and related leg symptoms

Make a diagnosis and differential diagnosis in patients

with back and leg pain

Learn about effective non pharma treatment options

Mysteries of

Low Back Pain

Mystery #1

Prevalence Back Pain

Mystery #1- Prevalence- Back Pain

Point prevalence

10% to 20%

Yearly

25% to 45%

Lifetime

70% to 80%

Female gender

Age

40-80 yrs

Carey et al. Spine. 2000; Andersson. Lancet. 1999, Hoy et al Arth Rheum 2012

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Evolution of Man Prevalence- Back Pain

Role of Primary Prevention?

Mystery #2-

Mystery #2

Cause of low back pain

Classification LBP

90% non specific LBP

10% specific LBP

- herniated discs 2-4%

- lumbar spinal stenosis 3%

- compression fracture 4%

- spondylolisthesis 2%

- cancer, infection, inflammatory 1%

Deyo et al. N Engl J Med. 2001;344:363-370 (C).

What causes LBP?

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Back Pain Disability

Mystery #3

Back Pain Disability

Lancet 2012:380:2163-96

Lancet 2012:380:2163-9620122012

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Loisel et al 2005

Back Pain Disability

Back Pain Management

Case No. 1

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Case No. 1

20 yo female

Picked up child

Lower back ache x 24 hours

Decreased ROM

No numbness/tingling

No B/B problems

Healthy, no medications

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Acute or Sub Acute LBP

1st line Treatment

Advice to stay active

Avoid bed rest

Superficial heat

Massage

Acupuncture

Spinal manipulation

2nd Line Treatment

NSIADS

Muscle relaxants

ACP Guidelines Feb 2017

Case No. 2

Case No. 2 45 yo construction worker

Multiple work related back injuries most recent 5 months ago

Since then persistent LBP

Pain all the time across the LB

Worse with physical activity

Off work for 5 months

Physical exam unremarkable

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Yellow FlagsPsychosocial

Fear of re-injury/ activity avoidance

Catastrophizing

Depressed mood

Negative expectation

Passive coping

Pain focused

Lack of social networkRamond 2011, Nicholas 2011, Steenstra 2005

Blue Flags

Workplace

Work satisfaction

High physical load

Low job control

Low supervisor/co-workers support

Lack of communication with workplace/supervisor

Unsafe work/ergonomic design/equipment

High stress/pace/demandNicholas 2011, Guzman 2007,

Chronic Non Specific LBP

Management

No investigations

Reassurance/Advice to stay active

Psychosocial/workplace factors

Focus on RTW not pain

Return-to-work coordination

Chou et al 2007, Dagenais et al , Spine J 2012,

Costa-Black et al Best Pract Rhuem 2010

Back Group reviews, The Cochrane Library 2012, issue 2.

Case No.3

Case No. 3

35 yo medical researcher

Has had vague back pain for a month while writing grant

While bending forward to tie shoes

Excruciating, lancinating pain down right leg to foot– toothache

Worsens with sitting, and coughing

Needs to lie down to relieve pain

Case No. 3

Ambulatory, antalgic

Lumbar spasm

Decreased ROM

Positive neural tension

Numbness L5

Great toe dorsiflexion decreased

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Neural Tension - SLR Neural Tension - Slump

Lumbar Radiculopathy

Management

No initial imaging /investigations (6w)

Monitor for progressive weakness -referral

Bladder/bowel control- ER

Qaseem et al ACP 2017

Chou et al 2009, Dagenais et al , Spine J 2012

Back Group reviews, The Cochrane Library 2012, issue 2.

van Tulder et al. Eur Spine J 2006; 15 Suppl 1:S64-S81.

Lumbar Radiculopathy

NSAIDS?

Gabapentin +/?

Symptom guided

exercises

Epidural injections

Stabilization exercise

or SMT

Opioids?

Surgery

Traction/VAD-not likely

Management- pain control

Qaseem etal 2017, Dagenais etal 2010, Jacobs et al 2011, Luijsterburg etal 2007, Chou etal 2009

Lumbar Radiculopathy

Avoid sitting

Keep active

Extension exercises

Self management

Neuro-mobilization

.

Advice for Patients

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Directional

Preference

Flexion

Aggravated

Directional

Preference

Extension

Aggravated

Non-Directional

Preference

Recovery

Positions

Daily

Positions

Standing

Walking

Reduced sitting

Lumbar Roll

Sitting

Limited walking

Flex one leg

Frequent changes

No sustained

postures

Starter

Exercises

Repeated passive

extension in lying

progressing to

standing

Sitting trunk

flexion

Knees-to-chest

stretch

Neutral Positions

Small

progressions

43Hall, Rampersaud, Alleyne Provincial LBP Strategy 2013

Case No.4

Case No. 4

70 yo retired female

Bilateral buttock pain and radiating right

leg pain when standing and walking

Limited walking to 2 blocks

Relieved by sitting and forward bending

Worsens with lumbar extension

SLR negative

Most useful

Age > 70

Age < 60

Bilateral buttock or leg pain

No pain when seated

Symptoms worse standing/walking/extension

Symptoms improve when bending forward

Positive Rhomberg / wide stance gait

Urinary disturbancesSuri 2010, Genevay 2017, Tomkins-lane 2017

Diagnosis

Peripheral vascular disease-vascular claudication

Hip OA

Hip-Spine Syndrome

Greater Trochanteric Syndrome

Lumbar Disc Herniation

Cervical stenosis (myelopathy)

Metabolic syndromes – diabetes and hypothyroidism

Nutritional – Vit B12, B1 and folic acid

Ammendolia 2014

Differential DiagnosisNeurogenic Claudication

Management

No initial imaging /investigations unless

surgical candidate

Monitor for progressive weakness –referral

Monitor balance-high risk for falls

Chou et al 2009, Dagenais et al , Spine J 2012

Back Group reviews, The Cochrane Library 2012, issue 2.

van Tulder et al. Eur Spine J 2006; 15 Suppl 1:S64-S81.

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Neurogenic Claudication

Gabapentin ?

Vit B12?

prostaglandins?

NSAIDS/opioids?

Physical

therapy/exercise/

manual therapy

Surgery

Epidural injections-not

likely

Management

Ammendolia et al Spine 2012

Dagenais etal 2010, Jacobs et al 2011, Luijsterburg et al 2007, Chou et al 2009

Neurogenic Claudication

Aerobic exercise –

stationary bike

Self management

strategies/education

Avoid extension

Standing/walking

pelvic tilt

Assisted devices-

walkers, canes

Balance Exercise

.

Advice for Patients

ImagingNon Specific LBP- no imaging

Specific LBP

-Radiculopathy-Herniated Disc *–not routine- MRI

-Neurogenic claudication- Spinal Stenosis*- not routine- MRI

-Spinal fracture- Plain radiography

-Cancer/infection/cauda equina- MRI

-AS- plain radiography/MRI

* No response 4- 6w and decrease QOL and need to refer

Chou et al , Ann Intern Med 2007

Summary

Prevalence LBP not decreasing

90% LBP non specific

LBP disability on the rise

Acute LBP –less is more, normal activity

Chronic LBP- address psychosocial and workplace

factors

Radiculopathy- pain control, avoid sitting and

positional therapy

Neurogenic claudication- conditioning, flexion

exercises, avoid extension, gabapentin

Contact info:cammendolia@mtsinai.on.ca

Carlo Ammendolia

Funded by the Canadian Chiropractic Research Foundation and

The Arthritis Society

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