Low Back Pain

Dr.Kishore Nallapu

Goals To recognize red flags To recognize yellow flags To recognize disability from simple low

back pain To relieve pain To improve ability to function and

alleviate disability To prevent recurrence and the

development of chronicity

How Common? 4% of GP consultations. £1632 million (1998). 800,000 in-patient bed-days. 52 million lost working days each year in

Britain. Lifetime prevalence is. -- >80% in adults. -- >40% in adolescents. Men and women are equally affected. Aged 30 to 50.

How Common Are Serious Causes ? <5% have true nerve root pain <1% have serious disease such as

spinal tumour or infection

<1% have inflammatory disease such as ankylosing spondylitis

Anatomy

Anatomy

Risk factors Heavy physical work Lifting and handling of loads Awkward postures and movements

Whole body vibration (truck

driving) Trauma

Causes Mostly unknown (simple low back pain)

Traumatic Referred pain Degenerative Inflammatory Infective Neoplastic Metabolic etc

Referred pain

Abdomen: aortic aneurysm Kidney: pyelonephritis, hydronephrosis,

calculi, tumour, perinephric abscess Ovary: cysts, cancer Pelvis: endometriosis, period pain,

pelvic inflammatory disease Bladder: infections

Degenerative and Structural Spondylosis Spondylolisthesis

Gross scoliosis and/or kyphosis

Inflammatory Conditions Ankylosing spondylitis

Polymyalgia rheumatica

Rheumatoid arthritis (rarely)

Coccydynia

Infections Shingles

Discitis

Osteomyelitis

Epidural abscess

Metabolic Bone Disease Osteoporosis Osteomalacia

Paget's disease

Neoplasm Secondaries

Myeloma , etc

Red flags Spine fracture

Cancer or Infection

Cauda equina syndrome

Red flags for spine fracture Major trauma Minor trauma, or even just

strenuous lifting, in people with osteoporosis

Suspicion of secondaries

Rx –suspected spinal # X-ray Refer if #, if not follow up in 10

days On follow-up -if fracture still suspected, or -multiple sites of pain, consider bone scan and referral

Red flags for cancer or infection Age > 50 years and new back pain, or age

<20 years History of cancer Constitutional symptoms (fever, unexplained

wt. loss) Recent bacterial infection (e.g. UTI) IVDU Immune suppression Pain that worsens when supine; severe night-

time pain; thoracic pain Structural deformity

Rx –suspected cancer or infection

Check FBC,ESR, Urine analysis If still concerned, consider -referral - bone scan, X-ray, etc. Note that a negative X-ray alone

does not rule out disease.

Red flags for cauda equina syn. Perianal/perineal sensory loss (Saddle

anaes.) Bladder dysfunction (e.g. urine retention,

increased frequency, overflow incontinence)

Faecal incontinence Neurological deficit in the lower extremities Unexpected laxity of the anal sphincter

Rx-suspected Cauda equina syn.

Refer immediately

Yellow FlagsBelief that pain and activity are harmful Sickness behaviours (extended rest)Social withdrawal Emotional problems Problems and/or dissatisfaction at work Problems with claims or compensation or

time off work Overprotective family; Lack of support Inappropriate expectations of treatment

How do I know my patient has simple low back pain? Thorough history + brief

examination Red & yellow flags Distinguish referred pain from

nerve root pain Consider diagnostic imaging only if

red flags

Chronicity Acute :< 6 weeks Sub-acute : 6-12 weeks Chronic >12 weeks

Complications Chronicity Depression Disability and loss of employment Cauda equina syndrome

Table 1. Questions for disability assessment.

Does back pain limit you in:

Standard limits

Bending, lifting? Lift 15-20 kg, heavy suitcase, 3- to 4-year-old

Sitting? Sit in an ordinary chair: less than 30 minutes

Standing? Stand in one place: less than 30 minutes

Walking? Walk less than 30 minutes or 1-2 miles

Travelling ? Travel less than 30 minutes

Socializing? Miss or curtail social activities (excluding sport)

Sleeping? Sleep disturbed by pain at least twice a week

Sex life? Sexual activity reduced or curtailed

Dressing? Dress: help required with footwear

Rx of Simple Low Back Pain Educational advice Symptom control Rapid return to usual activities (incl. work) Consider referral to -physiotherapists -osteopaths -chiropractors Address any psycho-social risk factors. Assess response to treatment after about 4

weeks.

Drug treatment Paracetamol – 1st choice If it is unsuitable/ineffective

-NSAID s’ if suitable -Combination : e.g. paracetamol, an

NSAID, or codeine Muscle relaxant (diazepam-1st

choice)

Traction Electrotherapy Ultrasound Interferential therapy Laser treatments TENS - not to be confused with

PENS

Not recommended Rx

What do I do if it remains after 4-6 weeks?

Reassess Address concerns Adjust analgesia to control pain -Pcm ,NSAIDs’ ,Diazepam , -Antidepressants, Gabapentin, Amitriptyline, Opioids

not responding to analgesia ? Referral Multi-disciplinary (bio-psycho-

social) assessment Cognitive behavioural therapy Spinal manipulation therapy (SMT) Exercise therapy Back school

Evidence based medicine Routine physiotherapy was no

more effective for chronic low back pain than one session of assessment and advice from a physiotherapist [Frost et al, ‘04]

Evidence …. Exercise and spinal manipulation

therapy (SMT) provide at best only modest clinical benefits

acupuncture is more effective than no treatment

acupuncture compared with other active treatments is inconclusive.

Summary Red & Yellow flags Analgesia Disability Support

NICE Referral guidelines Cauda equina - immediately Serious spinal pathology – in 1 wk Progressive neurological deficit –in 1 wk Nerve root pain that is not resolving

after 6 weeks –in 3 wks Inflammatory disorder -soon Yellow flags not resolved in 3 mon-soon