low back pain pitfalls in its managementbsmedicine.org/congress/2008/dr._rajibul_alam.pdf · 2018....
TRANSCRIPT
Low back pain –
Pitfalls in its management
Prof (Dr) Rajibul Alam MBBS, FCPS, MD, MACP
Professor of Medicine
SSMC and Mitford Hospital
Who will treat? NSAID
Rest
Exercise
DMARD
Education
How to overcome?
Physical
therapy
Anti
depressant
Drugs for
systemic
disease
General surgeon +
Neurosurgeon +
Rheumatologist +
Physician +
Psychiatrist +
Physical
therapist
+
Ortho surgeon +
Gynaecologist +
Outcome? (Mortality, Morbidity, Cost)
Initial decision, nature and severity of disease
depends on
90% Mechanical,
short lasting; and
resolved within 6 wks
To Exclude “Red flag signs”
• Neurological Deficit
• Systemic pathology (wt loss, fever)
Acute back pain with/without sciatica
Rest
Acupuncture
Exercise
Traction
Mattress
Patient education
NSAID
Which one? Which combination?
SHOULD BE INDIVIDUALIZED
Muscle relaxant
Rx Options
Rest
Randomized trials
183 patients with sciatica
Bed rest
87% improved at 12 wks in both group
“Watchful waiting”
for 2 wks
Ref: Hagen, KB, Hilde, G, Jamtvedt, G, Winnem, M. Bed rest for acute low-back pain
and sciatica. Cochrane Database Syst Rev 2004; :CD001254
Return to work is recommended - INDIVIDUALIZED
Exercise
Ref: Hayden, JA, van Tulder, MW,
Malmivaara, A, Koes, BW. Exercise
therapy for treatment of non-specific
low back pain. Cochrane Database
Syst Rev 2005; :CD000335
• No value in acute LBP
• Prevent recurrent
attack in chronic LBP
Study Population (n=186), employees of
city of Helsinki, Finaland
• Bed rest 2 days, (n=67)
• Back mobilizing exercise (n=52)
• Ordinary activity (n=67)
Low back pain patient
Ordinary activity within the limit permitted by pain
Rapid recovery than either bed rest / back
mobilization exercise
Ref: Antti Malmivaara, Unto Hakkinen, Timo Aro et. al. The treatment of acute low back pain –
Bed rest, exercises, or ordinary activity? New England Journal of Medicine 1995:332:351-5
Traction
24 randomized
control trials (5 high
quality)
Traction provides NO significant benefit in short- or
long-term outcome for LBP with or without sciatica
Ref: Van Tulder, MW, Jellema, P, van Poppel, MN, et al. Lumbar supports for prevention
and treatment of low back pain. Cochrane Database Syst Rev 2000; :CD001823
Acupuncture
• Short term benefit in chronic back pain
• Better than no treatment
• Equivalent to NSAID
Ref: Furlan, AD, van Tulder, MW,
Cherkin, DC, et al. Acupuncture and dry-
needling for low back pain. Cochrane
Database Syst Rev 2005; :CD001351
NSAID + Muscle relaxant → not superior
to NSAID alone (randomized trial)
Ref: Childers, MK, Borenstein, D, Brown, RL, et al. Low-dose cyclobenzaprine
versus combination therapy with ibuprofen for acute neck or back pain with
muscle spasm: A randomized trial. Curr Med Res Opin 2005; 21:1485
Mattress
European randomized trial (n=313)
Ref: Kovacs, FM, Abraira, V, Pena, A, et al. Effect of firmness of mattress on chronic
non-specific low-back pain: randomised, double-blind, controlled, multicentre trial.
Lancet 2003; 362:1599
Medium firm mattress superior to firm mattress
Sciatica
• Conservative Rx and / or surgery
• Rx on the basis of X-ray and MRI (?)
MRI done on 98 normal person
Normal 36%
Disc bulged 52%
Disc prolapse 27%
Radiology dependent management sometimes
MISLEADING
Abnormal
findings }
Study Reports
Abnormal findings from 100
normal population
CT 34%
MRI 64%
Myelogram 25%
Ref: Akerman SJ, S Jeinberg EP, Bryan RN,et al. Trends in diagnostic imaging
for low back pain - Has MR imaging been a substitute or add on? Radiology
1997: 203: 533-8
Patient Education
• Cause of LBP
• Favorable
prognosis
• Minimal value of
lab test
• Activity and work
recommendation
• Rest
• NSAID
• Physical therapy
• Patient education
• Recurrence
• Maximum
investigation
required
• Minimum
investigation
Treatment
64 articles published between 1966-2000
Stronger association of low education with higher
duration and / or higher recurrence of back pain
Ref: J Epidemiol Community Health 2000: 55: 455-468
Acute Low Back Pain
• Appropriate specialist and regime
• Rx options having scientific basis
• Looking for “Red Flag Signs”
RECAPITULATION
Spondyloarthropathy
• Spinal (spondylo) arthritis
• Sacroilitis
• Asymmetrical large (lower limb) joint involvement
• Enthesitis
• Mucocutaneous inflammation
• Iritis
• Association with HLA B27
• Rheumatoid factor negative
• Ankylosing spondilitis
• Psoriatic arthritis
• Reiter’s syndrome & reactive arthritis
• Enteropathic arthritis
Type Presentation
Spdyloarthropathy
Patients of spondyloarthropathy suffer
badly because of -
• Historical lack of coordination and cooperation
for making
– Diagnostic criteria
– Outcome measurement
• Limited scope of drug treatment particularly for
axial disease
Spondyloarthropathy
Uncertain
destination
• Long term trial of
DMARD – few
• Selection of
standard drug
Case History
Mrs S., 25 years, married
Bilateral hip arthritis (inflammatory back pain) for 5 years
Moves with wheel chair
Synovial biopsy → Non-specific (Calcutta)
Rx anti TB → No response
Methotrexate + Sulphasalazine @ Maximum dose
After 2 years treatment,
patient could walk without support
SP
A
SPA : investigation dependent
2004 Dhaka
Case History: Mr Z.
• 45 years
• Inflammatory back pain
• Recurrent asymmetric oligo arthritis (wrist, knee, ankle) - 17 years
• X-ray SI joint normal (NSAID, steroids, traction
no response
• Improved with maximum dose of Methotrexate + Sulphasalazine
Undifferentiated SPA may not have SI joint involvement
SPA : investigation dependent
2002 SSMC
Rx given usually X-ray SI joint normal + OA (incidental)
Physical
steroid
NSAID
X 60% develops sacroilitis in 10 years
Inflammatory back pain + HLA B27 positive 59% probability
So diagnosis by inflammatory back pain, peripheral arthritis,
enthesitis, buttock pain, uveitis, family history
Inflammatory
chronic back pain
SPA : investigation dependent
Spondyloarthropathy
• Inflammatory arthritis and / or
back pain more than 3 months
• SPA
Rx
• Sulphasalazine 1 tab (500
mg) BD for 3 months (?)
HOW TREATED?
X-ray SI joint abnormal
Spondyloarthropathy
• Underdiagnosis
• Overdiagnosis
• Appropriate Rx schedule ?
• Patient education ?
Acute back pain
• Short history: 1 months duration
• SI joint X-ray normal
• Treated as mechanical
Spondyloarthropathy
Acute pain Long history of
Inflammatory back pain
missed during history
taking (chronic)
X
Missing long history of back pain
1 month
Case History
• Young female 19 years
• Hematemesis & malena (NSAID induced)
• LBP (inflammatory) - 1 year
• Could not appear in SSC exam
• Both SI joints very tender and hip joints stiff
• X-ray SI joint sclerosed
Missing long history of back pain
* Spondyloarthropathy improved with Sulphasalazine
2007 SSMC
Clark and his colleagues reported that depression (2%) leading to back pain not vise versa
Ref: Psychiatric news, April 18, 2003
Back pain & Psychiatry
Back pain cases
Case History
• A beautiful lady, 25 years;
husband, 50 years
• Back pain for 6 months
• On anti-depressant
• Back pain was inflammatory
• Both SI joint tender
• X-ray SI joint normal
• SPA: Sulphaasalazine full
dose → dramatic
improvement after 2 months
Back pain & Psychiatry
2008 Dhaka
Case History
• 13 years girl, back pain for few months
• No specific tender points
• On antidepressant (HCR)
• No improvement
What to do?
• Planter response extensor
• MRI meningioma of spinal cord
• Surgical treatment → improved
Back pain & Psychiatry
Neurological examination is a must in a case of backache
1994 Khulna
Underdiagnosis
Overdiagnosis
Sometimes overdiagnosis dangerous
Back pain & Rheumatic Fever
Case History
• Mr. Su 17 yrs
• Back pain with knee pain for 4 yrs
• Bed redden for 3 months
• D/H: Penicillin
• Arthritis, rt hip and lt knee
• * JIA
• Improved with DMARD (Sulphasalazine)
Back pain & Rheumatic Fever
2007 SSMC
Case History
• Mr X : passport officer 40 yrs
• Admitted in a hospital with stretcher with severe back pain
• Rec. oligoarthritis (knee, ankle) since childhood
• Rx: NSAID, Penicillin as RF
• O/E both SI joint were very tender
• SI joints sclerosed and fused
• * : SPA improved with Methotrexate
Back pain & Rheumatic Fever
2004 Dhaka
Case History
• Mr X 38 yrs
• Back pain and peripheral arthritis 11 years
• Echocardiography → AR (operated in Calcutta)
• Penicillin for rheumatic carditis
• Ankylosing spondylitis é A/R
• Back pain improved with Sulphasalazine + Methotrexate
Back pain & Rheumatic Fever
2002 Dhaka
Back pain &
Spondyloarthropathy
• Diagnosis – mostly clinical
• Female SPA
• Diagnosis of RF, depression – to be
careful
RECAPITULATION
Elderly, Post
Menopausal, Senile
Back pain & Osteoporosis
Story of an osteoporotic lady
• Mrs. N, 65 years
• Menopause – 25 years
• Back pain – 15 years
Vertebral Fracture, 1990 (1st), 1996 (2nd)
(NSAID and traction)
Severe back pain - 3 months Multiple vertebral fractures (X-ray Spine)
Osteoporosis (T score -4.5 LS -3.8 hip)
Improved with Risedronate, Vit D, Calcium
Back pain & Osteoporosis
2002, SSMC
If medical
treatment is
not given
Operated for right hip fracture in the past,
recently developed left hip and vertebral fracture
Back pain & Osteoporosis 2005 SSMC
Elderly, post menopausal → # Hip / Vertebra
Hip operation
Another fracture
Another operation
Hip operation
BMD
Rx of Osteoporosis
X
Back pain & Osteoporosis
Osteoporosis
in male
Frequently missed
as it is thought to be
present in post
menopausal lady
Back pain & Osteoporosis
Back pain, osteoporosis
frequently not diagnosed
below 40 years
Mrs. K, 22 years – back pain (Osteoporosis)
Back pain & Osteoporosis
Patient on steroid for asthma
Back pain elderly patient
Treated as osteoarthritis
without doing BMD
Frequently
osteoporosis is
missed from
diagnosis
Back pain & Osteoporosis
Back pain & Osteoporosis
It is effective only for pain due to
osteoporotic vertebral fracture
Rx:
Inj calcitonin for pain
of osteoarthritis
Back pain and Osteoporosis
• Female post menopausal
• Male, early age
• Pathological # BMD }
RECAPITULATION
Case History
• Male 35 years
• Back pain 1 year
• Not responding to therapy
• MRI: soft tissue shadow in the lumber spine
• Operation: Laparotomy → soft tissue in and around spinal cord
• Histopathological examination: NHL
• Subsequent Rx and F/U in Narayangonj, Bangladesh in 1998
Back pain and systemic disease In
BD
In
KS
A
Case History • Male 60, H/O acute pancreatitis 3 months back
• Admitted in SSMC (2005) with sever abdominal pain
for 3 days
• P/A soft, no tenderness
• Tender lumber spine
Back pain and systemic disease
* Multiple myeloma: Spine pathology presented as
abdominal pain
• Acute pancreatitis (past history) due to hypercalcemia
Case History
• Elderly male 55 yrs
• Back pain for 2 months
• Husband & wife were separated due to some
familial problem
• O/E: no specific tenderness and no neurological
findings in leg
• On antidepressant
• Patient died after 1 week → What happened?
Back pain and systemic disease
• Before death he was examined thoroughly → pulses in dorsalis pedis & ant. post tibial absent
• Arotic aneurysm (presented as back pain), finally ruptured, caused sudden death
Pulse examination in lower limb is a must in a case of back pain
Back pain and systemic disease
Case History • Back pain, wt loss – 1 year
• D/H: NSAID
Back pain and systemic disease
Royal disease should not be missed
2008, SSMC
Gibbus
Pott’s disease
Back examination in back pain
Back pain and systemic
diseases
• Wide range of systemic / serious disease
• Critical clinical evaluation
RECAPITULATION
Cost of Rx,
morbidity,
mortality
Correct assessment
(clinical +++, Lab +) • ALBP vs. CLBP
• Mechanical vs.
inflammatory
• Red flag signs (?)
↑
Appropriate package
of Management
Source of information
• Journals
• Personal diary (real stories and reports)
• Pictures – original, sketch
• Names – not real to protect identity
Thank you