The evaluation and management of low back pain

Asgar Ali KallaAsgar Ali Kalla Professor and HeadProfessor and Head Division of RheumatologyDivision of Rheumatology University of Cape TownUniversity of Cape Town

Some helpful statistics

Backpain affects Backpain affects two thirds oftwo thirds of adults adults Second to URTI in frequencySecond to URTI in frequency Affects men and woman equallyAffects men and woman equally Most common between 30 and 50 yearsMost common between 30 and 50 years Expensive cause of work related disabilityExpensive cause of work related disability Uncertainty about optimal approachUncertainty about optimal approach

90% of low back pain is mechanical

Musculoligamentous injuriesMusculoligamentous injuries Age-related degeneration in the Age-related degeneration in the

intervertebral discs and facet jointsintervertebral discs and facet joints Spinal stenosisSpinal stenosis Disc herniationDisc herniation Osteoporotic compression fracturesOsteoporotic compression fractures Spondylolysis and spondylolisthesisSpondylolysis and spondylolisthesis

Natural history

Spontaneous improvement is the ruleSpontaneous improvement is the rule 50% better at 1 week50% better at 1 week > 90% better at 8 weeks> 90% better at 8 weeks 7-10% persist beyond 6 months7-10% persist beyond 6 months

Medical causes

UncommonUncommon but important not to miss them but important not to miss them SpondylarthropathySpondylarthropathy Spinal infectionSpinal infection OsteoporosisOsteoporosis MalignancyMalignancy Referred visceral painReferred visceral pain

• pelvis, renal, aortic aneurysm, pancreatitispelvis, renal, aortic aneurysm, pancreatitis

Clinical evaluation

Precise anatomical diagnosis often elusivePrecise anatomical diagnosis often elusive Is a systemic disease causing the pain?Is a systemic disease causing the pain? Is there neurological compromise that may Is there neurological compromise that may

require surgical evaluation?require surgical evaluation? Is there social or psychological distress that Is there social or psychological distress that

may amplify or prolong pain?may amplify or prolong pain?

BACK PAIN BACK PAIN

seriousneurology

seriousneurology

serious medical

serious medical

systemicsymptoms

systemicsymptoms

conservative management

conservative management

Management: Watchful waiting

Patient educationPatient education Spontaneous recovery is the ruleSpontaneous recovery is the rule Those who remain active despite pain have less future Those who remain active despite pain have less future

chronic painchronic pain Exercise has prevention powerExercise has prevention power

Rest: 2 days Rest: 2 days or lessor less Analgesics to permit activityAnalgesics to permit activity Reassess if pain worsens or neurological Reassess if pain worsens or neurological

symptoms developsymptoms develop

Why not get imaging studies?

Imaging can be misleading: many Imaging can be misleading: many abnormalities as common in pain-free abnormalities as common in pain-free individuals as in those with back painindividuals as in those with back pain

If under age 60If under age 60 low yield: unexpected Xray findings 1: 2500low yield: unexpected Xray findings 1: 2500 bulging disc in 1 of 3bulging disc in 1 of 3 herniated disc in 1 of 5herniated disc in 1 of 5

Over age 60 and pain-freeOver age 60 and pain-free herniated disc in 1 of 3herniated disc in 1 of 3 bulging disc in 80%bulging disc in 80% all have age-related disc and apophyseal joint all have age-related disc and apophyseal joint

degenerationdegeneration spinal stenosis in 1 of 5 casesspinal stenosis in 1 of 5 cases

BACK PAINBACK PAIN

conservative management

PERSISTENT PAINDEVELOPING NEUROLOGY

PERSISTENT PAINDEVELOPING NEUROLOGY

red flagsred flags imagingimaging lab testslab tests

Red flags for serious back pain

Fever, weight lossFever, weight loss Pain with recumbency, nocturnal painPain with recumbency, nocturnal pain Morning stiffnessMorning stiffness Persistent pain lasting > 6 weeksPersistent pain lasting > 6 weeks Age over 50 with new onset painAge over 50 with new onset pain Abnormal neurologyAbnormal neurology Point tenderness Point tenderness

Further evaluation

Goal is to discriminate between “ benign” Goal is to discriminate between “ benign” cases and disorders that require further cases and disorders that require further diagnostic studiesdiagnostic studies

Radiological imaging: Xray/ CT Scan/ MRIRadiological imaging: Xray/ CT Scan/ MRI Useful lab tests:Useful lab tests:

FBC, ESRFBC, ESR Calcium, ALPCalcium, ALP protein electrophoresis protein electrophoresis

What should I be worried about?

Herniated discHerniated disc Spinal stenosisSpinal stenosis Cauda equina syndromeCauda equina syndrome Inflammatory spondylarthropathyInflammatory spondylarthropathy Spinal infectionSpinal infection Vertebral fractureVertebral fracture CancerCancer Referred visceral painReferred visceral pain

CT scan shows spinal stenosis due to hypertrophic changes in the facet joints

CT myelogram reveals canal occlusion with flexion due to spondylolisthesis

Imaging Studies: Spinal Stenosis

MRI image shows a protruding disk (arrow) that compresses the thecal sac (short arrow)

Disk Herniation

Ankylosing Spondylitis: X-Ray Changes

Spinal infection — X-Rays

Multiple compression fractures

Osteoporosis- X-Ray

•RRed flags for spinal malignancy•PPain worse at night•OOften associated local tenderness•CFBC, ESR, protein electrophoresis if ESR elevated

Multiple Myeloma

When is surgical referral indicated?

Sciatica and probable herniated discsSciatica and probable herniated discs Cauda equina syndromeCauda equina syndrome Progressive or severe neurological deficitProgressive or severe neurological deficit Persistent neuromotor deficit after 4-6 weeks Persistent neuromotor deficit after 4-6 weeks

conservative treatmentconservative treatment Persistent sciatica with consistent neurologic Persistent sciatica with consistent neurologic

and clinical findingsand clinical findings

When is surgical referral indicated?

Spinal StenosisSpinal Stenosis Progressive or severe neurological deficitProgressive or severe neurological deficit Persistent back and leg pain improving with Persistent back and leg pain improving with

flexion and associated with spinal stenosis on flexion and associated with spinal stenosis on imagingimaging

SpondylolisthesisSpondylolisthesis Progressive or severe neurological deficitProgressive or severe neurological deficit Severe back pain/ sciatica with functional Severe back pain/ sciatica with functional

impairment that persists > 1 yearimpairment that persists > 1 year

Key Points about low back pain

90% are due to mechanical causes and will 90% are due to mechanical causes and will resolve spontaneously within 6 weeks to 6 mthsresolve spontaneously within 6 weeks to 6 mths

Pursue diagnostic workup if any red flags Pursue diagnostic workup if any red flags found during initial evaluationfound during initial evaluation

If ESR elevated, evaluate for malignancy or If ESR elevated, evaluate for malignancy or infectioninfection

In older patients initial Xray useful to diagnose In older patients initial Xray useful to diagnose compression fracture or tumuorcompression fracture or tumuor

Key Points about low back pain

Bed rest is not recommended for low back pain Bed rest is not recommended for low back pain or sciatica, with a rapid return to normal or sciatica, with a rapid return to normal activities usually the best courseactivities usually the best course

Back exercises are not useful for the acute Back exercises are not useful for the acute phase but help to prevent recurrences and treat phase but help to prevent recurrences and treat chronic painchronic pain

Surgery is appropriate for a small portion of Surgery is appropriate for a small portion of patients with low back painpatients with low back pain

Further reading

Deyo RA, Weinstein JN. Low back pain. NEJM Deyo RA, Weinstein JN. Low back pain. NEJM 2001;344:363-3702001;344:363-370

Malmivaara A, Hakkinen U, et al. The Malmivaara A, Hakkinen U, et al. The treatment of acute low back pain. NEJM treatment of acute low back pain. NEJM 1995;332:351-3551995;332:351-355

Borenstein DG. Low back pain. In:Klippel J , Borenstein DG. Low back pain. In:Klippel J , Dieppe P, editors. Rheumatology. London : Dieppe P, editors. Rheumatology. London : Mosby; 1994. p.5.4.1-5.4.26Mosby; 1994. p.5.4.1-5.4.26