LOW BACK PAIN
in
PRIMARY CARE
Bennet Davis, MD
Integrative Pain Center of Arizona
PART I
• Very brief review of impressive epidemiologic statistics
• General comments regarding back pain
• Evaluation of back pain, whether acute or chronic
*Warning signs for immediate referral*
• General management, according to duration of symptoms
– 0-8 weeks
PART II
• General management, according to duration of symptoms
– 8 weeks - 6 months
– Greater than six months
• Common diagnoses in chronic low back and leg pain
Is This Really A Problem?
• 80 % 0f adults in industrial countries have
at least one episode of disabling back pain.
Bonica 1980
Is This Really A Problem?
• 80 % 0f adults in industrial countries have
at least one episode of disabling back pain.
• By the 3rd decade 50% of people have
experienced an episode of LBP that required
alteration in activity.
Leboeuf-Yde 1998
Is This Really A Problem?
• 80 % 0f adults in industrial countries have
at least one episode of disabling back pain.
• By the 3rd decade 50% of people have
experienced an episode of LBP that
required alteration in activity.
• In spite of “optimal management” 5% of
acute back pain progresses to a chronic and
disabling endpoint.
Spengler 1986
Is Back Pain a Problem?
• 86 million Americans suffer from chronic
pain
• 66 million are partially disabled
• 8 million are totally disabled from back
pain
• There are 65,000 cases of pain related
permanent disability diagnosed each year.
Medical Data International
1998
Is Back Pain a Problem?
Pai found in 20041 that in the U.S.
low back pain was the
• Second leading symptomatic cause for physician
visits
• Third most common cause for surgical procedures
• Fifth most common reason for hospitalization
.
1. Pai S, Sundaram LJ. Low back pain: an economic assessment in the
united states. Orthop Clin N Am. 2004;35:1-5.
Is Back Pain a Problem,
At Work?
Back pain is the most common reason for filing
workers‟ compensation claims1
From an economic perspective, the average cost of a
workers‟ compensation claim for low back pain was
$8,300, which was more than twice the average cost
($4,075) for all compensable claims combined2
1. Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in US
industry and estimates of lost workdays. AM J Public Health. 1999;89:1029-1035.
2. Pai S, Sundaram LJ. Low back pain: an economic assessment in the united
states. Orthop Clin N Am. 2004;35:1-5.
Is Back Pain a Problem at Work?
Absences from Work
In 1999, back pain
accounted for 40 percent
of absences from work,
second only to the
common cold.
Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in
US industry and estimates of lost workdays. AM J Public Health.
1999;89:1029-1035.
General Aspects Regarding Back Pain
Three facts that should help frame our approach
from here forward (evidence follows):
1. Low back pain is recurrent in 33-70% of patients1,2
Expectations fail to reflect this: Patients want a
cure, physicians pursue it, yet many times there is
none
2. Psychosocial issues often contribute to, and many
times are the main cause of disability
3. Physical therapists are a vastly underutilized yet
readily available resource.
1. Von Korf, Spine 1996 21(24):2833-37; 2. Haestbaek L
European Spine Journal 2003 Apr;12(2):149-65
Evidence base for these statements:
Acute Back Pain is a chronic, relapsing/remitting
Illness
• Von Korf, Spine 1996: 1/3 of primary care
patients who presented with acute back pain
reported back pain on at least 50% of the
days of the year at 1 and 2 year follow-up.
Von Korf M 1996 Spine;
21(24):2833-37
Evidence base for these statements:
Acute Back Pain is a chronic, relapsing/remitting
Illness
Screened Cochrane data base, Medline, and
EMBASE for back pain literature on the
general population with at least 12 month
follow-up.
• 62% had pain at 12 months after onset
• 60% had > 2 relapses
• 33% had relapses of work absence
Haestbaek L Eur Spine J 2003
Evidence base for these statements:
Psychosocial issues are important in determining
who goes to the doctor for help with back pain
Prospective study looked for medical and
psychosocial factors that predict onset of new
chronic back pain in asymptomatic volunteers.
Found that only psychosocial factors, especially
poor coping skills, Predict future chronic back
pain. Poor coping skills increase the odds of
future back pain by 3 fold.
Carragee EJ Spine 2005 May
15;29(10):1112-7
Evidence base for these statements:
The patient‟s psychosocial issues are the leading cause
of failure of back pain treatment
#1
Anxiety, Depression, and amount of time off
work were the primary determinants of failure
to return to work in a program designed to
treat employees off work due to low back
pain.
Watson P European J Pain 2004 Aug;
8:359-69
Evidence base for these statements:
The patient‟s psychosocial issues are the leading cause of
failure of back pain treatment
#2
Prospective study looked at factors that predicted
failure of medical therapy plus stabilization training
and manual therapy in a national health service
database over 5 years.
• Depression, anxiety, generalized somatic
complaints, poor life control topped the list
• Concluded: “Psychosocial differences seem to be
the important determinants for treatment outcome”
Niemisto L J Rehab Med 2004 May;
36(3):104-9
Evidence base for these statements:
Psychosocial factors that predict poor outcome for
treatment of back pain
• Motivation for self-care
• Depression
• Job satisfaction
• Job stress
• Support of significant other/marital stress
• Secondary gain
• Maladaptive thinking and coping styles
– History of physical or sexual abuse
• Multiple somatic complaints
PSYCHOSOCIAL FACTORS IN
PAIN, Gatchel and Turk, Eds
Evidence base for these statements:
Does any evidence show that treatment of Psychosocial
factors is and effective way to treat back pain? YES
• Randomized trial of Cognitive Behavioral Therapy
(CBT) vs. patient education: 243 patients with acute
or subacute back pain1
– Both reduced sick days compared to controls, but 9 fold
less sick days in the CBT group at 1 year.
• Randomized trial of spinal fusion vs. CBT plus
exercise for chronic low back pain2
– Equal improvement, no difference in outcome at 1 year.
1Linton SJ Spine 2000 Nov 1;25(21):2825-31
2Brox JI Spine 2003 Sep 1;28(17):1913-21
The evidence is clear that optimal treatment
of back pain includes evaluating the patient
for psychosocial factors and treating them
when found; and when they are refractory
to treatment we should anticipate poor
outcomes from medical, physical therapy,
and surgical treatment.
We rarely do so, however.
No wonder back pain treatment
outcomes are poor in this country!
No wonder research shows that
increasing numbers of surgeries and
other medical treatments have had
little impact on the incidence of
back-related disability.
New Topic: Duration of symptoms
It is generally useful to break back pain into
three categories according to duration of
symptoms:
1. Less than eight weeks duration
2. Eight weeks-six months duration
3. Greater than six months duration
General management, according
to duration of symptoms
0-8 wks 8 wks-6 mo >6 mo
•Most people recover from an acute episode
within 8 weeks
•Conformity: The NASS guidelines define
“the initial phase of care” as lasting about 8
weeks1
•Patients remaining symptomatic after six
months have a poor prognosis for significant
improvement2 for Multidisciplinary Spine Specialists,
1Phase III Guidelines
North American Spine Society, 2000
2Mayer TG, pg 3-9 in Contemporary Conservative Care for
Spine Disorders
0-8 weeks
8 weeks – 6 months
0-8 weeks
Overview
• A specific anatomic diagnosis is usually not
necessary, perhaps impossible
• Diagnostic efforts are directed at identifying those
who have diagnoses that require urgent referral
• Use both pain and function as your measure of
disease severity and as endpoints for therapy.
• Patients with significant functional impairment need
to be flagged for more aggressive symptom palliation
• Screen for predictors of chronicity
• Physician‟s role: palliate symptoms to support
spontaneous recovery
• Patient education is key
Diagnoses we don‟t want to miss
• Tumor (of bone or viscera)
• Infection
• Fracture
• Any process resulting in severe compromise
of nervous tissue
• Systemic illnesses affecting joints
• Leaking abdominal aortic aneurysm
How not to miss them
History: the nine red pain flags
• Prominent neurological symptoms of
weakness, numbness, loss of bowel or
bladder control, difficulty walking
• Pain is much worse at night
• Fever
• Other constitutional symptoms that always
worry us
• Patient cannot sit or stand due to pain
The nine red flags on history 2
• Pain following a fall in the elderly or in a
patient at risk for osteoporosis
• Leg pain is much worse than back pain
• History of cancer in the last five years,
particularly breast, lung, prostate,thyroid,
renal
• Polyarthralgias
Historical aspects that increased
suspicion for infection
• Recent IV drug abuse
• Immunosuppression
• Diabetes
Things we don't want to miss
physical exam
Neurological signs such as:
• loss of reflex in the area of pain
• profound focal weakness
• profound diffuse proximal weakness
• upgoing toes
• clonus at the ankle
• hyperreflexia
• patulous sphincter tone
Things we don‟t want to miss
physical exam 2
• The patient can‟t walk or sit due to back or leg pain.
• Severe pain with movement when it has lasted for
more than one week history
• Severe muscle spasm when it has lasted more than
one week on history
• Extreme and localized tenderness to percussion over
the spinous processes or other bony prominences
• Joint effusions, redness, synovial bogginess,
tenderness
0-8 weeks
Where to start after conditions
requiring immediate referral are
ruled out?
• Evaluate functional impact of pain, measure
the disability
• Understand what your patient wants from
you, and
– Manage expectations
– Tune treatment to your patient‟s needs
Why is function and degree of
disbility worth quantifying and
following over time?
1. It is our “blood pressure” for chronic pain
2. Disability - impairment of function due to
pain - is what we are treating
3. Pain and disability are not the same thing
PATHOANATOMIC LESION PAIN DISABILITY
SOCIAL
FACTORS
CULTURAL
FACTORS
PSYCHOLOGIC
AL FACTORS
COGNITIVE
FACTORS
•Measure disability
Concept: •Evaluate the cause of disability
•Treat the cause of the disability
PATHOANATOMIC LESION PAIN DISABILITY
SOCIAL
FACTORS
CULTURAL
FACTORS
PSYCHOLOGICAL
FACTORS
COGNITIVE
FACTORS
Measuring disability
Brief Pain Inventory, etc.
• How well do you sleep?
– Good fair poor very poor
• Do you miss any work because of pain?
– # days per month
• How much time on a typical day do you
spend “down” because of pain?
• Rate your mood
– Good fair poor very poor
What is the evidence that pain and
disability are not well correlated
(that factors other than pain are
important in producing disability)?
In a formal study of the correlation
between pain and disability, the
relationship was week, with
correlation coefficient of 0.3-0.4
Waddell G, Spine; 17: 617-628
Measuring disability
The key question is not:
Is this activity painful?
The key question is:
Are you restricted in this activity, and how
much so?
Functional impairment:
Disability consequent to pain
The 6 major areas of function worth
quantifying:
• Impairment of work life
• Impairment of recreational activity
• Impairment of social activity
• Impairment of sleep
• Impairment of sex life
• Patient specific disability
Decision Making:
The Patient‟s basis
• Function at work
• Function at home
• Social function
• Recreational function
–“I can‟t lift my grandchild”
–“I can‟t make it through a day at
work”
–“I have to sleep in a recliner, can‟t
join my spouse in bed”
–“I can‟t sit through a game of cards”
Decision Making:
The Physician‟s basis
• Symptom driven
• Limited to Pathoanatomy
“Bio-reductionist model”
“Bio-medical model”
For Example:
“This is a patient with:
• Chronic back pain
• Due to degenerative disc
disease”
What does research say about
how often physicians ask about
the patients function?
76 audiotaped primary care back pain visits:
• 13.2% asked if the patient had taken time off work
for back pain
• 14.5% asked if back pain interferes with work
• 10.5% asked if back pain interferes with social
activities
• 19.7% asked if back pain interferes with activities
such as driving, walking, etc.
TURNER JA, SPINE; 23: 463-469
1998
How does this compare to the
patient‟s perspective?
• 74% of patients indicated that they had
significant interference with work, 42%
rated this as > 7/10.
• 83% of patients rated receiving information
on what could be done to return to normal
activities as quickly as possible as
“very/extremely important”
TURNER JA, SPINE; 23: 463-469
1998
0-8 weeks
Where to start after conditions
requiring immediate referral are
ruled out?
• Evaluate functional impact of pain, measure
the disability
• Understand what your patient wants from
you, and
– Manage expectations
– Tune treatment to your patient‟s needs
Patients rated the following as either “very
important” or “extremely important”:
• 85%: how to manage back pain
• 83%: how to reduce back pain without
prescription drugs
• 81%: what they can do to get back to usual
activities
• 76%: how to prevent a recurrence of back
pain
PSYCHOSOCIAL FACTORS IN
PAIN Gatchel and Turk, Eds
Patients rated the following as either “very
important” or “extremely important”:
• 76%: understand the likely course of back
pain
• 68%: receive a medical diagnosis
• 52%: received reassurance that there is no
serious disease
PSYCHOSOCIAL FACTORS IN
PAIN Gatchel and Turk, Eds
Patients rated the following as either “very
important” or “extremely important”:
• 35%: receive a prescription medication to
relieve back pain
• 34%: get an x-ray or other diagnostic test
• 30%: get a referral to physical therapy
• 27%: get a referral to a specialist
PSYCHOSOCIAL FACTORS IN
PAIN Gatchel and Turk, Eds
0-8 weeks
Identify early predictors of chronicity
– Identify unrealistic expectations, such as
complete cure.
• 51% of patients expect this
– Identify the patient‟s motivation for self-
care
– Identify and treat depression and anxiety
– Look for a pattern of multiple somatic
complaints
1/2
0-8 weeks
Symptom palliation
To support progress toward resumption of activity
– Analgesics, paying particularly close attention
to good analgesia 1. at night to help the
patient sleep and 2. to help the patient stay at
work.
– Short-term muscle relaxants.
– Physical therapy modalities: TENS,
ultrasound, hot packs, massage
2/2
0-8 weeks
Symptom palliation
To support progress toward resumption of
activity
– Acupuncture
– Trigger point injections
– Epidural steroid injection for radiculopathy
and for the “acute disc”with mostly back pain.
0-8 weeks
Symptom palliation
Epidural steroid injection when back pain is
greater than leg pain
"There may be a limited role for epidural
steroid injections in the documented
presence of a central disc herniation or
annular tear, but [epidural steroid injection]
cannot be recommended for non-specific
unremitting low back pain."
Phase III Clinical Guidelines For Multidisciplinary Spine Care Specialists,
North American Spine Society, 2000
0-8 weeks
Symptom palliation
When leg symptoms predominate
• Oral steroids or
• Early referral for epidural steroid injection1
• Imaging and early referral if neurological
red flags are present on history or exam
1Phase III Clinical Guidelines For Multidisciplinary Spine Care Specialists,
North American Spine Society, 2000
When leg symptoms predominate
Physical therapy should include a trial traction
0-8 weeks: Patient‟s worries,
Patient education
• 64% “the wrong movement could lead to a serious
problem”
• 60% “I might become disabled for a long time”
• 51% “Avoiding movement is the safest way to
prevent pain from worsening”
• 45% “I wouldn‟t have this much pain of the work
something dangerously wrong”
• 31% “I might injure myself if I exercise”
PSYCHOSOCIAL FACTORS IN
PAIN, pg 365 Gatchel and Turk, Eds
0-8 weeks
Yet more information gathering
• Identify and reinforce positive self-help
strategies, help patient add new ones
– Research has shown that only 10% of physicians
do this.
– Existence of 3 or more appropriate self help
activities is one of the strongest predictors of
rapid recovery from acute low back pain
PSYCHOSOCIAL FACTORS IN
PAIN Gatchel and Turk, Eds
0-8 weeks
Education
• Educate regarding diagnosis: most have a
limited episode of pain originating from
lumbar intervertebral disc, but it may recur
• Focus on typical “worries” and any specific
worries:
• Educate some more!
– develop a program with your local physical
therapist
Role of the physical therapist
Cognitive
• Patient education
• Assessment and reporting of progress
towards functional goals
• Identify barriers to recovery in
communicate these to the physician
Is there evidence that early referral to a
physical therapy program for patient education
and monitoring of progress is effective?
• 2004 primary care study of >600 patients with acute LBP in
a national health care setting
•Early “hand-off” to physical therapy for evaluation,
treatment, patient education, and monitoring progress with
reporting to MD.
•Treatment outcomes were as good as MD management, but
lost work days were reduced, and PCP return visits and
specialist referrals were drastically reduced.
Pennington MA Fam Pract. 2004
Aug;21(4):372-80
0-8 weeks
What can the physical therapist do besides
teach exercises and apply modalities?
Cognitive therapy!
• Review and modify the patients self-
management strategies
• Reinforced the diagnosis
• Address patients worries
• Review red flags and action to take should
they occur, reassure that none are present
• Address any unrealistic expectations
0-8 weeks
What can the physical therapist do besides
teach exercises and apply modalities?
• Educate the patient on how to prevent
recurrence of pain
• Help you grade the patient‟s progress
toward functional goals
• If your patient is missing work, design a
return to work program and follow it along
with the physical therapist
Role of the physical therapist
Cognitive
• Patient education
• Assessment and reporting of progress
towards functional goals
• Identify barriers to recovery in
communicate these to the physician
Role of the physical therapist
Procedural
• Apply analgesic modalities
• Teach aerobic exercise appropriate to
patient
• Train in core stabilization exercise
• Manual therapy
• For radiculopathy
– Extension –biased exercise (McKenzie)
– Flexion-based exercise (Williams)
– Traction
Role of the physical therapist
(stretching is not evidence based medicine)
Role of the physical therapist
Procedural
A wide range of skills is needed, as is the
time to employ them (time is unfortunately
limited by low-ball insurance contracts
these days) so that the right techniques can
be found (empirically) and applied: each
patient is different. Routine exercise for all
is not effective.
Maintenance exercise
• Yoga
• Pilates
If the patient is not improving and
psychosocial factors appear prominent, refer
to behavioral health for evaluation and
treatment recommendations early.
Eight weeks - six months
1. Re- evaluation
2. Treatment
Eight weeks-six months
Re-evaluation
• A known diagnosis, not yet treated?
– Managed-care, patient has not been triaged to appropriate
care, geography
• A known diagnosis, the nature of which is chronic?
• A missed medical diagnosis? (includes the patient who
shows up for first evaluation two months into the pain)
• Are psychosocial factors contributing significantly to
disability?
Eight weeks-six months
Re-evaluation
The “missed medical diagnosis”
Common “benign” diagnoses in
chronic back and leg pain
Predominantly back pain
1. Discogenic pain (annular tear)
2. Painful osteoarthritis of the facet joints
3. Structural pathology
1. Congenital or degenerative kyphosis/scoliosis
4. Compression fracture
5. Spondylolysis/spondylolisthesis
6. Inflammatory spondylitis
7. Visceral pathology
Predominantly leg pain
1. Herniated nucleus pulposus
2. Spinal stenosis
Less common “benign” causes of
chronic back and leg pain
• Sacroiliac joint pain
• Coccydynia
• Polymyalgia rheumatica
• Stiff man syndrome
• Multiple sclerosis
• Parkinson‟s disease
• Sciatic nerve entrapment
• Post viral and other autoimmune radiculitis/plexitis
Nonexistent causes of chronic
back and leg pain
• Chronic low back strain
• Chronic myofascial pain
First question:
Which is worse, back pain or leg pain?
First question:
Which is worse, back pain or leg pain?
BACK PAIN
NOT
Why might pain radiating down the legs
to the feet occasionally, especially with
heavy loads and activity?
Back pain without radiculopathy
8 weeks - 6 months
Further evaluation
• Plain x-ray and ESR, with flexion extension
in elderly patients and patients with
significant sharp sudden pain with
movement.
– Fracture, instability, infection, tumor,
inflammatory spondylitis
Back pain without radiculopathy
8 weeks - 6 months
Further evaluation for the “missing diagnosis”
• Neuroimaging: MRI recommended for
initial screening of persistent back pain,
over CT and Bone scan:
– Infection, tumor, stress fracture, or visceral
pathology are suspected but not seen on plain x-
ray (sensitivity of x-ray about 42%).
What is the role of MRI in low
back pain diagnosis/treatment?
• To rule out scary stuff when it might be the cause of
back pain
• To confirm suspected diagnosis, when confirmation is
necessary
– EX: compression fracture when plain films are unremarkable
• To plan treatment
– EX: to evaluate disc height
• Special circumstances
– EX: to gauge the age of the compression fracture
Is MRI useful in diagnosing
painful degenerative disc
disease?
LAID Back
Longitudinal Assessment of Imaging and
Disability of the Back
Is MRI useful in screening for
painful degenerative disc disease
?
• Evaluated lumbar disc hydration, height, annular
tears, bulging, protrusion, and extrusion
• No relationship between previous episodes of pain
and bulges, annular tears, end plate changes, facet
joint degeneration, and spondylolithesis on MRI.
• Current MR imaging provides little to no correlate
with pain
Is MRI useful in diagnosis of
painful degenerative disc disease
in patients with chronic back pain
?
• Posterior annular high intensity zone most likely
does have meaning when present in the clinical
context of low back pain
• The disc(s) with the HIZ are very likely to be have
a painful annular tear on provocative discogram
Low back pain from
intravertebral disc and facet joint
The two most common causes of pain in
the 8 week – 6 month period
Low back pain from intravertebral
disc
(the disc is painful)
What shall we call it?
• Painful degenerative disc disease
• Discogenic pain
• Internal disk disruption
Trending the thinking on back pain
• Dynasty of the Prolapse
– 1934. Mixter WJ, Barr JS: Rupture of the intervertebral disc with
involvement of the spinal canal. New Engl J Med.
– 1957. Morgan FP, King T. Primary vertebral instability as a cause of low
back pain. J Bone Joint Surg.
– 1972. Sprangfort EV. The lumbar disc herniation. Acta Orthop Scand
• Dynasty of the facet joint
• 1976. Mooney V, Robertson J. The facet syndrome. Clin Orthop.
• 1992. Jackson RP. The Facet Syndrome. Myth or reality? Clin
Orthop.
• Dynasty of discogenic pain
• 1948. Lindblom. Diagnostic puncture of the intervertebral disc. Acta
Orthopedica Scand.
• 1986. Crock. The presidential Address: ISSLS. Internal disc
disruption. A challenge to disc prolapse fifty years on. Spine
Low back pain from lumbar facet
joint
What shall we call it?
• Painful degenerative joint disease of the spine
• Osteoarthritis of the spine
• Facet pain
• Zygoapophyseal joint pain
Patho-mechanical:
compression
Normal disc Damaged endplate
posterior anterior posterior anterior
Distance across L1-2 disc Distance across L1-2 disc
Adapted from: Adams M, et al. Mechanical initiation of disc degeneration. Spine.
2000;25:1625-36
Patho-mechanical:
compression
• Discogenic pain was found to be associated
with anomalous loading of the
posterolateral anulus (P 50% pain relief 51% 86% 73%
>70 % pain relief 28% 55% 64%
No pain relief 41% 14% 27%
Davis et al unpublished data
Outcomes of RF IDEA: athletes
3 Div 1 Back to 100% in Better in routine Latest follow up
Collegiate competition activities (years post
athletes procedure)
BASKETBALL yes yes 1
SWIMMING yes yes 3
GYMNAST no yes 4
Davis et al unpublished data
Outcomes of IDEA
• 1 year, 25 patients
• 3.5 average reduction of VAS
• 68% of patients >50% functional
improvement on Roland scale
• 74% very satisfied with results
• 17% went on to successful (in terms of
patient satisfaction) fusion
Outcomes of IDEA
Metanalysis of prospective cohort studies-
the best information we have thus far:
“The studies published so far suggest that the
pain resulting from lumbar disc disease may
be diminished by intradiscal electrothermal
annuloplasty. All these studies project a
positive therapeutic effect.”
Wetzel T Spine 2002 Nov
15;27(22):2621-6
Outcomes of IDEA
Pauza
• Double-blind, randomized, sham treatment
controlled study of 64 subjects, 6 mo. follow-up
• Statistically significant improvement in pain in the
treatment group only
• Statistically significant improvement in physical
functioning in the subgroup of patients who had
pre-op limitation in Physical functioning
Pauza A Spine 2004 Jan-Feb;4(1):27-
35
Disease specific intervention
Other diagnoses that may cause
persistent back pain
1. Painful osteoarthritis of the facet joints
2. Structural pathology
1. Congenital or degenerative kyphosis/scoliosis
3. Compression fracture
4. Spondylolysis/spondylolisthesis
5. Inflammatory spondylitis
6. Visceral pathology
Painful lumbar facet joints
Facet Pain:
Incidence by placebo controlled
Median Branch Blocks
• Lumbar
– Incidence 15% in younger population s/p injury
Schwartzer Spine 1994
– Incidence 40% in patients over 50 without
trauma Schwartzer Ann Rheum Disease 1995
• Cervical (after whiplash)
– Headache: 27- 53% C2-3 Lord 1994
– Neck pain: 54%, most common C4-5
Barnsley Spine 1995
Facet Pain: a note on history and exam
• No one piece of information is useful
• “Revel Criteria” 5 of the 7 predict relief
with median branch blocks
– Age > 65
– Better with lying down
– No increase in pain with coughing
– Not worse with forward bend
– Not worse with extension
– Not worse with rising from forward bend
– Not worse with extension-rotation
Revel Spine 1998
Facet Pain
Median Branch Blocks
• Perform as advertised - Dreyfuss Spine 1997
• Also anesthetize the lamina - spondylolysis
may respond
• Must be performed with a control to avoid
unacceptable false positive - Schwartzer Pain 1994
• Predict sustained pain relief with median
branch neurotomy (data presented later)
Results of treatment Based on
Median Branch Blocks
“RF Neurotomy”
• Cervical: 70% of patients pain free at 1
year Lord Neurosurgery 1999
• Lumbar: 70 % average decrease in pain
at 1 year Dreyfuss Spine 2000
Other causes of back > leg pain
Lumbar instability
• Definition: unequivocal anterior-posterior
translation of one vertebral segment on
another > 6 mm on lateral standing flexion
extension radiograph, or side to side motion
of one vertebral body on another with
sidebend.
Lumbar instability
• Congenital or traumatic “lytic” Spondylolysis
– Incidence of this condition with listhesis: 5-9%
• Degenerative disease
• Post-operative
– When more than 50% of the facet joint is removed
– Flexion-extension films may be normal, instability
may be rotational
Phase III Clinical Guidelines For Multidisciplinary Spine
Care Specialists, North American Spine Society, 2000
Lumbar instability
History
• There may be a complaint of sudden sharp pain
– rolling over in bed at night
– transitions between sitting and standing
• Pain worst with standing and walking
Exam
• Guarding of lumbar spine during standing flexion: patient
maintains lordosis through the movement
• Sudden “catch” (brief sharp pain) in the back part way
through standing flexion or extension of the lumbar spine
Lumbar instability
• L4-L5 is the most common level in
degenerative instability, followed by
L3-L4, and less common L5-S1
• L5-S1 is the most common level
affected in younger patients with
spondylolysis
Lumbar instability
Action to take when instability is
identified:
• Early surgical referral when it presents
with neurologic symptoms or signs,
even if intermittent
Lumbar instability
Action to take when instability is identified and no
neurological signs or symptoms are present:
• External bracing is not effective for mid to lower
lumbar spine instability.
• Push trunk strengthening (core stabilization)
• Consider referral for treatment of possible facet
component
• Monitor over time with repeat history, exam, and
radiographs
• Surgical stabilization
Spondylolysis
• Possible cause of pain in athletic younger patients
• Some sports present particular risk
– Gymnastics
– Weight lifting
– Wrestling
– Offensive linemen
– Dancers
– High jumpers
– Pole vault
Spondylolysis
• Pain at first with activity, later may be
constant
• Fracture may heal, may not
• In those that do not heal, instability can
develop over time and become symptomatic
• Spondylolisthesis may develop and needs to
be followed at intervals to assess for
progression
Sacroiliac joint painful instability
“sacroiliac joint dysfunction”
• Over diagnosed, but real (estimates of
prevalence range between back pain, no significant neurological compromise
Oral steroids
Physical therapy modalities
Imaging Analgesics/TCA/Gabapentin
Epidural steroid1
Percutaneous disc decompression
1 Diskectomy
Spinal stenosis
• NOT a cause of back pain
• The clinical presentation is neurogenic
claudication
– Classical presentation:
• Bilateral thigh and or lower extremity pain for canal
stenosis
• Unilateral dermatomal radicular pain for foraminal
stenosis
– Variant presentation:
• Buttock pain only with standing and walking
Spinal stenosis
• However, claudication often coexists with
back pain because they derive from the
same process: degenerative disease of the
spine
Why is pain in the legs present with
standing and walking?
Supine, standard technique Axial loaded
Spinal stenosis
• Epidural steroid injections may be effective for
reducing symptoms four months at a time
• In most cases, physical therapy is not helpful, but
occassionally…
• Tolerance for standing and walking will decrease
slowly with time in most cases
• Surgical decompression results are excellent and this
should be considered earlier in the course of the
disease then it often is.
Prolotherapy injection for chronic
back pain
“In the presence of „co-interventions‟,
prolotherapy injections were more effective
than control injections; there is no evidence
that prolotherapy injections are more
effective than control injections alone”
Yelland MJ The Cochrane Library,
Issue 3, 2004
The end