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 Flags
Belief 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: Bending, lifting?
Standard limits Lift 15-20 kg, heavy suitcase, 3- to 4-year-old
Sitting? Standing? Walking? Travelling ? Socializing? Sleeping? Sex life? Dressing?
Sit in an ordinary chair: less than 30 minutes Stand in one place: less than 30 minutes Walk less than 30 minutes or 1-2 miles Travel less than 30 minutes Miss or curtail social activities (excluding sport) Sleep disturbed by pain at least twice a week Sexual activity reduced or curtailed 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)
Not recommended Rx
Traction Electrotherapy Ultrasound Interferential therapy Laser treatments TENS - not to be confused with PENS
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