About your presenter LOW BACK PAIN. Epidemiology. Outline. Outline. Anatomy: Superficial Muscles 12/10/2012

Transcription

1 About your presenter LOW BACK PAIN Chronic Care Lecture Series Brian Liem, MD Sports Medicine Fellow University of Washington Department of Rehabilitation Medicine Hometown: Seattle, WA College: University of Washington Med School: NYU School of Medicine Residency: Northwestern t University it Interests: Biking, Hiking, Running Favorite quote: Don t ever think that you are useless. You can always be used as a bad example. Epidemiology Anatomy Review Pain Generators History Physical Exam Differential Work Up Cases and Treatment Epidemiology LBP is the 2 nd most common reason for physician visits (cold is #1) 50% of population has experienced LBP by age 20 Up to 1/3 of pts with back pain report continued moderate intensity pain for up to 1 year after acute event 5% of the people with back pain disability are estimated to account for 75% of the LBP Costs. Anatomy: Superficial Muscles Epidemiology Anatomy Review Pain Generators History Physical Exam Differential Work Up Cases and Treatment Trapezius Thoracolumbar fascia Latissimus Dorsi Glut max 1

2 Anatomy: Deep Muscles Anatomy: Psoas Paraspinals -Erector Spinae -Multifidi Iliopsoas Quadratus lumborum Anatomy: Spine Overview Anatomy: Bony Landmarks 7 cerivical Vertebrae 12 Thoracic Vertebrae 5 Lumbar Vertebrae 5 Sacral Vertebrae 3-4coccyx Anatomy: Bony Landmarks 2 Anatomy: Ligaments Transverse Process Spinous Process Why is it called the Ligamentum Flavum? Superior Articulating Process (SAP) It s Yellow in color Lamina Pedicle Inferior Articulating Process (IAP) 2

3 Anatomy: Disc and Nerves Anatomy: Disc and Nerves Things you should know What vetebral level does the spinal cord end? A: L1. Why is this important? A: When you do a lumbar tap or any spinal procedure if you know you are below the cord, there is little risk to SCI What vetebral level is at the same level as your iliac crests? A: L4. Why is this important? A: This helps you know which level you are at for both physical exam, diagnosis about offending nerve roots, and for procedures Epidemiology Anatomy Review Pain Generators History Physical Exam Differential Work Up Cases and Treatment Pain Generators Muscle (Myofascial) Bone (Fracture, compression fracture, spondylolysis) Ligaments (interpsinous) Jit(F Joints (Facets, Endplates) Disc Annular Fissure (Tear), Degenerative disc Nerves (Radiculitis) Supratentorial (ie: Chronic Pain) Epidemiology Anatomy Review Pain Generators History Physical Exam Differential Work Up Cases and Treatment 3

4 History: Basics History: Red Flags Time course 2 weeks ago? 1 month? 6 months? 10 years! Acute vs. Chronic Trauma history Especially for old ladies who fall! Where specifically Have patient point to Exactly where it hurts Radicular Symptoms Does the pain TRAVEL down the legs or just stays in the back? Positions that WORSEN symptoms Bending, Twisting, Walking, Lying Flat, Climbing Stairs Positions that ALLEVIATE symptoms Numbness? Weakness? Sign of nerve damage Clarify Pain vs. True Weakness Fevers, Chills, Nightsweats? (Constitutional Symptom) What you re after is do they have an epidural abcess (infection), osteomyelitis, or malignancy (primary or metastatic) Bowel or Bladder Symptoms? Primarily: Incontinence of bowel or bladder Tells you if this is involving the Cauda Equina (sacral regions) History: Function How bad is the pain? 0-10 This helps you get a baseline and later after some treatment you can compare What are they functionally NOT able to do? You want to see how much this is affecting their life. If they are going to work, still doing everyday tasks then they are relatively high functioning History: Prior Work up What other medical history? Cancer, Hx of Neurologic problems, Family hx of Rheum disorders? Prior work up X-rays MRIs Often pts have already had an MRI before even trying any therapy EMGs/NCS History: Treatments History: Secondary Gain Medications (type, duration, frequency) Other treatments Injections? (ESI, Myofascial Trigger points) Chiropractic Care? Massage? Surgery? ICE/Heat TENS Have the had Physical Therapy? How much? How many sessions? What did the therapist actually do? Passive vs. Active What s their motivation? Do they have a lawsuit Do they even want to get better? History of psych issues? Depression and Anxiety affect pain perception. 4

5 The Rotisserie Epidemiology Anatomy Review Pain Generators History Physical Exam Differential Work Up Cases and Treatment Physical Exam: Gait Physical Exam: Standing Gait Weakness on one side Antalgic Gait (Limping) Trendelenberg Gait Weakness of Glut Medius Posture Look for asymmetry, Any lean to one side (lateral shift)? Increased thoracic kyphosis (hunch back), loss of lumbar lordosis (flat lower back)?, increased lumbar lordosis ROM in standing (Flexion, Extension, Lateral Side Bending) Percussion/Palpation Balance Single Leg Squats: Tests hip abductor strength Physical Exam: Sitting Strength testing Strength of Lower Extremities (HF/HE, KF/KE, DF/PF/EHL) Sensation L2-S2 Dermatomes Reflexes (Patellar L4, Medial Hamstring L5, Achielles S1) Seated SLUMP 5

6 Sensation Testing Physical Exam: Supine Passive SLR Hip ROM Helps to rule out Hip as source of pain FABER = Flexion, ABduction, External Rotation (aka: Patrick s) Helps rule out SI joint vs. Intrarticular Hip as sources of pain Physical Exam: Side Lying Physical Exam: Prone Testing hip abductor strength mainly Palpation for tenderness spine, buttox, SI jt Prone instability a test of lumbar core Differential Epidemiology Anatomy Review Pain Generators History Physical Exam Differential Work Up Cases and Treatment Basically after you combine the history and physical exam you can generate a list of possible etiologies (causes) for the pain. Think back to the Pain Generators Muscle? Bone? Ligaments? Nerves? Chronic Pain? 6

7 Epidemiology Anatomy Review Pain Generators History Physical Exam Differential Work Up Cases and Treatment Work Up 80% diagnoses can be made with H&P alone When do you get imaging? Any history of trauma or red flags Indicated if no improvement in symptoms after 6 weeks X-ray L-spine AP and Lateral Tells you about Alignment, Arthritis (spondylosis), Fractures MRI Helps to evaluate canal narrowing, soft tissues, discs, and nerves Order this if pain continues despite conservative treatment has already had negative X-rays weakness is present Red flags present X-rays (Plain Films): AP and Lateral MRI: Sagital and Axial Epidemiology Anatomy Review Pain Generators History Physical Exam Differential Work Up Cases and Treatment Case 1 30 y/o man presents with 3 day history of LBP after helping his friend move into his new apartment. Key History: No radiation of back pain down legs. Just stays in back. Worse: Bending forward, Transitional Movements Better: Bending backwards Physical Exam: Pain with forward flexion, nl strength, reflexes and sensation. Work Up: None needed 7

8 Case 1 cont Case 2 Diagnosis: Acute Discogenic Low Back Pain Pain generator: Disc herniation or annular fissure (tear) Muscles tense up to help stabilize the back in response to pain. Treatment: Reassurance! Key is that most back pain resolves on own % of acute LBP resolves in 2 weeks. 90% get better w/o physician intervention NSAIDS prn. Other modailties: Heat/TENS 78 y/o woman presents with low back pain x 6 months with buttock and right leg pain Worse: Leaning back, Walking down hills. Pain makes her legs feel tired Better: Leaning forward, leaning on a shopping cart. Physical Exam: Stooped posture. Pain with lumbar extension Work Up: X-ray and MRI MRI Case 2 Case 2 cont Central stenosis L4-L5 Wide open L5-S1 level Diagnosis: Spinal Stenosis and Neurogenic Claudication Pain generators: arthritic bony spine, degenerative discs and compression of nerves because of narrowing of spinal canal and foramen Treatment: Physical Therapy goal improve pain free ROM, strengthen/stabilize the core musculature Lumbar Epidural Steroid Injection during Flare Surgery--Decompression Case 3 MRI 46 y/o W with LBP and pain going down his Right legs. He tells you he thinks he has sciatica. Worse: Bending forward Better: Not moving. Extending the back. Physical Exam: Radiating pain reproduced with lumbar flexion. Slight weakness with ankle dorsiflexion, Numbness over dorsal foot. +Seated slump Work Up: X-ray and MRI or EMG/NCS 8

9 Case 3 cont Diagnosis: Radiculopathy from Herniated Nucleus Pulposis (HNP) Pain generator is a posteriroly herniated disc compressing on a nerve root or chemomechanically irritating the nerve root Most common level l is L4-L5 L5 and L5-S1 disc impinging i i on L5 and S1 nerve roots Treatment: Physical Therapy w/ Extension base, NSAIDS, Steroid dose pack Epidural Steroid Injection, Disectomy if fail conservative tx. Education: Educate the patient that sciatica isn t the proper term necessarily because the sciatic nerve is not what is affected, but rather a nerve root. Case 4 80 y/o woman with hx of osteoporosis presents with pain in her low back after a fall Worse: Any movement. Sleeping. Better: Sitting very very very still Physical Exam: Pain with percussion over lumbar spine Work Up: X-ray and MRI X-Ray Case 4 Cont Diagnosis: Lumbar Compression Fracture Pain Generator: Bone Treatment Lumbar Corset Opioids for pain managment Vetebralplasty or Kyphoplasty Case 5 X-ray 14 y/o gymnast presents with back pain x 2 months Worse: Doing a back bend Better: Staying in flexion Physical Exam: Tender to palpation over spinous process. Pain with one-legged extension Work up: X-ray, CT scan, Bone scan 9

10 Case 5 cont Diagnosis Spondylolysis Fracture of the pars interarticularis Pain generator: Fractured bone Mechanism: Repetitive extension Treatment Rest x 3 months no sport NSAIDs PT once pain free ROM Other common LBP diagnoses 55 y/o man with low back pain. He has also noted some easy brusing. Diagnosis: Multiple Myeloma 75 y/o man with hx of prostate cancer and low back pain Diagosis: Mestatsitc Prostate Cancer 61 y/o woman w/ hx of breast cancer and low back pain Diagnosis: Metastatic Breast Cancer Other LBP Diagnoses Anklylosing Spondylitis Tarlov Cysts LBP Pearls Take a good HISTORY and PHYSICAL Most acute LBP back pain resolves on its own. Don t go by results of MRI. Go by how the patient feels and functions. In other words, don t treat an image, treat the patient Watch out for Red Flags Don t use sciatica to explain radicular pain. Be more specific! 10