Approach to Primary Care Evaluation of Low Back Pain. Kirk Whetstone, MD OhioHealth Neurological Physicians Medical Spine

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1 Approach to Primary Care Evaluation of Low Back Pain Kirk Whetstone, MD OhioHealth Neurological Physicians Medical Spine

2 Disclosure Statement I have no relevant disclosures or conflicts of interest to report

3 Main Areas of Focus 1) How to approach a patient who walks in with back pain 2) Know the limitations of low back imaging 3) Know when to refer

4 Objectives Understand clues in the history that can help narrow the differential diagnosis and guide work up Understand how to predict the most likely pain generator based on history and pre test probability Understand the shortcomings of advanced imaging in the lumbar spine and how to convey this to patients Know how to discuss imaging results with patients using best language Understand when to escalate care to a specialist and what options exist for secondary care/specialty care

5 Main Areas of Focus 1) How to approach a patient who walks in with back pain 2) Know the limitations of low back imaging 3) Know when to refer

6 Patient walks in complaining of back pain, what next? Define what they mean by back pain? Have them describe the location and point to the location Is there associated leg pain? Ask about red flag symptoms, ask about relevant past medical history Look at their age and risk factors Have they had surgery in the low back? Do they have significant psychiatric history/somatization? Now you can begin to use then information to narrow differential and make medical decisions

7 L1 L5 region is low back or lumbar spine Iliac Crest at L4 L5 level Sacrum and lower is buttock or hip Calling something back pain is not specific enough!

8 Keep in Mind Majority of patients with low back pain and absence of neurologic symptoms will get better through natural disease course As we move from volume to value we will be judged on how often we order imaging that may not make a difference in care Insurance companies are already cracking down on advanced imaging for spine

9 Rule out bad things Cancer (History of cancer, especially those that metastasize to spinebreast, lung, prostate) Infection (IVDU, immunosuppression, recent surgery or procedure) Cauda Equina (Rare but presents dramatically) Fracture (Osteoporosis, trauma, steroid use, risk for pathologic fracture) Majority of patients DON T fall into this category >90% Jarvik 2002 Ann Internal Medicine

10 Systemic Disease/Sinister Diagnoses are Rare In Primary Care Presentation with leg and back pain 0.7% metastatic disease 0.01 % spine infection 4.0 % compression fracture 0.3 % ankylosing spondylitis Jarvik 2002 Ann Internal Medicine

11 Red Flags Red Flags Children under 18 (absence of trauma) New onset after age 55 Night pain History of Cancer History of chronic steroid use Weight loss Change in bowel/bladder Significant new weakness History of IVD use and fever History of trauma in >70

12 If you follow guidelines and look for red flags/risk factors, will patients be missed? All three showed no missed systemic disease, cancer, infection etc

13 Following guidelines decreases overutilization Choosing Wisely (AAFP) Don t order imaging for low back pain the first 6 weeks in the absence of red flag symptoms. Imaging in the first 6 weeks does not improve outcomes and increases costs in the absence of red flags

14 What does associated leg pain suggest If leg pain is greater than or equal to low back pain this suggests neurocompression/nerve irritation Neurocompression can come in different forms intra spinal compression (central stenosis, foraminal stenosis, lateral recess stenosis) *Most common* Neurocompression can come from extra spinal compression (tumor, muscle, compression neuropathies) *Much less common* Non compressive causes (muscle injury, referred pain from joint, vascular issues, polyneuropathy)

15 When a patient has leg pain They are more likely to respond to epidural steroid injection and spine surgery They are more likely to respond to physical therapy They are more likely to have a concordant finding on imaging that will allow for more exact diagnosis Pearson 2011 Spine, Ghahrema 2010 Pain Medicine

16

17 Take a finger and draw the pain down your leg

18 Testing for low back pain and leg pain X ray after 6 weeks of conservative treatment MRI without contrast after 2 months of conservative treatment If history of surgery, MRI with and without contrast If MRI contraindication, CT myelogram This should be done ASAP if weakness or red flag symptoms EMG can be helpful if trying to narrow differential (more specific than MRI) (timing often dictated by insurance companies, many have different rules) Barr 2011 Phy Med Rehabil Clinic

19 When a patient has primarily back pain Can be more difficult to accurately diagnosis a pain generator This is the majority of patients with low back symptoms Can also be multifactorial contribution (disc, facet, muscle) Low back pain has links to depression, anxiety, somatization, disability, secondary gain. This can make things COMPLICATED

20 Do we need to determine a pain generator? Is this even possible? For acute pain, or improving subacute pain with no neurologic deficits, likely will not change the course of care Getting an accurate anatomic diagnosis for low back pain is sometimes hard, frustrating to patients (patient on merry go round) For patients with subacute or chronic pain, it is reasonable to pursue a pain generator with the understanding that it may not be possible, patient education should start early regarding this This is where things can get tricky and patients get mixed messages from providers and specialty referral may be helpful

21 Main Pain Generators Low Back Pain Muscle Facet Joint Disc Sacroiliac Joint

22 Low back pain pre test probability Low Back Pain Anatomic Cause Other Internal Disc Disruption % % (Higher as we age) Facet Joint Sacroiliac Joint % Internal Disc Disruption Sacroiliac Joint Facet Joint Other

23 How is IDD different than Disc Herniation?

24 What is Other? Myofascial Pain/ muscle pain Scoliosis Spondylolisthesis Somatization Causes outside the spine (kidney, bladder, reproductive etc)

25 Low back pain pretest probability DePalma 2011

26 Internal Disc Disruption Common cause of low back pain, especially in the age group under 50 This is different than disc herniation causing nerve compression Part of what is called degenerative disc disease, however this is not really a disease The disc itself is innervated, and if there is a disruption in the disc which can include tears, this can be a pain generator Pain is axial, worse with prolonged sitting, bending, twisting

27 Internal Disc Disruption

28 Internal Disc Disruption

29 Internal Disc Disruption Imaging provides clues but is not diagnostic for determining a pain generator (there is no true gold standard test) Provocative discography can be used, this is controversial, you will see some providers doing it and others against it HIZ (High intensity Zone) and modic changes (imaging changes of the endplate) have some correlation to pain These can be seen in people with no pain

30 Internal Disc Disruption Imaging High Intensity Zone Modic Changes

31 Facet joint arthritis Facet joint arthritis is nearly ubiquitous as we age, not all causes pain, therefore imaging has limitations Think about in people with high OA burden, RA Over the age of 50, I generally move facet joint arthritis up the differential, studies have showed higher prevalence over age 50 Pain is axial off of mid line, worse with prolonged standing, extension maneuvers Imaging including MRI and bone scan have not been shown to be predictive (can provide clues) Diagnostic procedure is medial branch block

32 Facet Joint Arthritis

33 SI joint In patients with history of lumbar spine fusion, the rate of SI joint degeneration appears higher One study that studied SI joint before and after fusion surgery radiographically showed that up to 75 % incidence of SI joint degeneration versus 38 % control group If a patient has history of fusion and buttock/sacral pain, SIJ rises on differential diagnosis Imaging can be useful, especially with sacroiliitis (rheumatologic) but not diagnostic Injection can be diagnostic and therapeutic Ha 2008 Spine

34 Sacroiliac joint

35 Testing for low back pain and leg pain X ray after 6 weeks of conservative treatment MRI without contrast after 2 months of conservative treatment If history of surgery MRI with and without contrast If MRI contraindication, CT Imaging should be done ASAP if weakness or red flag symptoms EMG not helpful in low back pain alone If multiple joint involvement, morning stiffness, synovitis consider rheumatologic work up If evaluating buttock pain/sij bilateral hips and pelvis xray (timing often dictated by insurance companies, many have different rules)

36 Main Areas of Focus 1) How to approach a patient who walks in with back pain 2) Know the limitations of low back imaging 3) Know when to refer

37 Imaging in low back pain has limitations MRI, CT and X rays are a great tools, can have limitations Degenerative changes in the lumbar spine are nearly ubiquitous by the 50 s One study (Eubanks et al) looked at 647 cadaver facet joints By age group 93% had degenerative facets, by 60 y/o 100% One study (Weishaupt et al) looked at 60 asymptomatic people y/o Disc bulge (62%) Disc protrusion (67%), Disc Disruption (32%), Extrusions (18%)

38 Summary of Studies Low Back Pain (Asymptomatic)

39 So why do imaging for low back pain? When taken with examination, history, and imaging concordance can suggest causation and pain generator Can lead to most likely pain generator to help spine injection or surgery planning Can rule out the bad things Can give patient piece of mind, but can also add to frustration if no exact pain generator can be found

40 Examples of Discs Infant Young Adult 60 year old 30 year old With disease/pain

41 Saal 1990 Spine

42

43 Imaging Key Points Imaging in low back pain can often be misleading. Degenerative disc disease, facet joint arthritis, disc bulging are present in many people with NO PAIN. Multiple studies have bore this out Be very careful to use terms like Degenerative Disc Disease, moderate stenosis This is radiologist and physician physician language

44 Imaging Key Points Use terms like disc wear and tear, wear and tear of the joints that is normal for aging, nerve irritation, narrowing where the nerve exits the spine and travels to the leg Tell patients that over the age of 20 many people have changes in their lumbar MRI, over the age of 40 having a normal lumbar MRI is not expected

45 Main Areas of Focus 1) How to approach a patient who walks in with back pain 2) Know the limitations of low back imaging 3) Know when to refer

46 When to escalate/refer New onset red flag symptoms ER Slower onset weakness, hyperreflexia, neuro exam change Referral to Spine Surgery Patients who have not improved with conservative management Medical Spine (majority of patients)

47 Why refer? When to refer? You have ruled out the bad things Patient has tried initial usual conservative measures (medications, physical therapy, activity modification, time) and needs further workup and recommendations Try to identify a treatable cause and pain generator if possible You are having trouble getting imaging approved You think the patient would benefit from a more thorough discussion about back pain (diagnosis, treatment options, prognosis). This can be a complicated and lengthy discussion

48 Why Medical Spine Many patients want all conservative options first and may not be ready to discuss surgical options Referral into spine care can be confusing and disjointed(leads to medical merry go round) Can offer the spectrum of conservative care options in one place and complete work up, refer if necessary, development treatment plan Focus is on rehabilitation and understanding their spine condition, leads to lower utilization of care and increased engagement

49 Referral Options Undifferentiated Spine Diagnoses Acute/Subacute Pain Spine Surgery Physical Therapy PCP (Starts Usual Care and Workup) Medical Spine Start here for secondary spine care Rheumatology Manual Medicine Psychiatry Physical Therapy

50 Referral Options Current Options Riverside Grant Medical Center Westerville Medical Campus Hilliard Health Center 2017 Pickerington Medical Campus Additional locations pending

51 Summary Using physical exam, history, and pre test probability you can narrow differential and educate patients while you start conservative care management Treat the patient and not the pictures, the pictures only tell part of the story. The only way to make a diagnosis is using exam, history, and utilize concordant portions of the imaging Refer for red flags/change in neuro status, also for patients who need secondary care

52 THANK YOU! Questions?

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