DIFFERENTIAL DIAGNOSIS OF LOW BACK PAIN. Arnold J. Weil, M.D., M.B.A. Non-Surgical Orthopaedics, P.C. Atlanta, GA

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1 DIFFERENTIAL DIAGNOSIS OF LOW BACK PAIN Arnold J. Weil, M.D., M.B.A. Non-Surgical Orthopaedics, P.C. Atlanta, GA

2 MEDICAL ALGORITHM OF REALITY LOWER BACK PAIN Yes Patient will never get better until case is settled. Due to an auto or work-related injury? Yes No Is patient trying to get disability? No Patient will never get better until case is settled. Is patient trying to get workers comp? Yes No Patient will never get better until case is settled. Is the patient narcotic seeking? Yes No Patient will never get better.period. Patient might get better

3 Introduction to Low Back Pain LBP very disabling and accounts for over 50% of Workers Comp costs 80 - $100 billion per year Affects up to 85% of adults during their lives Leading Cause of Disability Ages In 2010 in the United States there were over 15 million office visits to physicians for low back pain, second only to the common cold as a symptomatic reason for a physician visit. 75% of costs due to 5% of patients 95% of all LBP is non-surgical

4 Risk Factors Smoking Obesity Older age Gender Strenuous or sedentary work Job satisfaction Psychological factors (anxiety, depression, etc.)

5 The Natural History of Back Pain By Six Weeks 65% of patients have recovered By Twelve weeks 85% of patients are improved After 12 weeks recovery is less likely After 26 weeks fewer that half ever return to work After 104 weeks the likelihood of returning to work is virtually nil.

6 The Evolving Approach Towards Back Pain Then Prolonged bed rest Absence from work Sedating medications Physical modalities Passive patient Routine diagnostic testing Aggressive surgical approaches Now Minimal or no bed rest Rapid return to work Sedation not desired Active rehabilitation Active patient participation Look for the red flags first Aggressive non-surgical treatment

7 Is the Low Back Pain Acute or Chronic? Acute Give them 6 weeks of whatever you want (physical therapy, mud wrestling, sea bass fishing) Chronic Try your best to get them to work out, stop smoking, lose weight, stretch 5% don t get better 95% get better 5% actually do it and get better 95% don t do anything MRI YOU RE A GREAT DOC! They demand and get an MRI 95% have negative findings 5% have fixable findings 5% have fixable findings 95% have nothing to fix on MRI Send to a spine surgeon Refer to anyone else Patient thinks you can t help which you can t. Patient thinks you can t help which you can t.

8 Learning Objectives Discuss the anatomy of the low back Discuss the common causes of low back pain Discuss the evaluation of low back pain Discuss common non-surgical treatments

9 Lumbar Anatomy Bones / Joints Muscles Discs Ligaments Nerve roots

10 Lumbar Spine

11 Multiple anatomic sources Low Back Pain No standard methods for categorizing, diagnosing, or treating pain syndromes Treatment protocols varied Rest, exercise Physical therapy Spinal manipulation Oral medications Injection therapies Surgery/other

12 Sources of Low Back Pain Discs Bone / Joint Muscles / Ligaments Nerve roots Inflammatory

13 History Evidence of systemic disease Evidence of neurologic compromise Social or psychological issues Risk factors Mechanism of injury Red flags

14 Causes of Low Back Pain Hereditary Disorders Degenerative Disorders Traumatic Injuries Soft Tissue / Muscle Injuries Insidious Onset Other

15 Common Disorders of the Spine Herniated Disc Degenerative Disc Facet Arthropathy Sacroiliac Joint Dysfunction Lumbar Strain Fibromyalgia Arthritis

16 COMMON SYMPTOMS ASSOCIATED WITH BACK PAIN Low back discomfort Sciatica/leg pain Muscle spasms Hip, buttock, or groin pain Numbness or tingling into the extremity Motor weakness Other unusual symptoms

17 Herniated Disc Bulging / protruding Herniated Ruptured Extruded fragment

18 Herniated Disc

19 Herniated Disc

20 Herniated Disc Symptoms Symptoms Commonly involve Back Pain Radiation into the extremities Associated with Muscle Spasm Treatment is non-surgical

21 Degenerative Disc Hereditary Traumatic Progressive Exacerbated by obesity, inactivity Thinning of disc material with nerve root compression

22 Symptoms of Degenerative Disc Disease Symptoms are centrally located May involve buttock or proximal leg pain Associated with facet syndrome Non-surgical

23 Fractures

24 Sacroiliac Joint Dysfunction Localized pain in the SI joint Common in women and with trauma Conservative treatment

25 Lumbar Strain Muscular pain and weakness Local lumbar pain with lateral radiation Over utilized diagnosis and misdiagnosed Difficult to treat - know anatomy

26 Lumbar Strain

27 Soft Tissue Injuries Sprains and strains strain = stretching injury to muscle trapezius, rhomboids sprain = injury to ligament capsular injury connecting lumbar facet joint and vertebrae Piriformis Syndrome Myofascial pain

28 Nerve Injuries Sciatic nerve injury Peripheral nerve injuries Nerve root injuries Distal nerve injuries

29 Fibromyalgia Chronic Pain Syndrome Non-specific complaints Non-specific objective findings Usually overlying back pain

30 Arthritis Osteoarthritis Rheumatoid Arthritis Seronegative spondyloarthropathies Autoimmune diseases

31 Other Disorders Associated with Back Pain Hip Piriformis Hamstring Pelvic or abdominal mass Gynecological (adhesions, fibroids, endometriosis)

32 Other Spine Entities Meningeoma Destructive / Lytic Lesions

33 Physical Examination Observation & Palpation / Tenderness Range of Motion Straight leg raise Neurological Exam Evaluation for malignancy Non-organic or Waddell s signs Psychological Assessment

34 Diagnostic Studies X-Rays MRI CT EMG / NCS Discography

35 X-Rays

36 MRI

37 CT

38 EMG / NCS

39 Discogram

40 Treatment Medications Therapies Alternative Medicine Injections

41 Medications Anti-inflammatory medications Muscle Relaxants Analgesics Neuropathic medications Topical medications

42 Therapy Physical Therapy Massage Therapy Chiropractic Therapy

43 Injections Trigger Point Injections Botox Injections Epidural Steroid Injections Joint Injections Facet Injections

44 Trigger Point Injections

45 Botox Injections

46 Epidural Steroid Injections Acute radiculopathies Disc Bulges Disc Herniations Deg Disc Disease Spinal Stenosis

47 Intra-articular Injections

48 Facet Injections

49 Radiofrequency Lesioning

50 Percutaneous Disc Decompression

51 IntraDiscal ElectroThermal Therapy (IDET)

52 Spinal Cord Stimulation Trial SCS for one to two weeks If > 50 % pain relief may benefit from permanent implant Dual electrodes available for bilateral extremity coverage or complex pain patterns

53 Surgical Treatment Discectomy Fusion Disc Decompression Fracture stabilization

54 Summary Back pain is 2nd most common reason for MD visit Focused history and examination variety of causes for low back pain Physician must identify and treat the cause Conservative treatment Surgery is the last option

55

56 Arnold J. Weil, M.D. Anthony R. Grasso, M.D.

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