Diagnosing Low Back Pain

Fritz Sumantri Usman

Neurologist & Interventional Neurologist

I. History:

 Mechanism of injury Associated symptoms:

Bladder / bowel function Fevers / chills Sleep disturbance Numbness / tingling

Prior injuries, treatment and outcomes Medications Family history Social history:
Vocational Education Tobacco / ETOH / Illicit drugs Function: ADLs & Mobility
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Litigation

Pain Specifics:

Quality: sharp, dull, shooting, burning, etc. Location / Distribution:

Radicular: Dermatomal distribution, dysesthesias Radiating: Nondermatomal

Onset:
Gradual: DDD Acute: Disc abnormality, strain, compression fractures

Severity / Intensity Frequency: Constant vs. Intermittent Duration Exacerbating and Alleviating Factors Time of Day: If nocturnal, consider malignancy

Red Flags:
Significant trauma history, or minor in older adults Nocturnal pain in supine position with history of cancer Bladder or bowel incontinence or dysfunction Constitutional symptoms:
Fever / chills Weight loss Lymph node enlargement

Risk factors for spinal infection

Recent infection IV drug use Immunosuppression

Major motor weakness

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II. Examination:

A. Physical:
Posture:
Splinting Body language

Gait:
Antalgia Heel / Toe pattern Trendelenberg

Musculoskeletal:
ROM Leg length Vascular Atrophy
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 Abdomen:
Presence of masses

Back:
Inspection Palpation ROM Scoliosis

Neurological:
Sensation Motor DTRs

Rectal if indicated:
Evaluation of sphincter tone
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B. Symptom Magnification Examination:

Waddell signs: Presence of nonorganic signs suggesting symptom magnification and psychological distress
Superficial or nonanatomic distribution of tenderness Nonanatomic or regional disturbance of motor or sensory impairment Inconsistency on positional SLR Inappropriate/excessive verbalization of pain or gesturing Pain with axial loading or rotation of spine

Give-away weakness: Inconsistent effort on manual motor testing with ratcheting rather than smooth resistance

C. Pathological Examination:
Spurlings maneuver: Lateral rotation and extension of spine resulting
in neuroforaminal narrowing and nerve root encroachment, clinically reproducing extremity pain, usually in dermatomal distribution

Straight-leg raise (SLR): Elevation of lower extremity, seated or

standing, resulting in neural tension at S1 nerve root with extremity pain

Patricks maneuver: Crossed leg with unilateral pain indicative of

sacro-iliac (SI) joint dysfunction

Femoral stretch: Hip extension stretch with heel pushed to buttock in

lateral supine or prone position resulting in anterior thigh pain

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III. Low Back Pain:

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A. Epidemiology:
Incidence of LBP: 60-90 % lifetime incidence 5 % annual incidence 90 % of cases of LBP resolve without treatment within 6-12 weeks 40-50 % LBP cases resolve without treatment in 1 week 75 % of cases with nerve root involvement can resolve in 6 months LBP and lumbar surgery are: 2nd and 3rd highest reasons for physician visits 5th leading cause for hospitalization 3rd leading cause for surgery 12

B. Disability:
Age and LBP:
Leading cause of disability of adults < 45 years old Third cause of disability in those > 45 years old

Prevalence rate:
Increased 140 % from 1970 to 1981 with only 125 % population growth Nearly 5 million people in the U.S. are on disability for LBP
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C. Lifetime Return to Work:

Success of less than 50 % if off work greater than 6 months 25 % success rate if off work greater than 1 year
Nearly 0 % success if return to work has not occurred in 2 years

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D. Occupational Risk Factors:

Low job satisfaction Monotonous or repetitious work Educational level Adverse employer-employee relations Recent employment Frequent lifting
Especially exceeding 25 pounds Utilization of poor body mechanics in technique
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E. Differential Diagnoses:
Lumbar strain Disc bulge / protrusion / extrusion producing radiculopathy Degenerative disc disease Spinal stenosis Spondyloarthropathy Spondylosis Spondylolisthesis Sacro-iliac dysfunction
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F. Diagnostic Tools:
1. Laboratory:

Performed primarily to screen for other disease etiologies

Infection Cancer Spondyloarthropathies

No evidence to support value in first 7 weeks unless with red flags Specifics:
WBC ESR or CRP HLA-B27 Tumor markers:
Kidney Breast Lung Thyroid Prostate
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 2. Radiographs:
Pre-existing DJD is most common diagnosis Usually 3 views adequate with obliques only if equivocal findings Indications:
History of trauma with continued pain Less than 20 years or greater than 55 years with severe or persistent pain Noted spinal deformity on exam Signs / symptoms suggestive of spondyloarthropathy Suspicion for infection or tumor

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 3. EMG / NCV ( Electrodiagnostics):

Can demonstrate radiculopathy or peripheral nerve entrapment, but may not be positive in the extremities for the first 3-6 weeks and paraspinals for the first 2 weeks Would not be appropriate in clinically obvious radiculopathy

4. Bone scan:
Very sensitive but nonspecific Useful for:
Malignancy screening Detection for early infection Detection for early or occult fracture
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 5. Myelogram:
Procedure of injecting contrast material into the spinal canal with imaging via plain radiographs versus CT In past, considered the gold standard for evaluation of the spinal canal and neurological compression With potential complications, as well as advent of MRI and CT, is less utilized:
More common: Headache, nausea / vomiting Less common: Seizure, pain, neurological change, anaphylaxis

Myelogram alone is rarely indicated Hitselberger study 1968 Journal of Neurosurgery:

24 % of asymptomatic subjects with defects
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 6. CT with myelogram:
Can demonstrate much better anatomical detail than myelogram alone Utilized for:
Demonstrating anatomical detail in multi-level disease in preoperative state Determining nerve root compression etiology of disc versus osteophyte Surgical screening tool if equivocal MRI or CT

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 7. CT:
Best for bony changes of spinal or foraminal stenosis Also best for bony detail to determine:
Fracture DJD Malignancy

SW Wiesel study 1984 Spine:

36 % of asymptomatic subjects had HNP at L4-L5 and L5-S1 levels

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 8. Discography (Diagnostic disc injection):

Less utilized as initial diagnostic tool due to high incidence of false positives as well as advent of MRI Utilizations:
Diagnose internal disc derangement with normal MRI / myelo Determine symptomatic level in multi-level disease

Criteria for response:

Volume of contrast material accepted by the disc, with normals of 0.5 to 1.5 cc Resistance of disc to injection Production of pain---MOST SIGNIFICANT

Usually followed by CT to evaluate internal architecture, but also may utilize MRI As outcome predictor (Coulhoun study 1988 JBJS):
89 % of those with pain response received benefit from surgery 52 % of those with structural change received surgical benefit
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 9. MRI:
Best diagnostic tool for: Soft tissue abnormalities:
Infection Bone marrow changes Spinal canal and neural foraminal contents

Emergent screening:
Cauda equina syndrome Spinal cored injury Vascular occlusion Radiculopathy

Benign vs. malignant compression fractures Osteomyelitis evaluation Evaluation with prior spinal surgery
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 Has essentially replaced CT and myelograms for initial evaluations Boden study 1990 JBJS: 20 % of asymptomatic population less than 60 years with HNP 36 % of asymptomatic population of 60 years Jensen study 1995 NEJM: 52 % of asymptomatic patients with disc bulge at one or more levels 27 % of asymptomatic patients with disc protrusion 1 % of asymptomatic patients with disc extrusion
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 MRI with Gadolinium contrast:

Gadolinium is contrast material allowing enhancement of intrathecal nerve roots Utilization:
Assessment of post-operative spine---most frequent use Identifying tumors / infection within / surrounding spinal cord Diagnosis of radiculitis

Post-operatively can take 2-6 months for reduction of mass effect on posterior disc and anterior epidural soft tissues which can resemble pre-operative studies Only indications in immediate post-operative period:
Hemorrhage Disc infection
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 10. Psychological tools:

Utilized in case scenarios where psychological or emotional overlay of pain is suspected
Symptom magnification Grossly abnormal pain drawing Non-responsive to conservative interventions but with essentially normal diagnostic studies

Includes:
Pain Assessment Report, which combines: McGill Pain Questionnaire Mooney Pain Drawing Test MMPI Middlesex Hospital Questionnaire Cornell Medical Index Eysenck Personality Inventory

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MRI Nomenclature:
Anular fissure:
transverse distribution

(PER NASS)

Focal disruption of anular fibers in concentric, radial or

Disc bulge:

Circumferential, diffuse, symmetric extension of anulus beyond the adjacent vertebral end plates by 3 or more mm, usually due to weakened or lax anular fibers Focal, asymmetric extension of disc segment beyond margin of vertebral end plates into the spinal canal with most of anular fibers intact Focal, asymmetric extension of disc segment and / or nucleus pulposis through the anular containment into the epidural space with migration into the canal

Disc protrusion: Disc extrusion:

Disc sequestration: Extruded disc segment that is detached from original

Disc degeneration:
Irreversible structural and histiological changes in nucleus seen on MRI T2WI images (commonly associated with bulge)

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Specificity / Sensitivity
Diagnosis
Disc Herniation

Test
CT MRI CT Myelo

Sensitivity
0.90 0.90 0.90 0.90 0.90 0.77

Specificity
0.70 0.70 0.70 0.80-0.95 0.75-0.95 0.70

Spinal Stenosis

CT MRI Myelogram

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G. Treatment
Medications
NSAIDS Membrane stabilizers
TCA / Neurontin re-establish sleep pain reduce radicular dysesthesias

Muscle relaxers:
re-establish sleep patterns more useful in myofascial/muscular pain

Narcotics: rarely indicated Steroids: more useful for radiculitis Non-narcotic analgesics: Ultram

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 Physical therapy
Modalities electrical stimulation/TENS Postural education / body mechanics Massage / mobilization / myofascial release Stretching / body work Exercise / strengthening Traction Pre-conditioning / work-conditioning

Injections
Epidural blocks Facet blocks Trigger point SNRB SI joint

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 Surgery:
Laminectomy Fusion Discectomy Percutaneous Lumbar Discectomy
Success rate variable 50 -85 % Low rate of complications:
Infection Peripheral nerve injury

Benefits:
Outpatient procedure Minimal to no epidural scarring No general anesthesia Spine stability preservation Decreased cost
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 Chemonucleolysis IDET: Intradiscal Electrotherapy or Spine CATH Alternative:

Chiropractic:
Clinical studies show benefit only in first 3 weeks of symptoms

Acupuncture Biofeedback

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IV. Specific Disorder Considerations

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A. Sacroiliitis:
History:
Trauma is very common Repetitive LS motion--lumbar rotation or axial loading No specific correlation with exacerbating activities Commonly have leg length discrepancy or condition contributing

Biomechanics:
Movement of the SIJ is involuntary, usually from muscle imbalances Can occur at multiple levels: lower extremities, hip, LS spine Motion is complex and not single-axis based
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 Differential Diagnosis:
a. Fracture
Traumatic Insufficiency stress fractures: elderly patient with osteoporosis
without history of trauma

Fatigue stress fractures: usually athletes / soldiers

b. Infection
Hematogenous spread with predisposing history Usually unilateral symptoms present

c. Degenerative joint disease d. Metabolic disease e. Referred pain

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f. Seronegative spondyloarthropathies
RA--usually not until late in course of disease Ankylosing spondylitis Psoriatic arthritis

g. Primary SI tumor
Rare and usually synovial villoadenomas

h. Iatrogenic instability
Via pelvic tumor resection or bone graft site

i. Osteitis condensans ilii

Prevalence of 2.2 %, primarily in multiparous women Usually self-limiting and bilateral

j. Reactive disease as sequellae of PID

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 Diagnostic Tools:
X-rays: Up to 25 % of asymptomatic adults over 50 years
can have abnormalities

MRI / CT: Only if looking for tumor Bone scan: Good for fractures but less favorable for inflammation

Treatment:
Medications: NSAIDS Physical therapy Correct limb discrepancy Injection: Fluoroscopy-guided vs. local Surgical fusion: Few figures for efficacy
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B. Cauda Equina Syndrome:

History:
Sudden, partial or complete loss of voluntary bladder function due to massive disc impingement on spinal nerves Can include loss of sensation as well as sphincter tone

Treatment:
Urgent decompression is mandatory for prevention of irreparable / irreversible bladder damage 12 hours is the maximum time prior to irreversible changes

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C. DDD and Spondylosis:

Clinical:
Up to 75 % of involvement of the spine occurs at 2 levels: L5-S1 and L4-L5 Possible factors that contribute to development:
Changes with maturation in:
Nutrition Disc chemistry Hormones

Occupational forces

Progression of disc narrowing leads to degenerative changes of bony structures, especially posterior components, leading to spondylosis
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 Treatment:
Medications Physical therapy Lifestyle changes:
Smoking cessation Weight loss Vocational changes

Injections:
Less helpful if pain is limited to central low back only

Surgery:
Laminectomy Fusion
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D. Spinal Stenosis:
Clinical:
Results from narrowing of spinal canal and / or neural foramina (CONGENITAL OR DEGENERATIVE) Most common complaint is leg pain limiting walking Neurogenic / Pseudoclaudication = pain in lower extremities with gait Relief can occur with:
stopping activity sitting, stooping or bending forward

Common are complaints of weakness and numbness of extremities Usually becomes symptomatic in 6th decade

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 Diagnosis:
CT and MRI may yield false-positive results, therefore EMG / NCV can be helpful to confirm diagnosis Myelography also can be confirmatory and pre-surgical screening tool

Treatment:
Medications Physical therapy TENS Epidural injections Surgical decompression laminectomy
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E. HNP:
Clinical:
Low back pain wit associated leg symptoms Positions can induce radicular symptoms Posterolateral disc pathology most common:
Area where anular fibers least protected by PLL Greatest shear forces occur with forward or lateral bend

Central disc pathology:

Usually with LBP only without radicular symptoms, unless a large defect is present

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 Treatment:
Conservative treatment: Saul and Saul study 1989 Spine:
> 90 % success rate of symptom resolution with non-operative management

Bozzao study 1992 Radiology:

69 patients with HNP studied longitudinally with MRI 63 % with >30 % reduction with 48 % > 70 % reduction over time

Medications Physical therapy Injections Surgery

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F. Pars Interarticularis Defects:

Spondylolysis:
Anatomic defect in the bony pars interarticularis within the lamina May uni- or bilateral Can be congenital or induced Usually without clinical symptoms with incidental findings on radiographs

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 Spondylolisthesis
Progression of spondylolysis with separation
Grades assigned I-IV for level of translation Most common levels are L5-S1 (70 %) and L4-L5 (25 %)

May be asymptomatic, but can result in

Spondylosis DDD Radiculopathy

Treatment:
Medication Physical Therapy Injections Surgery
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V. Chronic Pain Issues

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A. Pain Reinforcing Factors:

Secondary gain: Support system allows passive / inactive role for
patient via catering to needs and hence fostering dependency

Environmental: Inadequate opportunity or skills to compete in the

professional community

Physician knowledge deficit: In areas of diagnosis and appropriate

treatment, can prolong symptoms and validate pain behavior

Workers compensation: Laws have become counterproductive-financial compensation or open claim may discourage desire for return work and impede recovery

Litigation: Anticipation of large financial settlement can reinforce pain

behavior and develop into learned pain behavior
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B. Risk Factors for Delayed Recovery:

Occupational

Psychosocial

Medical

Job availability

Anger with system

History of narcotic or substance abuse Poor fitness History of prior injury

Patient perception of work load Job dissatisfaction Time off of work

Disabled spouse Poor English proficiency

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C. Discouraging Chronic Pain:

Requiring employer to accommodate restrictions to allow continued working during treatment and recovery
Rapid abjudication of disability and compensation claims Physician education re: appropriate treatments and limiting use of potentially addictive medications Ergonomic work environments Patient education re: disease process and treatment options

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D. Considerations of PM & R Treatment:

Physical therapy is initially usually one of modalities with progression into more active exercise
Pre-conditioning therapy is more functional with transition into Work Conditioning (Work Hardening) program

Always consider return to work, whether modified duty with restrictions or limiting hours worked
If patients poorly tolerate standard therapy, consider pool therapy intervention which allows elimination of gravity effects

Functional Capacity Evaluations utilized if patients are not progressing through therapy or if have reached a plateau and abilities as well as restrictions need to be assessed
Job site evaluations appropriate if concerns re: ergonomics
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E. Final Thoughts:
It is the patient, not the diagnostic test, that is treated 80 % of patients will recover from acute low back pain within 3 days to 3 weeks, with or without treatment, with up to 90 % resolved in 6-12 weeks
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