Acute Low Back PainAcute Low Back Pain

Richard W. Kendall, DO.Richard W. Kendall, DO.

Assistant ProfessorAssistant Professor

Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation

OutlineOutline

Introduction / Epidemiology.Introduction / Epidemiology. Most Important lecture!!Most Important lecture!!

Anatomy / Pain generatorsAnatomy / Pain generators

DiagnosisDiagnosis

TreatmentTreatment

Course ObjectivesCourse Objectives

Know the RED FLAGS in history taking.Know the RED FLAGS in history taking.

Know the Pain Generators of the Lumbar Know the Pain Generators of the Lumbar spinespine

Know the Guidelines for Imaging of the spine Know the Guidelines for Imaging of the spine with acute low back pain. with acute low back pain.

Know the general guidelines to rehabilitation.Know the general guidelines to rehabilitation.

Epidemiology of Back PainEpidemiology of Back Pain

Who gets it?Who gets it? 60-90% lifetime prevalence.60-90% lifetime prevalence. 80-90% have recurrent episode.80-90% have recurrent episode.

What is the Natural history?What is the Natural history? 80-90% resolves in 1 month.80-90% resolves in 1 month. 20-30% remains “chronic”20-30% remains “chronic” 5-10% “disabling” 5-10% “disabling”

AnatomyAnatomy

5 lumbar vertebra5 lumbar vertebra Transitional segmentsTransitional segments

ComponentsComponents BodyBody PediclesPedicles FacetsFacets LaminaLamina Spinous and transverse processesSpinous and transverse processes

Typical VertebraTypical Vertebra

Vertebral BodyVertebral Body

End- plate attachmentEnd- plate attachment

Tall (L1).. Wide (L5)Tall (L1).. Wide (L5)

L3 SquareL3 Square

Posterior ElementsPosterior Elements

Spinous ProcessSpinous Process

LaminaLamina

PediclePedicle

Transverse processTransverse process

Lumbar Intervertebral DiscLumbar Intervertebral Disc

Annulus FibrosisAnnulus Fibrosis Dense connective tissue, interwoven matrixDense connective tissue, interwoven matrix Outer 1/3 innervated from sinuvertebral nerve and Outer 1/3 innervated from sinuvertebral nerve and

gray rami communicans.gray rami communicans. Concentric layers attaching to end platesConcentric layers attaching to end plates

Nucleus pulposusNucleus pulposus 80-90% water, mucuopolysaccharide, collagen.80-90% water, mucuopolysaccharide, collagen.

Zygopophyseal JointsZygopophyseal Joints

Joint CapsuleJoint Capsule

MeniscoidMeniscoid

10% wt bearing10% wt bearing

Sagital plane L1Sagital plane L1

45° orientation L5.45° orientation L5.

Lumbar ligamentsLumbar ligaments

ALLALL PLLPLL Ligamentum flavumLigamentum flavum Facet capsulesFacet capsules Interspinous ligamentsInterspinous ligaments Supraspinous ligamentsSupraspinous ligaments

Muscle LayersMuscle Layers

DeepDeep Multifidus, Quadratus lumborumMultifidus, Quadratus lumborum Iliocostalis, longissimus, (Erector s.)Iliocostalis, longissimus, (Erector s.)

SuperficialSuperficial Thoracolumbar fasciaThoracolumbar fascia Lattisimus dorsiLattisimus dorsi

Nerves and VesselsNerves and Vessels

Neural ForamenNeural Foramen

Spinal NerveSpinal Nerve

Dorsal Root ganglionDorsal Root ganglion

RelationshipsRelationships

Pain GeneratorsPain Generators

Annulus Fibrosis (outer 1/3 only?)Annulus Fibrosis (outer 1/3 only?) PeriosteumPeriosteum Neural Membranes (Anterior Dura)Neural Membranes (Anterior Dura) Ligaments/ Z-joint capsulesLigaments/ Z-joint capsules Muscles.Muscles.

DiagnosticDiagnostic

Pain- location (radiation), qualitative, what Pain- location (radiation), qualitative, what makes pain better / worse.makes pain better / worse.

Neurologic SymptomsNeurologic Symptoms Paresthesias.Paresthesias. Bladder /Bowel retention or incontinence. Bladder /Bowel retention or incontinence. Weakness. Weakness.

Diagnostic Diagnostic

History:History: RED FLAGSRED FLAGS

Trauma, Trauma, Age >50, Age >50, Hx of CA, Hx of CA, Unexplained wt loss, Unexplained wt loss, fever or immunnosupression, fever or immunnosupression, IV Drug use, IV Drug use, Neurologic deficit.Neurologic deficit.

ExaminationExamination

Range of Motion (document range and pain)Range of Motion (document range and pain) Flexion- 40Flexion- 40° ° Extension- 15° Extension- 15° Lateral bending- 30° Lateral bending- 30° Rotation- 45° Rotation- 45°

Neurologic Examination INeurologic Examination I

Strength testsStrength tests L1, L2- Hip flexion (Psoas, rectus femoris)L1, L2- Hip flexion (Psoas, rectus femoris) L2,3,4 – Knee extension (Quads) L2,3,4 – Knee extension (Quads) L2,3,4 -- Hip adductors (adductors and gracilis)L2,3,4 -- Hip adductors (adductors and gracilis) L5 – ankle/ toe dorsiflexion (ant. Tibialis, EHL)L5 – ankle/ toe dorsiflexion (ant. Tibialis, EHL) L5– Hip abductors (gluteus medius, TFL)L5– Hip abductors (gluteus medius, TFL) S1- ankle plantarflexion (gastroc/ soleus)S1- ankle plantarflexion (gastroc/ soleus) S1– Hip extensors (Gluteus max., Hamstrings)S1– Hip extensors (Gluteus max., Hamstrings)

Neurological examination IINeurological examination II

ReflexesReflexes L2,3,4- QuadsL2,3,4- Quads L5- Medial hamstringL5- Medial hamstring S1- AchillesS1- Achilles

SensationSensation Pin prick- primarily spinothalamic tractPin prick- primarily spinothalamic tract Vibration/ position sense- dorsal columnsVibration/ position sense- dorsal columns

Vibration tested with 256cps fork!Vibration tested with 256cps fork! Position on 3-4Position on 3-4thth digit digit

Provocative ManeuversProvocative Maneuvers

Straight Leg Raise (supine or seated)Straight Leg Raise (supine or seated) For L5-S2 radicular symptomsFor L5-S2 radicular symptoms

Femoral StretchFemoral Stretch For L2-4 radicular symptomsFor L2-4 radicular symptoms

FABER’s testFABER’s test For SI joint, hip joint, lumbar z-joint symptomsFor SI joint, hip joint, lumbar z-joint symptoms

Provocative ManuversProvocative Manuvers

Seated SLR (Slump Test) Standing Femoral StretchSeated SLR (Slump Test) Standing Femoral Stretch

Imaging or Not?Imaging or Not?

Low yield without RED FLAGS present.Low yield without RED FLAGS present.

““Abnormal” findings in Asymptomatic. Abnormal” findings in Asymptomatic. Jarvik- LAIDback study. Jarvik- LAIDback study.

Psychological. Psychological. Anxiety, fear-avoidance- possibly help?Anxiety, fear-avoidance- possibly help? Depression- “there must be something wrong”Depression- “there must be something wrong”

Guidelines for ImagingGuidelines for Imaging

NO RED FLAGS!NO RED FLAGS! Acute pain- symptomatic treatment for 4 Acute pain- symptomatic treatment for 4

weeks, re-evaluate. Image if pain continues.weeks, re-evaluate. Image if pain continues. AHCPR Guidelines for Acute LBP.AHCPR Guidelines for Acute LBP.

Sub acute pain- Pain for >4wks. Failed Sub acute pain- Pain for >4wks. Failed symptomatic treatment. Image. symptomatic treatment. Image.

Chronic pain- none, unless changes in sx’sChronic pain- none, unless changes in sx’s Chronic intermittent- TX as acute patientsChronic intermittent- TX as acute patients

TreatmentsTreatments

MedicationsMedications

NSAID’s- anti-inflammatory, mild pain relief.NSAID’s- anti-inflammatory, mild pain relief. Tylenol- mild- moderate pain relief. Tylenol- mild- moderate pain relief. Narcotics- moderate to severe pain. (fail Narcotics- moderate to severe pain. (fail

above). above). Anticonvulsants- neurogenic pain. Anticonvulsants- neurogenic pain. TCA’s- neurogenic symptoms, paresthesias.TCA’s- neurogenic symptoms, paresthesias. Muscle relaxants- acute spasm. Muscle relaxants- acute spasm.

General Therapy GuidelinesGeneral Therapy Guidelines

Pain Control (symptomatic TX.).Pain Control (symptomatic TX.). Tissue injury (physiologic TX.) Tissue injury (physiologic TX.) Motion in Pain-free range.Motion in Pain-free range. Restore Full pain free range of motion.Restore Full pain free range of motion. Core CONTROL for Neutral spine. Core CONTROL for Neutral spine. Restore Muscle Restore Muscle ENDURANCEENDURANCE. . Restore Functional movements. Restore Functional movements.

TherapiesTherapies

Bed Rest.Bed Rest. Less than 2 days.Less than 2 days.

ROM.ROM. Lower extremity, multifidus, lats.Lower extremity, multifidus, lats.

Core strengthening.Core strengthening. Transversus Ab., quadratus, multifidus, glutes.Transversus Ab., quadratus, multifidus, glutes.

Multiplanar exercises.Multiplanar exercises.

ModalitiesModalities

Thermal (hot/cold)Thermal (hot/cold) UltrasoundUltrasound Electrical Stimulation (NMES)Electrical Stimulation (NMES) TENS (transcutaneous electrical neurostim.)TENS (transcutaneous electrical neurostim.) BracingBracing

InjectionsInjections

Epidural proceduresEpidural procedures Helpful in radicular pain and stenosisHelpful in radicular pain and stenosis

Z-joint BlocksZ-joint Blocks Short-term relief for furthering therapy.Short-term relief for furthering therapy.

Medial branch blocksMedial branch blocks radiofrequency lesions.radiofrequency lesions.

Who needs Surgery?Who needs Surgery?

Unstable SpineUnstable SpineAcute fractures with Neurologic deficit. Acute fractures with Neurologic deficit.

Severe Stenosis Severe Stenosis After failure of aggressive non-operative tx.After failure of aggressive non-operative tx.

Tumor?Tumor?

Progressive Neurologic deficitProgressive Neurologic deficit