Low Back PainLow Back Pain

Prof. Dr. Hidayet SarıProf. Dr. Hidayet SarıCerrahpaşa Medical SchoolCerrahpaşa Medical SchoolPhysical Medicine and Rehabilitation Physical Medicine and Rehabilitation

DepartmentDepartment

Lumbosacral PainLumbosacral Pain

60-90% life time 60-90% life time incidenceincidence

5% annual incidence5% annual incidence Peak in 40’sPeak in 40’s 12-26% in children and 12-26% in children and

adolescentsadolescents cost in US upwards of cost in US upwards of

100 billion per year100 billion per year

Lumbosacral PainLumbosacral Pain

15-25% of workman’s 15-25% of workman’s comp= LBPcomp= LBP

30-40% of workman’s 30-40% of workman’s comp paymentscomp payments

Return to work ratesReturn to work rates 50% if disabled for 6 50% if disabled for 6

monthsmonths 25% if disabled 1 year25% if disabled 1 year 0% if disabled > 2 years0% if disabled > 2 years

Lumbosacral PainLumbosacral Pain 90% resolve in 6-12 90% resolve in 6-12

weeksweeks Croft et al (1998) Croft et al (1998)

found that 90% did found that 90% did not seek care after not seek care after three monthsthree months

40-80% in 1 week40-80% in 1 week 75% sciatica clear in 75% sciatica clear in

1-6 months1-6 months 70-90% recur70-90% recur

Diagnosis: Low Back Pain ?Diagnosis: Low Back Pain ?

A physiologic cause of back pain can A physiologic cause of back pain can not be definitively determined in 85% of not be definitively determined in 85% of patientspatients

AnatomyAnatomy VertebraVertebra

Body, anteriorlyBody, anteriorlyFunctions to Functions to Support weightSupport weight

Vertebral archVertebral arch,, posteriorlyposteriorly

Formed by twoFormed by two pediclespedicles and two and two laminaelaminaeFunctions toFunctions to protect neuralprotect neural structuresstructures

Vertebral ArchVertebral Arch

PediclesPedicles (Latin for Little Feet) (Latin for Little Feet)Attached anteriorly to bodyAttached anteriorly to bodyContinuous posteriorly with laminaeContinuous posteriorly with laminaeIntervertebral foramenIntervertebral foramen

Superior vertebral notchSuperior vertebral notchInferior vertebral notchInferior vertebral notch

LaminaeLaminae (Latin for Thin Plates) (Latin for Thin Plates)Meet posteriorly to form spinous processMeet posteriorly to form spinous process

Facet JointFacet Joint Formed by articulation of inferior and Formed by articulation of inferior and

superior processes of subsequent superior processes of subsequent vertebraevertebrae

Orientation in lumbar spine is toward Orientation in lumbar spine is toward sagittal plane, sagittal plane, allowingallowing flexion and flexion and extension but extension but limitinglimiting rotation of the rotation of the lumbar vertebraelumbar vertebrae

Helps to Helps to preventprevent anterior movement of anterior movement of superior vertebra on inferior vertebrasuperior vertebra on inferior vertebra

Articular surfaces are made up of non-Articular surfaces are made up of non-innervated articular cartilageinnervated articular cartilage

Capsule and synovial membrane are Capsule and synovial membrane are innervated with pain receptorsinnervated with pain receptors

LigamentsLigaments

Anterior longitudinal Anterior longitudinal ligamentligament

Posterior longitudinal Posterior longitudinal ligamentligament

Interspinous ligamentInterspinous ligament Supraspinous ligamentSupraspinous ligament Ligamentum flavumLigamentum flavum

Intervertebral DiscIntervertebral Disc

Most common site of back painMost common site of back pain Normally comprises ~ 25% of length of spineNormally comprises ~ 25% of length of spine Consists of a central nucleus pulposusConsists of a central nucleus pulposus

Reticulated and collagenous substanceReticulated and collagenous substance Composed of ~ 88% waterComposed of ~ 88% water

Annulus fibrosusAnnulus fibrosus Consists of concentric lamellae of fibrocartilage fibers Consists of concentric lamellae of fibrocartilage fibers

arranged obliquelyarranged obliquely With each layer, they are arranged in opposite directionsWith each layer, they are arranged in opposite directions

MusclesMuscles

Psoas Major/minorPsoas Major/minor Quadratus lumborumQuadratus lumborum IntertransversalisIntertransversalis InterspinalsInterspinals MultifidusMultifidus Longissimus thoracisLongissimus thoracis Iliocostalis lumborumIliocostalis lumborum Erector spinaeErector spinae

Differential DiagnosisDifferential Diagnosis

MSLBP/Mechanical/...MSLBP/Mechanical/... Osteoarthritis - Osteoarthritis -

Facet/disk/SIFacet/disk/SI Facet SyndromeFacet Syndrome DiskitisDiskitis

Fracture –Fracture – StressStress CompressionCompression OtherOther

Spinal StenosisSpinal Stenosis TumorTumor DiscogenicDiscogenic

Differential DiagnosisDifferential Diagnosis

Non-back painNon-back pain retroperitoneal process retroperitoneal process

(Pancreatic, Renal, (Pancreatic, Renal, Duodenal, Gyn, Prostate)Duodenal, Gyn, Prostate)

AAAAAA ZosterZoster Diabetic radiculopathyDiabetic radiculopathy

SI jointSI joint Rheumatologic disordersRheumatologic disorders

ReitersReiters Ankylosing SpondylitisAnkylosing Spondylitis

Differential DiagnosisDifferential DiagnosisYoung Middle Age Older

MSLBP Diskitis Pars Defect HNP Scheurmann’s Kyphosis

MSLBP Annular Tear HNP Tumor SI Dysfunc Spondylo- Arthropathy

OA/DJD Facet DDD HNP Spinal Stenosis Tumor Referred AAA Retroperitoneal Prostate

Common Causes of Common Causes of Low Back PainLow Back Pain

Muscular spasm, strainMuscular spasm, strainLigament sprainLigament sprainSpondylosisSpondylosisHerniated nucleus pulposusHerniated nucleus pulposusFacet joint dysfunctionFacet joint dysfunctionSpondylo-lysis or -listhesisSpondylo-lysis or -listhesisSeronegative spondyloarthropathiesSeronegative spondyloarthropathies

Clearing up the termsClearing up the terms

SpondylSpondylosisosisDegenerative joint disease affecting the vertebrae Degenerative joint disease affecting the vertebrae

and intervertebral discand intervertebral disc

SpondyloSpondylolysislysisFracture in pars interarticularisFracture in pars interarticularis

SpondyloSpondylolisthesislisthesisDisplacement of one vertebra on anotherDisplacement of one vertebra on another

Spondylo-lysis and -listhesisSpondylo-lysis and -listhesis

Spondilo-lysthesisSpondilo-lysthesis

Facet joint painFacet joint pain

Ankylosing spondylitisAnkylosing spondylitis

HistoryHistory

HistoryHistory

Three major concerns:Three major concerns: Is there evidence of systemic diseaseIs there evidence of systemic disease Is there evidence of neurological diseaseIs there evidence of neurological disease Is there social or psychological stress which is Is there social or psychological stress which is

contributing?contributing?Exclude serious underlying pathology, such as Exclude serious underlying pathology, such as

infection, malignancy or cauda equina syndromeinfection, malignancy or cauda equina syndrome

Red FlagsRed Flags GeneralGeneral

> 1 month> 1 month Rest +/-Rest +/-

CancerCancer> 50> 50History of CancerHistory of CancerWeight lossWeight lossUnrelenting night painUnrelenting night pain

InfectionInfection IVDUIVDU Steroid useSteroid use FeverFever UTIUTI

FractureFracture Age > 70Age > 70 Steroid useSteroid use Trauma hxTrauma hx Bladder dysfunctionBladder dysfunction OsteoporosisOsteoporosis

Cauda Equina SyndromeCauda Equina SyndromeSaddle anesthesiaSaddle anesthesiaBowel/bladder Bowel/bladder

dysfunctiondysfunction Loss of sphincter toneLoss of sphincter tone Rapid progressionRapid progression Unilat or bilat major motor Unilat or bilat major motor

weaknessweakness

Yellow FlagsYellow Flags

Belief that back pain is Belief that back pain is harmful or severely disablingharmful or severely disabling

Fear-avoidance behavior and Fear-avoidance behavior and reduced activity levelreduced activity level

Social withdrawal and low Social withdrawal and low moodmood

Expectation that passive Expectation that passive treatments will helptreatments will help

Back Pain Risk FactorsBack Pain Risk Factors

CaucasianCaucasian Western statesWestern states SmokerSmoker Increasing age up to 55Increasing age up to 55 Prolonged driving of Prolonged driving of

vehiclevehicle Hard physical laborHard physical labor

vibration or repetitive lift > vibration or repetitive lift > 40 lbs40 lbs

Back Pain Risk FactorsBack Pain Risk Factors

Psychological stressPsychological stress Job dissatisfactionJob dissatisfaction Prior episode of back Prior episode of back

painpain OsteoporosisOsteoporosis

OnsetOnset Acute - Lift/twist, fall, MVAAcute - Lift/twist, fall, MVA Subacute - inactivity, Subacute - inactivity,

occupational (sitting, occupational (sitting, driving, flying)driving, flying)

?Pending litigation?Pending litigation Pain effect on:Pain effect on:

work/occupationwork/occupation sport/activity (during or sport/activity (during or

after)after) ADL’sADL’s

Pain CharacterPain Character

SharpSharp BurningBurning Dull acheDull ache

Pain with…Pain with…

Prone positionnProne positionn Facet, Lat HNP, systemicFacet, Lat HNP, systemic

SittingSitting Paramedian HNP, annular Paramedian HNP, annular

teartear

StandingStanding Lateral HNP, central Lateral HNP, central

stenosis, facet syndromestenosis, facet syndrome

WalkingWalking central stenosiscentral stenosis

RadiationRadiation

Up backUp back To sacrumTo sacrum To buttocksTo buttocks Down legDown leg

Other SymptomsOther Symptoms

Cough/valsalva Cough/valsalva exacerbationexacerbation

Distal neuro sx - Distal neuro sx - weakness/paresthesiaweakness/paresthesia

Perianal paresthesiaPerianal paresthesia Bowel/bladder sxBowel/bladder sx

Other HistoryOther History

Prior treatments and Prior treatments and responseresponse

Prior h/o back painPrior h/o back pain Exercise habitsExercise habits Occupation/recreational Occupation/recreational

activitiesactivities

ExaminationExamination

WalkWalk StandingStanding SittingSitting SupineSupine

WalkingWalking

GaitGait length of stridelength of stride arm swingarm swing trunk motiontrunk motion ?pelvic tilt?pelvic tilt

StandingStanding

PosturePosture

KyphosisKyphosis HyperlordosisHyperlordosis ScoliosisScoliosis

Range of MotionRange of Motion

FF ~90FF ~90o o (reversal of (reversal of lumbar lordosis with FF)lumbar lordosis with FF)

Ext ~15-20Ext ~15-20oo

Side bend ~ 30Side bend ~ 30oo

Trunk rotationTrunk rotation

PalpationPalpation

Spinous processesSpinous processes Dorsal lumbar fascia/soft Dorsal lumbar fascia/soft

tissuestissues

OtherOther

Single leg extensionSingle leg extension Stork TestStork Test

Gastroc strengthGastroc strength Toe raisesToe raises

SquatSquat Standing single-leg Standing single-leg

balance (nl 15-30 sec)balance (nl 15-30 sec)

SittingSitting

Distracted SLRDistracted SLR DTR - patellar & AchillesDTR - patellar & Achilles Strength - EHL, TA, Strength - EHL, TA,

Peroneals, quads, hip Peroneals, quads, hip flexorsflexors

SensationSensation

Supine Tests to Stretch the Supine Tests to Stretch the Spinal Cord or Sciatic NerveSpinal Cord or Sciatic Nerve

Straight Leg RaiseStraight Leg RaiseCross Leg SLRCross Leg SLRKernig TestKernig Test

SupineSupine

Hamstring flexibility Hamstring flexibility (Popliteal angle)(Popliteal angle)

Leg lengthsLeg lengths measured ASIS to Med measured ASIS to Med

MalMal estimatedestimated

Waddell, et al. Spine 5(2):117-125, 1980.

Non-organic Physical SignsNon-organic Physical Signs(“Waddell’s signs”)(“Waddell’s signs”)

Non-anatomic superficial tendernessNon-anatomic superficial tenderness Non-anatomic weakness or sensory lossNon-anatomic weakness or sensory loss Simulation tests with axial loading and Simulation tests with axial loading and en blocen bloc

rotation producing painrotation producing pain Distraction test or flip test in which pt has no pain Distraction test or flip test in which pt has no pain

with full extension of knee while seated, but the with full extension of knee while seated, but the supine SLR is markedly positivesupine SLR is markedly positive

Over-reaction verbally or exaggerated body Over-reaction verbally or exaggerated body languagelanguage

Neurologic TestingNeurologic Testing

Primary focus on the L5 and S1 never Primary focus on the L5 and S1 never roots, since 98 percent of clinically roots, since 98 percent of clinically important disc herniations occur at L4-important disc herniations occur at L4-L5 and L5-S1L5 and L5-S1

Sacral PlexusSacral Plexus

L4L4 Quads/Tibialis AnteriorQuads/Tibialis Anterior Patellar reflexPatellar reflex Sensory Great toe and Sensory Great toe and

medial legmedial leg

Sacral PlexusSacral Plexus

L5L5 Strength of Ankle and Strength of Ankle and

great toe dorsiflexiongreat toe dorsiflexion Extensor Hallucis LongusExtensor Hallucis Longus Sensory to dorsum of footSensory to dorsum of foot

Sacral PlexusSacral Plexus

S1S1 Ankle reflexes and Ankle reflexes and

sensation of posterior calf sensation of posterior calf and lateral footand lateral foot

Peroneals/GastrocPeroneals/Gastroc Achilles reflexAchilles reflex Sensory to lateral and Sensory to lateral and

plantar footplantar foot

OtherOther

Rectal toneRectal tone Anal winkAnal wink Cremasteric reflexCremasteric reflex

Diagnostic StudiesDiagnostic Studies RadiographsRadiographs

Early if ominous signsEarly if ominous signsFeverFevernight pain night pain age extremesage extremesh/o Cah/o Cawt losswt lossTrauma osteoporosisTrauma osteoporosis

Symptoms present > 1 Symptoms present > 1 monthmonth

Diagnostic StudiesDiagnostic Studies

MRIMRI More sensitive for More sensitive for

infection and cancerinfection and cancer > 12 weeks of pain> 12 weeks of pain Herniated discsHerniated discs Spinal StenoisSpinal Stenois order if hx/exam confusingorder if hx/exam confusing roadmap for surgeonroadmap for surgeon more costly, increased more costly, increased

time to scan, problem with time to scan, problem with claustrophobic patientsclaustrophobic patients

Diagnostic StudiesDiagnostic Studies

Bone Scan (SPECT)Bone Scan (SPECT) suspectsuspect for stress fx, for stress fx,

Ca, inflammationCa, inflammation

Diagnostic StudiesDiagnostic Studies

EMG/NCVEMG/NCV r/o peripheral neuropathyr/o peripheral neuropathy localize nerve injurylocalize nerve injury correlate with radiographic correlate with radiographic

changeschanges order after 4 weeks of order after 4 weeks of

symptomssymptoms

Lab StudiesLab Studies

CBC, ESR, UACBC, ESR, UA Avoid RF, ANA or Avoid RF, ANA or

others unless others unless indicatedindicated

TreatmentTreatment

Treatment RecommendationsTreatment Recommendations

Based on the Joint Clinical Practice Guidelines Based on the Joint Clinical Practice Guidelines from the American College of Physicians and from the American College of Physicians and the American Pain Societythe American Pain Society

Level of evidenced reviewed and gradedLevel of evidenced reviewed and gradedGuidelines published in Annals of Internal Guidelines published in Annals of Internal

Medicine in 2007Medicine in 2007

RecommendationsRecommendations

A Panel Strongly recommendsA Panel Strongly recommendsB Panel recommends consideration for eligible B Panel recommends consideration for eligible

patientspatientsC Panel makes no recommendationC Panel makes no recommendationD Panel recommends againstD Panel recommends against I Panel found insufficient evidenceI Panel found insufficient evidence

Acute MnagementAcute Mnagement MedicationsMedications

Pain controlPain control Acetaminophen/NSAID’sAcetaminophen/NSAID’s Minimize use of opioidsMinimize use of opioids 2007 joint guidelines from 2007 joint guidelines from

ACP and APS recommend ACP and APS recommend against steroidsagainst steroids

Muscle relaxersMuscle relaxers Short term use of benzo or Short term use of benzo or

non benzodiazepine muscle non benzodiazepine muscle relaxers in combination with relaxers in combination with NSAIDs/acetaminophenNSAIDs/acetaminophen

Acute ManagementAcute Management Back ExercisesBack Exercises

There is no evidence that There is no evidence that suggests that back suggests that back exercises are helpful exercises are helpful during acute pain and during acute pain and may actually be may actually be counterproductivecounterproductive

Upon recovery, back Upon recovery, back exercises may be useful exercises may be useful in preventing recurrencein preventing recurrence

Resume normal activity Resume normal activity as quickly as possibleas quickly as possible

Subacute ManagementSubacute Management

Continue patient Continue patient educationeducation

Mechanics - lifting Mechanics - lifting technique, sport, ...technique, sport, ...

AvoidAvoid prolonged prolonged

sitting/standingsitting/standing recurrent bendingrecurrent bending twistingtwisting

ConditioningConditioning

ACTIVITY & ACTIVITY & CONDITIONINGCONDITIONING walkingwalking

Stretching - HS, hip Stretching - HS, hip extensors, erector spinaeextensors, erector spinae

Strengthening - abs, Strengthening - abs, erector spinaeerector spinae

Chronic Low Back PainChronic Low Back Pain

> 3 months> 3 monthsTreatment goals:Treatment goals:

Control painControl painMaintain functionMaintain functionPrevent disabilityPrevent disability

Evidenced-Based Reasonable Evidenced-Based Reasonable Therapies for Chronic Low Back Therapies for Chronic Low Back

PainPain

AcetaminophenAcetaminophen NSAIDSNSAIDS TCAsTCAs +- Opioids+- Opioids +- Benzodiazepines+- Benzodiazepines

Physical therapyPhysical therapy Exercise therapyExercise therapy Interdisciplinary Interdisciplinary

rehabrehab Spinal ManipulationSpinal Manipulation YogaYoga MMaassagessage

ReferralReferral

FracturesFractures HNP (> 8 weeks)HNP (> 8 weeks) Ominous signs/sx - Ominous signs/sx -

fever, weakness, fever, weakness, bowel/bladder bowel/bladder dysfunctiondysfunction

Refractory sx > 12 weeksRefractory sx > 12 weeks

Referral to…Referral to…

PM&RPM&R Pain ClinicPain Clinic NeurosurgeryNeurosurgery OrthopedicsOrthopedics

Caveats of ManagementCaveats of Management

Adequate/complete Adequate/complete initial evaluationinitial evaluation

Follow-up evaluationsFollow-up evaluations 1-3 days for acute pain1-3 days for acute pain 4-6 weeks for chronic 4-6 weeks for chronic

painpain

Activity Activity ActivityActivity Activity Activity Survey for Red FlagsSurvey for Red Flags

Rehabilitation Exercises for Chronic Rehabilitation Exercises for Chronic Back PainBack Pain

All of the following are Red Flags All of the following are Red Flags EXEPT?EXEPT?

> 5

0 ye

ars

of a

ge

His

tory

of C

ance

r

Wei

ght lo

ss

Rad

icula

r sym

ptom

s

0% 0%0%0%

1.1. > 50 years of age> 50 years of age

2.2. History of CancerHistory of Cancer

3.3. Weight lossWeight loss

4.4. Radicular symptomsRadicular symptoms

10

Indications for an MRI Indications for an MRI include:include:

Initi

al tr

aum

a ev

aluat

ion

A h

isto

ry o

f ost

eoporo

sis

Rea

ssur

ance

>=

12 w

eeks

of p

ain

0% 0%0%0%

1.1. Initial trauma Initial trauma evaluationevaluation

2.2. A history of A history of osteoporosisosteoporosis

3.3. ReassuranceReassurance

4.4. >= 12 weeks of pain>= 12 weeks of pain

10

Effective treatment for acute Effective treatment for acute low back pain includes all low back pain includes all

except:except:

Ace

tam

inophen

NSAID

S

TCAs

Phys

ical

ther

apy

0% 0%

100%

0%

1.1. AcetaminophenAcetaminophen

2.2. NSAIDSNSAIDS

3.3. TCAsTCAs

4.4. Physical therapyPhysical therapy

Treatment goals of Chronic Low Treatment goals of Chronic Low Back Pain include:Back Pain include:

Cure

pro

blem

Alle

viat

e pa

in

Res

tore

funct

ion

Pre

vent d

isab

ility

0%

100%

0%0%

1.1. Cure problemCure problem

2.2. Alleviate painAlleviate pain

3.3. Restore functionRestore function

4.4. Prevent disabilityPrevent disability

What is the lifetime incidence What is the lifetime incidence of low back pain of low back pain

>30

%

>40

%

>50

%

>60

%

0% 0%0%0%

1.1. >30%>30%

2.2. >40%>40%

3.3. >50%>50%

4.4. >60%>60%

10

In what percentage of patients can the In what percentage of patients can the cause of low back pain not be cause of low back pain not be

determined?determined?

65%

75%

85%

95%

0% 0%0%0%

1.1. 65%65%

2.2. 75%75%

3.3. 85%85%

4.4. 95%95%

10

Conclusions Conclusions

Describe the clinically relevant anatomy of the lumbar spineDescribe the clinically relevant anatomy of the lumbar spineDiscuss the “red flags” of lower back pain their associated Discuss the “red flags” of lower back pain their associated

clinical significanceclinical significanceDiscuss the common causes of low back painDiscuss the common causes of low back pain

Review and practice physical examination of the lower back Review and practice physical examination of the lower back and common rehabilitation exercisesand common rehabilitation exercises