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Lumbar Spine Conditions Evidence-Based Approach to Diagnosis and Triage
Anthony J. Lisi, DC
Chiropractic Program Director, Department of Veterans AffairsAssociate Research Scientist, Yale Center for Medical Informatics
Acute LBP
Serious Pathology
• Cancer• Infection• Acute CES
Fracture
• Trauma• Bone
weakening
Inflammatory
• Anklyosingspondylitis
Radiculopathy
• Herniated disc
• Spinal stenosis
Non-specific
• Mechanical
<1% ~1% ~1.4% ~10% >85%
Prevalence
Diagnostic Certainty
EB management approach
Serious Pathology
• Cancer• Infection• Acute CES
Fracture
• Trauma• Bone
weakening
Inflammatory
• Anklyosingspondylitis
Radiculopathy
• Herniated disc
• Spinal stenosis
Non-specific
• Mechanical
<1% ~1% ~1.4% ~10% >85%
Prevalence
Rule out serious/clearly treatable pathology
• Appropriate referral as indicated
Identify radiculopathy or non-specific LBP
• Reassure patients• Consider management options
EB diagnostic approach• Strategies
• Not over-testing those with benign pathology• Not missing those with serious/treatable disease
Chou R et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91.
Diagnostic approach
Risk factors for cancer ActionWeak Age >50
orHistory of cancer
Conservative tx trial and monitor
Significant History of cancerand any 1 of
Unexplained weight lossAge >50No improvement after 1 mo
Xray and ESR
High Positive xray/ESRand/or
High clinical suspicion
MRI w/contrast*
*Need recent creatinine to calculate eGFR
Diagnostic approach
Risk factors for infection ActionFeverIVDURecent infection/procedure
MRI w/contrastESR
Diagnostic approach
Risk factors for cauda equina syndrome ActionUrinary retentionBowel/bladder incontinenceSaddle anesthesiaMultilevel motor deficits
MRI
Diagnostic approach
Risk factors for vertebral fracture ActionAny age Significant trauma X-ray
Older adults Known osteoporosisCorticosteroid use
X-ray
Diagnostic approach
Risk factors for AS ActionYounger patients
Morning stiffnessBetter with exerciseAlternating buttock painPain awakens during later stage of sleep
X-ray
ESR / CRPHLA-B27
Diagnostic approach
Risk factors for lumbar radiculopathy ActionHerniated disc LBP with Radicular leg pain
(L4, L5, S1)+ SLR and/or +WLR
Conservativetreatment trial
If candidate for ESI or surgery MRI(EMG/NCV?)
Spinal stenosis Radiating leg painOlder agePseudo-claudication
Conservativetreatment trial
If candidate for ESI or surgery MRI(EMG/NCV?)
Non-specific LBP (~85%)• Likely reflects a spectrum
• Physical pain generators• Accurate diagnosis not often possible• Frustration for patients and providers
• Varying degrees of psychosocial factors
0%
20%
40%
60%
80%
100%
Patient 1 Patient 2 Patient 3
Bio
Bio Bio
Psycho
Psycho
Psycho
Social Social
Social
Patient Suffering
Biopsychosocial model
Non-specific LBP• After other causes ruled out:
• Reassurance• Avoid over-medicalization
• Consider EB treatment options
Recommendations
Acute/subacute (0–12 weeks)
Chronic(>12 weeks)
• Superficial heat• Spinal manipulation, massage,
acupuncture
• Exercise, yoga, tai chi• Spinal manipulation, massage,
acupuncture, low-level laser• Cognitive behavioral therapy,
operant therapy• Mindfulness-based stress
reduction, progressive relaxation
• If above inadequate, consider ibuprofen or skeletal muscle relaxant
• If above inadequate, consider 1) ibuprofen, then 2) tramadol or duloxetine
Qaseem et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14.
CHIROPRACTIC ADJUSTMENT
Chiropractic adjustment
Cavitation based
• HVLA thrust techniques
Non-cavitation based
• Mobilization techniques• Impulse instrument
techniques• Positional techniques
Spinal Manipulation
Spinal manipulation effects in-vivo• Lumbar intradiscal pressure
• Lisi AJ et al. Measurement of in vivo lumbar intervertebral disc pressure during spinal manipulation: a feasibility study. J Appl Biomech. 2006 Aug;22(3):234-9.
• Lumbar apparent diffusion coefficient• Wong et al. Differential patient responses to spinal manipulative therapy and their relation to spinal degeneration
and post-treatment changes in disc diffusion. Eur Spine J. 2019 Feb;28(2):259-269.
Mechanism
• Facet gapping• ↑ ROM• ↓ stiffness
• Mechanoreceptor response• Analgesia• Muscle tone
• Disc effects• Physiological pressures• Increased ADC
PSYCHOSOCIAL
Variable presentations
0%
20%
40%
60%
80%
100%
Patient 1 Patient 2 Patient 3
Bio
Bio Bio
Psycho
Psycho
Psycho
Social Social
Social
Patient Suffering
Chief complaint, clinical, imaging and lab findings identical
Considerations for MSK Providers
Patient
Do psychosocial factors play a
prominent role?
Can I address adequately in my
clinic?
When (and how) to refer to specialists?
Does the patient suffer from mental
illness?When (and how) to refer to specialists?
Approaches to psychosocial factors• In-office
• Goal-setting• Motivational Interviewing
• Specialist referral• Cognitive Behavioral Therapy for Chronic Pain
SMART Goal Format
•Specific•Measurable•Action Oriented•Realistic•Time-bound
Goals
Generic
• “I want to be more physically active”• “I should help more around the
house”• “I want to get my stress under
control”
SMART
• “I will go for a walk at least twice a week”
• “I will cook dinner every other day”• “I will practice the meditation tape
every night”
Resource LNI.WA.GOV
SUPPLEMENTARY MATERIALVA Chiropractic Program
DC Student Rotations• Available under a formal Academic Affiliation• Clinic Director / Off-Campus Training Coordinator
DC Residencies• www.rehab.va.gov/chiro• Application period opens second Monday in January• 3.5% acceptance rate• Common traits
• High GPA• Hospital rotations as a DC student• Recent graduation• Strong reference letters
DC Positions• www.usajobs.gov• Applications only accepted for open positions• 1% acceptance rate• Common traits
• High clinical acumen• Hospital practice and/or residency training• Track record of high quality interprofessional activities/CE• Scholarly activities
Community Provider Resources
• Update with latest Community Care Network, MISSION Act, etc. fact sheets,
• Post any Community Care programs and policy changes,
• Provide links to external websites of interest/use for providers
• https://www.va.gov/COMMUNITYCARE/providers/index.asp
VA Community Provider Website
• A monthly e-publication for community providers that delivers scheduled updates about programs, policies and changes.
• Subscribe at: https://public.govdelivery.com/accounts/USVHA/subscriber/new?topic_id=USVHA_1240
VHA Provider Updates Newsletter
• Office of Community Care Overview Series: An overview of Community Care Programs.
• Accredited Topics Series: Accredited webinars with VA experts presenting on health care-related topics.
• Register at: https://www.train.org/vha/welcome
VA Community Provider Webinar Series
