Back and Hip PainM. Andrew Greganti, MD

Back PainAccounts for 2.5% of medical visits – second most common

reason for office visits in USPrevalence varies widely – 1.2 to 43%Risk factors:

ObesitySmokingFemale genderPhysically strenuous or sedentary work – lifting over 25 lbsLow educational levelJob dissatisfactionSomatization disorder, anxiety, depressionWorkers’ Compensation InsuranceGenetic backgroundCultural differences

PrognosisGenerally good, especially if expectation is to

improve – most do get better with no intervention

Less than 5% have serious underlying pathology

A cause can be found only in a minority of patients

Chronicity seems to correlate with:Female genderIncreasing agePre-existing psychosocial factors

Clinical EvaluationKey concepts:

Most patients have mechanical low back pain – no infectious, inflammatory, or neoplastic cause.

Degenerative disc disease plays a substantial role but exactly how much of one is unclear. Many patients without pain have discs on MRI.

Muscular and ligamentous sources of pain are probably equally important.

Tender fibro-fatty nodules (back mice) may play some role but correlation with back pain remains in question.

HistoryConsider 3 major concerns:

Evidence for a systemic process – hx of cancer, age over 50, weight loss, nocturnal pain, unresponsiveness to Rx

Evidence for neurologic compromise – cauda equina syndrome, radiation of pain below the knee, pseudoclaudication as in spinal stenosis, focal weakness

Social or psychological distress contributing to chronic, disabling pain

Physical ExaminationCheck for spinal curvature – kyphosis,

scoliosis, etc.Check for spinal tendernessStraight leg raising and crossed straight

leg raisingEvaluate for deficits in L4, L5, and S1

distributions.Lymph node, breast, and prostate exams if

neoplasia is suspectCheck peripheral pulses

Diagnostic ImagingImaging is essential in these situations:

Progression of neurological findingsHistory of traumaHistory of neoplasiaAge <18 or >50Special situations:

Injection drug useImmunosuppressionIndwelling Foley catheter or recent GU

procedureConcomitant steroid use

Plain Films, MRI, CTIf symptoms persist for 4 to 6 wks with

no improvement, order two views of plain films without obliquesImplications of spondylosis, spondylolisthesis,

spondylolysisOrder MRI or CT to evaluate progressive

neurologic deficits, to evaluate for cancer, or to evaluate patients with refractory symptoms – greater than 12 wks of persistent pain

Treatment of Back PainBed rest is not indicated – may actually delay

recoveryNSAIDS and narcotics have similar efficacy –

use of NSAIDS should be limited to 2 to 4 wksAdverse effects more common in older patients

Acetaminophen is probably as good as NSAIDS.

Muscle relaxers are more effective than placebo for short-term relief

NSAIDS + muscle relaxants may be better - based on observational data.

Treatment of Back PainOpioids are effective in acute back pain but

obviously have multiple side effects and are addicting

Tramadol is a non-opioid and works on the opioid receptor – is worth a trial.

Oral glucocorticoids probably are not beneficial for acute pain.

Lidocaine patches, anticonvulsants, antidepressants are of limited effectiveness in acute pain.

Treatment of Back PainEpidural injection:

Efficacy remains unclear – conflicting results from controlled trials

Probably best in radiculopathy secondary to HNP – has short-term (at 6 wks) but no long-term benefit at 3 , 6, or 12 months

Not of proven benefit in spinal stenosis and nonspecific pain

No difference in translaminar, transforaminal, and caudal approaches

2 of 7 trials found epidural injection vs placebo associated with lower rates of subsequent surgery.

Adverse events: dural puncture, bleeding, infection

Treatment of Back PainLocal or trigger point injection rarely worksFacet joint steroid injection doesn’t help

at 1 and 3 months Medial branch of dorsal ramus nerve blocks are

of unknown efficacySacroiliac joint steroid injection was more

effective than anesthetic injection in one small trialProbably does work for spondyloarthropathies

Rx effectiveness of piriformis syndrome using injected steroids remains unclear

Treatment of Back PainChemonucleolysis for HNP should only be

used in patients who do not want surgery – not often done in US

Paravertebral botulinum toxin injection was superior to placebo at 3 and 8 weeks

Evidence for the efficacy of radiofrequency nerve ablation remains inconsistent – would only consider in the most refractory situations

Prolotherapy should not be used

Treatment of Back PainExercise is not good for acute pain in contrast to

more chronic pain.Encourage mobilization as soon as possible.Physical therapy is, in general, very helpful but

no difference in heat/cold, ultrasound, electrical stimulation

TENS effectiveness is very questionable at best.Spine manipulation by chiropractors may be

helpful.Accupuncture is probably equivalent to NSAIDS.Traction does not help lumbar pain.

Hip PainBasic issues:

The major dilemma is to differentiate among gluteus medius superficial and deep bursitis and osteoarthritis

The hip is “fixed” by the pelvic girdle, making it more difficult to differentiate pain originating in the lumbar spine and knee from hip pain.

The gluteus medius and gluteus minimus muscles abduct the hip and attach at the greater trochanter.

The gluteus maximus extends the hip and attaches just distal to the greater trochanter

The iliopsoas muscle, the major hip flexor, attaches at the lesser trochanter.

Clinical Presentation of Hip PainHip pain with weight bearing and

improvement with rest is most compatible with DJD.

Constant pain and pain while supine are more likely with infectious, inflammatory, and neoplastic processes.

Lateral hip pain is often from the joint or from the greater trochanteric bursa, especially if there is point tenderness. Hip joint pain is more often anteriorLateral paresthesias raise the possibility of

meralgia paresthetica.

Clinical Presentation of Hip PainAnterior hip or groin pain is most often

seen in DJD of the hip joint.Important to differentiate DJD from

osteonecrosisIf not worse with repetitive hip flexion, have to

consider inguinal hernia and intraabdominal process.

Anterior thigh pain just above the knee presents the most difficulty

Posterior hip pain is not usually from the hip. More commonly is secondary to lumbar disc, sacroiliac disease, facet joint disease.

Clinical Presentation of Hip PainTrochanteric bursitis is caused by exaggerrated

movement of the gluteus medius tendon and tensor fascia lata over the lateral femur.More likely to develop with leg length discrepancy,

knee arthritis, ankle sprain, LS spine stiffnessPoint tenderness over trochanteric bursa

Hip DJD presents with groin pain worse with movement, limited internal rotation (<15 º), limited flexion (<115 º)

Osteonecrosis presents in the groin, thigh, or buttockRest pain is common as is nocturnal pain

Hip ExaminationObserve patient’s gait - ? antalgic, short leg limp,

Trendelenburg gait Passive internal and external rotation - ? endpoint

stiffness – endpoint pain raises osteonecrosis, occult fracture, acute synovitis, metastatic disease

Fabere or Patrick testStraight leg raising to evaluate lumbar originCheck sensation lateral thigh - ? meralgia Evaluate L4, L5, and S1 nerve root distributionCheck for tenderness over the sacroiliac jointCheck leg pulses

Evaluation of Hip PainAP of pelvis and hip filmsMRI if occult hip or pelvic fracture is

suspected – also to evaluate early osteonecrosis

Local anesthetic blocks of sacroiliac joint, trochanteric area below gluteus medius tendon, lateral femoral cutaneous nerve

Treatment of Hip PainVery similar to Rx of back painAcetaminaphen, tramadol, NSAIDSPhysical therapyJoint replacement