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All Pain Comes to an End, Eventually

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All Pain Comes to an End, Eventually All Pain Comes To An End, Eventually Low Back Pain From Youth To Grave Michael Jaffe MD Physical Medicine and Rehabilitation 2017 CME-n-Ski 1 Low back pain age <5 Very uncommon Discitis (refuse to walk, avoid bending, back and abdominal pain, fever, usually staph aureus) Tumor (night pain, red flags) Osteomyelitis (Staph/TB) Labs CBC, ESR, CRP, blood Cx, peripheral smear, CMP Xray 2017 CME-n-Ski Adolescence LBP Spondylolyisis Discogenic Fracture Spondyloarthropathy Scoliosis Scheuermann’s kyphosis (thoracic) Posterior element overuse syndrome Pain amplification syndrome Slipped vertebral apophesis Hyperlaxity Infection Tumor 2017 CME-n-Ski 2017 CME-n-Ski Spondylolysis Common (4% age 6, 6% adults, 15% elite adolescent athletes) Overuse disorder Risk factor hyperlordosis PE: tight hamstrings, pain with lumbar extension, hyperlordosis Preferred work up… 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Spondylolysis +/- Spondylolisthesis- Diagnosis MRI with pars edema is best imaging. CT and bone scan are discouraged to limit radiation exposure. If a gap exists on CT or Xray the lysis can’t be healed. 2017 CME-n-Ski 2017 CME-n-Ski Treatment Spondylolysis Rehabilitate rest Posterior pelvic tilts Stabilization Stretching- quad and psoas Muscle imbalances Sports specific exercises Return to sport when asymptomatic Bracing Surgery 2017 CME-n-Ski If MRI normal but exam extension based Posterior overuse syndrome Treatment: relative rest Core stabilization- neutral to flexion biased Stretching- quads and psoas 2017 CME-n-Ski 2017 CME-n-Ski Spondylolytic Spondylolisthesis- Adult Average age of surgery 34.5 years Symptoms activity based Unilateral with or without L5 radicular pain/radiculopathy No need to rest Neutral or flexion biased stabilization, centralization and stretching quad and psoas >hamstring, neural glides Injections- L5 SNRBs, pars defect (no nerve free endings), MBB/RF Surgical- fusion 85% successful 2017 CME-n-Ski 2017 CME-n-Ski Adolescent disc problems Increasing prevalence with sedentary population Can be primary low back pain (degeneration, Schmorls nodes, annular fissure, internal disc disruption) Can cause radicular features if herniation 2017 CME-n-Ski Adolescent disc degeneration Treat similar to adults Activity modification (avoid lumbar flexion and sitting) Weight loss Stabilization Centralization (McKenzie/MDT) Manual/manipulation HEP Stretching Yoga 2017 CME-n-Ski Fracture Trauma Substance abuse Physical abuse Imaging: Xray, CT, MRI 2017 CME-n-Ski Inflammatory spondyloarthropathy Ankylosing spondyloarthropathy Morning stiffness SI tenderness and + FABER Test Associated joint pain and enthesopathies + Schober Test 2017 CME-n-Ski Inflammatory spondyloarthropathy Xray MRI Lab: CBC, ESR, CRP, HLA B27, ANA, RF 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Scoliosis 32% painful 10% underlying pathology (tethered cord, tumor) Idiopathic Congenital malformation Neuromuscular Adolescent idiopathic scoliosis 2017 CME-n-Ski 2017 CME-n-Ski Adolescent idiopathic scoliosis treatment <25 degrees- Observation. X-rays every 4 to 6 months 25-45 degrees- Bracing until finished growing >50 degrees or high risk of continued worsening- Surgery 2013 25% who wore a brace had curves 50º or more 58% who did not wear a brace progressed to 50º or more brace < 6 hours a day negligible help >13 hours a day better results Yoga, physical therapy, or chiropractic medicine have not been proven to prevent curve progression 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Scheuermann’s Kyphosis Typically thoracic pain Increase as day goes on Stiffness 5 degree, 3 adjacent vertebra, loss of disc height, Schmorls nodes, endplate irregularity 2017 CME-n-Ski Hypermobility Syndrome Ligamentous laxity Type 3 common 1:10,000 (mostly subluxation) Joint subluxations and dislocation Skin fragile and reduced elasticity Vascular disease 2017 CME-n-Ski 2017 CME-n-Ski Hypermobility Treatment Joint protection Strength Motor control Avoid overstretching 2017 CME-n-Ski Other Slipped vertebral apophosis (growth plate) Sickle cell Pain amplification syndromes 2017 CME-n-Ski Adult Low Back Pain? • Lifetime Prevalence: 84% • Cost: $90 billion annually in the U.S. (Treatment and lost productivity.) • Recurrence 50% at 6 months • Chronicity • Debility/disability • Savings opportunities • Reduction in treatment variation • Improved outcomes and utilization management • Prevention 2017 CME-n-Ski Why no routine imaging in acute LBP? • Xrays don’t usually change care (unless older, child/teenager, trauma or red flags) • MRIs and CT scans are reveal asymptomatic abnormalities, increase interventions • Higher cost and not improved outcomes 2017 CME-n-Ski Etiology- mechanical • Disc herniation/degeneration/internal disruption- younger, sitting, coughing, sneezing, bending, 50% prevalence if <50 years old • Facet- older, prevalence up to 50% if > 70 years old • Sacroiliac joint- buttock pain 5-15% • Spinal stenosis • Fracture or endplate injury • Degenerative spondylolisthesis >55, female • Spondylolysis and spondylolisthesis age 10-20 years old initially (LBP) then again at 30-55 (radicular pain) 2017 CME-n-Ski Etiology- Psychological • Fear avoidance (afraid work or exercise will cause harm or pain, and that pain = harm/injury) • Depression • Anxiety • Insomnia • Secondary gain • Poor coping skills 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Core Treatments- Mechanical Back Pain Manipulation- acute, non radiating, stiff back, limber hips, low fear avoidance Stabilization- core strength, 8-10 seconds hold in neutral spine, goal high muscular action but low spinal shear or spinal flexion, endurance Directional preference- McKenzie Avoid triggers- discs injured with flexion and sitting, maintain neutral spine, avoid morning flexion Prevention- low BMI, no smoking, aerobic fitness, endurance, coordination 2017 CME-n-Ski Discogenic LBP Most common cause of LBP especially in <55 year old 60% of all LBP Discs are part of the anterior column of the spine with vertebral body and support compression and flexion Mechanism of disc injury includes flexion Injury location can be at endplates, annulus or attachment of annulus (micro-fractures of trabecular bone) 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Risk factors- Disc Sedentary seated jobs and activities- compression and vibration Prolonged flexed postures Highest and lowest activity level are at highest risk of injury Flexion, creep and overload are the discs enemies 2017 CME-n-Ski Aggravating factors- Disc symptoms Sitting Driving Lifting Bending forward Mornings Sneezing 2017 CME-n-Ski Location of pain- Disc Midline Bilateral Unilateral- on side of tear or injury 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Other disc imaging finding Bulges, protrusions and endplate spurs not reliable findings as pain generators. Desiccation implies prior injury. Normal hydration but herniated implies acute injury Large high intensity zones suggest grade 4 or 5 annular tears and discs that don’t pressure properly (large disc herniations are uncommon in asymptomatic persons) 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Treatment- Disc (non specific LBP) Reassure patient improvement is anticipated but recurrence common so an active long term exercise program is indicated. Bed rest contraindicated. Avoid prolonged sitting/driving, and lumbar flexion. Avoid lifting in flexed spine position. McKenzie style extension exercises, stabilization, HEP, varied activity, core endurance, leg flexibility (not spine), aerobic training Manual treatments- mobilization and manipulation 2017 CME-n-Ski Future Experimental Treatment - Disc PRP Progenitor cells Enzymes Magic stuff de jour 2017 CME-n-Ski Older person (>55) with extension/activity based pain Degenerative spondylolisthesis (DS) Degenerative scoliosis Adult idiopathic scoliosis Facet arthropathy is not reliably extension based and MRI of facet OA is not diagnostic 2017 CME-n-Ski Facet Similar pain distribution Unilateral > bilateral More common aging population Imaging findings help diagnosis such as facet edema (T2 and STIR) “Gapped” facets (DS) Bone scan 2017 CME-n-Ski 2017 CME-n-Ski Facet Treatments PT program Medial branch blocks to diagnose Radiofrequency Ablation 2017 CME-n-Ski Sacroiliac Joint Pain 5-15% prevalence Buttock pain or below L5 Frequent below spinal fusion 2017 CME-n-Ski 2017 CME-n-Ski Radicular Pain and Radiculopathy 1. Disc herniation- acute, unilateral, inflammatory, + SLR, most recall no injury or bending type movement, hurts to sit 2. Spinal stenosis- chronic, bilateral (neurogenic claudication) if central stenosis or unilateral if foraminal or lateral recess, older, negative SLR, hurts to stand and walk 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Radicular Pain- Disc Herniation + SLR. Reabsorption of disc herniation is common but not guaranteed. SNRBs best for acute pain control. PT if not miserable or great responder. Microdiscectomy about 80-90% likely to be helpful (leg > back). Re-herniations are 20% but half the time are asymptomatic. After surgeries 20% of patients end up with repeat imaging suggesting 80% success. McKenzie, sciatic nerve glides and avoiding sitting may be helpful. 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Spinal Stenosis Chronic, bilateral (neurogenic claudication) if central stenosis Unilateral if foraminal or lateral recess stenosis Limits standing and walking Aging population Negative SLR 2017 CME-n-Ski Treatment- Spinal Stenosis Surgical- decompression Surgical - decompression with fusion Epidural
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