3/17/2017 Disclosures Modern Management of • Founder, RunSafe™ Back Pain • Founder, SportZPeak Inc. • Sanofi, Investigator initiated grant A n t h o n y L u k e MD, MPH, CAQ (Sport Med) University of California, San Francisco Primary Care Medicine: Update 2017 Outline Management Approach • Assessment • Sort patients into: • Imaging – Simple low back pain (mechanical low back pain) • Treatment – Flexion vs Extension back pain – Conservative – Nerve root pain – Surgical – Red flag signs for serious spinal pathology – Cauda equina syndrome • Identify which patients may benefit from specialist treatment 1 3/17/2017 Examination Approach Posture Standing • Posteriorly Sitting • Shoulders Supine • Inferior scapula –T8 • Iliac crests L4 Prone • Dimples of venus –S1 T8 L4 Examination Posture Observation • Lines: ear lobe‐ Skin acromion‐iliac crest • Café au Lait • Lordosis, kyphosis • Spina Bifida • Pelvic inclination ‐ ASIS lower than PSIS Gait Shift Repeated heel raises 2 3/17/2017 Examination Examination ROM ROM • Pain flexion vs extension Single leg extension Can check for: (Stork test) • Flat back • Scoliosis ‐ hump Trendelenberg Test • Rotation – stabilize the pelvis • Lateral flexion Examination Examination Sitting ‐ Provocation Sitting Indirect Straight Leg Raise • Reproduces SLR in the sitting Neurologic Exam position • May have “Sciatica” with sitting • Motor too long (i.e. driving) Slump Test • Sensory • Fully flex patient’s neck chin to chest Examiner holds foot in • DTR’s dorsiflexion and passively extends leg • Babinski/clonus • Highly reliable (k=0.83‐0.89) 3 3/17/2017 Examination Examination Supine ‐ Provocation Supine ‐ Hip Lasegue’s Straight Leg Raise Test • Hip Internal and • Tests primarily L5, S1‐2 sciatic nerve roots External ROM • Passive hip flexion with leg • Labral Impingement in extension from 30‐70 and Stress tests degrees • Sensitivity 0.85‐0.91, Spec • Thomas test –for hip 0.32‐0.52 flexor tightness “ ” Examination FABER Test Supine • For stressing anterior labrum • Popliteal Angle • Positive in 15/17 • Check for Limb length discrepancy • Also SI joint – Measure ASIS to medial malleolus • Perform Appropriate Abdominal Exam 4 3/17/2017 Examination Prone • Palpate lumbar spine / pelvis Case 1 Who? 35 year old female runner • Paravertebral muscles / Piriformis / gluteal areas What? Extension low back pain • Sacral thrust/ Sacral Apex Pressure/ Spring test When? Acute flare x 2 weeks since running, LBP on and off x 2 yrs, worse after pregnancy • +/‐ Rectal exam How? Pain with activity, some numbness and tingling L leg Where? Left sacroiliac joint pain with radiating pain into left hip Case 1 What to do? • LOOK 5’ 6”, 150 pounds • Mechanical Low Back Pain – Swayback Posture (mild thoracic kyphosis, hyperlordosis lumbar spine) • Differential Dx –SI joint dysfunction, early OA, DDD, • FEEL ligament, Muscle strain – Mild tenderness at L SI joint • Flexion vs Extension LBP? • MOVE – ROM extension 30° mildly tender; Flexion 70° • SPECIAL TESTS • Physical therapy or home exercise program – Direct and indirect SLR negative • Symptomatic treatment – March/Gillet test slight asymmetry • Education → address biomechanics – L/E 5/5, Reflexes normal 5 3/17/2017 Mechanical LBP Posterior elements / Facet Joints • 80% resolve within 2 • Superior / inferior weeks facet joints • Allow flex/ext and side • 90% resolve with in 6 • Pars interarticularis bending with minimal weeks rotational motion due to direction of facets • Usually NWB but can WB • Consider POSTURE with extension • Improve core stability, • Facet joint asymmetry conditioning may lead to disk • Decrease stress degeneration Does the Sacroiliac joint move ? • Is a Diarthrodial Joint • Synovial fluid • Cartilage on both surfaces • A joint capsule • Ligamentous connections • Articular connections allowing movement 6 3/17/2017 Femoral Acetabular Impingement Hip Pain can be Confusing (F.A.I.) Confounding Factors: • Cam effect • Protrusion of femoral • 27‐90% of patients head neck – “bump” with groin pain have • Orientation of the more than one acetabulum – coexisting injury acetabular version • Increased stress on Morelli and Weaver, 2005 labrum Examination Posterior Hip Pain Supine ‐ Hip Piriformis syndrome • Hip Internal and 10% of population External ROM have sciatic nerve passing through • Labral Impingement the piriformis and Stress tests Beaton et al. Anat Rec, 70, 1937. Muscle strain vs • Thomas test –for hip sciatica flexor tightness 7 3/17/2017 “FABER” Test Core Stability • For stressing anterior • Center of gravity lies anterior to spine • Erector spinae muscles, abdominal labrum musculature, the lumbodorsal fascia • Positive in 15/17 and gluteus maximus resist the body weight • Also SI joint • Deep Muscle stabilizers (type 1 fibers) maintain core stability • Multifidus, TA, pelvic floor and diaphragm ‐ affects posture • If impairment, may get reflex inhibition due to other pain and can affect sports activity “Usual” Non‐operative Care Activity modification • Education → address biomechanics and • Temporarily limit or avoid specific activities POSTURE known to increase mechanical stress on spine • Active physical therapy ‐ Exercises to improve (SE:D) core stability, conditioning • Consider requirements of the job, non‐ • Symptomatic treatment physical factors (SE:C) • Limited bed rest, if recommended should be 2 days or less (SE: A) • Aerobic exercise: avoid debilitation (SE: C) 8 3/17/2017 Red Flag – Spondyloarthropathy Patients with chronic back pain duration (≥ 3 months) with back pain onset Case 2 before 45 years of age should be referred to a rheumatologist if at least one of the following parameters is present: Who? 16 year old quarterback •Inflammatory back pain What? Extension low back pain •Human leukocyte antigen –B27 positivity •Sacroiliitis on imaging, if available (on x‐rays or MRI) When? 2 months •Peripheral manifestations (in particular arthritis, enthesitis and/or dactylitis) How? No injury; has been lifting weights (dead •Extra–articular manifestation(psoriasis, inflammatory bowel disease and/or uveitis) lifts) •Positive family history for spondyloarthritis Where? Diffuse low back •Good response to non‐steroidal anti‐inflammatory drugs •Elevated acute phase reactants Poddubbnyy D, van Tubergen A, Landawe et al. Ann Rheum Dis; 2015, 74: 1483‐1487. Case 2 Want images? LOOK 6’ 2”, 230 pounds • When in doubt • Posture within normal limits • Red flags FEEL • Children, elderly • Minimal tenderness with patient in prone MOVE • ROM extension 30° mildly tender; Flexion 60° SPECIAL TESTS • 1 leg‐hyperextension test positive • Neurological status normal 9 3/17/2017 Which X‐rays? Which X‐rays? AP Lumbar Spine • Lateral Alignment Alignment • Pedicles • Disk spaces • Spinous processes • Spondylolisthesis Other Imaging Which X‐rays? BONE SPECT SCAN • Obliques 10 3/17/2017 Staging Lesions by CT Spondylolysis Healing • Early –focal bony absorption or a hair‐line defect • Progressive –wide defect with small fragments • Terminal –sclerotic change Other Imaging MRI or CT myelography What to do? • Not recommended in the first 6 weeks in the • Physical therapy absence of red flags • • MRI modality of choice in LBP symptoms not Activity Modification / Rest responding to conservative treatment or red flags of • Avoid aggravating activity serious conditions (Tumor, infection etc.) • MR Neurogram • EMG and SEP Controversial – Useful in questionable nerve root symptoms +/‐ back pain • Modify activities only vs Bracing >6 weeks – Not recommended if the diagnosis of radiculopathy is obvious 11 3/17/2017 Lumbar Corset with Rigid Insert What about BOB? Causes of Back Pain The Boston Overlapping Brace (Micheli, Wood. Arch Pediatr Adolesc Med 1995; 149:15‐18) Lesion Youth Adult P value Discogenic 11 48 0.05 Spondylolytic 47 50.05 lesion Lumbosacral 6 27 0.05 strain Hyperlordotic 26 0 mechanical back pain Osteoarthritis 0 4 12 3/17/2017 Back Pain in Children • No EXACT cause is Case 3 identifiable in 90% of Who? 30 year old female ICU nurse adult back pain What? Extension low back pain • Diagnosis of pain When? LBP x 5 yrs, worse x 6 wks generator is more common in children’s How? Sitting >30 minutes causes numbness and back pain tingling R leg • Work up more Where? Low back with radiating pain into right aggressively hip and numbness right foot Case 3 X‐ray LOOK 5’ 5”, 155 pounds • Posture within normal limits FEEL • Mild tenderness at L3‐L4; L4‐L5 MOVE • ROM Extension 30° mildly tender; Flexion 70° SPECIAL TESTS • Direct and indirect SLR negative • 4+/5 strength over R EHL otherwise L/E 5/5 • Reflexes normal AP Lumbar Spine Lateral Lumbar Spine 13 3/17/2017 L4 subpedicular common iliac MRI arteries ivc • L to R psoas • L3‐L4 psoas • L4‐L5 QL • Moderate QL stenosis L4 spinal IL LL dural nerve sac m nerve roots dural sac MRI Axial Views Intervertebral Disk dorsal root ventral root L4‐L5 dural nerve‐root sleeve dorsal root ganglion spinal nerve L2‐L3 ventral ramus L5‐S1 L3‐L4 14 3/17/2017 Disk Herniation Treatment • Education Mechanism Symptoms • L5‐S1 most common • Acute herniation usually • Activity modifications 90% 30‐50 years • Physical Therapy • Compression of neural • Pain worse with flexion • Medications structures such as • May have “Sciatica” – NSAIDs should be recommended (Strength: sciatic nerve causes – Pain with sitting too long radicular pain (i.e. driving) Strong) • Rule out bowel or – Opioids may be considered but should be avoided bladder symptoms if possible (Strength: Weak) – Antidepressants should not be routinely used (Strength: Strong) White et al.