2020-09-25 OBJECTIVES ❑Describe a clinical classification scheme for the patient presenting with spinal pain ❑Identify risk factors suggestive of a serious pathology to explain the spinal pain ❑Describe spinal imaging ❑Describe key history and physical exam parameters of radiculopathy due to disc herniation and spinal stenosis ❑Discuss indications for surgical referral in patients with refractory spinal pain Adil Shaikh, MD, ABPMR, ABIME ❑Discuss treatment as relevant to evidence and the most recent practice guidelines • Physical Medicine and EVALUATION AND TREATMENT Rehabilitation • Clinical Associate Professor, USD OF LOW BACK PAIN • Chair of Neuroscience Dept, Avera Mckennan • Avera Mckennan Hospital Spine Center TERMINOLOGY FOR LOW BACK PAIN DERMATOMES ❑Chronology: ➢Acute< 4 weeks (6 weeks) ➢Subacute 4-12 weeks ➢Chronic >12 weeks ❑Spinal Stenosis: Narrowing of vertebral canal ❑Spondylolysis: Fracture of pars interarticularis ❑Spondylolisthesis, Anterolistehsis, Retrolisthesis ❑Sciatica (Symptom): Pain/Paresthesia down foot ❑Radiculopathy (Sign): Impairment of nerve root 1 2020-09-25 MYOTOMES INTRODUCTION/EPIDEMIOLOGY ❑Lifetime incidence 84% ❑Prevalence 22-48% ❑Substantial direct health care costs- Second most common reason the see PCP ❑Indirect costs related to disability and loss of productivity ❑Number one work related injury ❑Significant litigation Deyo, R. A., & Tsui-Wu, Y. J. (1987). Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine, 12(3), 264–268. https://doi.org/10.1097/00007632- 198704000-00013 CAUSES/CLASSIFICATION SCHEME RED FLAGS ❑Non-Specific: Myofascial, >85% History Physical Examination ❑Non-Serious Etiologies 10%: ❑Cancer ❑Saddle anesthesia ➢Vertebral fracture <4%: localized low back pain ❑Unexplained weight loss ❑Loss of anal sphincter tone ➢Radiculopathy<3% : 90% L5 and S1 radics ❑Immunosuppression ➢Spinal Stenosis <3%: Spondylosis (Degen), Spondylolisthesis, thick ligamentum flavum ❑Intravenous drug use ❑Major motor weakness in lower ❑Serious Etiologies <1%: ❑Urinary tract infection extremities ➢Spinal cord or Cauda equina compression: Pain, weakness, sensation, bowel or bladder ❑Fever ❑Fever ➢Metastatic Cancer: Breast, Prostate, Lung, Thyroid, Kidney- 80%. MM if lytic lesions 60%. ❑Significant trauma relative to age ➢Spinal Epidural Abscess: Recent spinal injection, epidural cath, IV drug use, other infections ❑Neurologic findings persisting beyond ➢Vertebral Osteomyelitis: gradually increases over months, pain on palpation ❑Bladder or bowel incontinence one month or progressively worsening ❑Others: Ankylosing Spondylitis(<0.5%), OA (facet joints), Somatization, Piriformis, SI ❑Urinary retention (with overflow incontinence) Joint Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the Jarvik, J. G., & Deyo, R. A. (2002). Diagnostic evaluation of low back pain with emphasis on imaging. American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491 Annals of internal medicine, 137(7), 586–597 2 2020-09-25 PHYSICAL EXAMINATION IMAGING ❑AAFP: DO NOT DO IMAGING IN THE FIRST 6 WEEKS, unless red flags are present ➢Inspection: Anatomic abnormalities eg. Scoliosis ❑Imaging before 6 weeks does not improve outcomes but does increase costs ➢Palpation: Vertebral vs Soft tissue tenderness ❑Studies show that patient with no back pain often show anatomic abnormalities ➢Neurologic Examination: Gait, Bulk, Tone, Reflex, Strength, Sensation ❑Cause unnecessary radiation exposure and patient labeling ❑The labeling phenomenon of patients with low back pain has been studied and shown to worsen ➢Special tests: SLR, Mod SLR, Slump test patients’ sense of well-being. ➢Labs: ESR, CRP, CBC based on clinical information ❑Increase rate of imaging in linked with the increase rate of surgery ❑Webster et al showed that patients with occupation-related back pain who had early magnetic ➢Non-Organic Signs (Waddell’s Signs) resonance imaging (MRI) had an eightfold increased risk of surgery. ❑Overreaction ❑Jarvik et al showed that patients with low back pain who had an MRI were more than twice as ❑Superficial or Widespread tenderness likely to undergo surgery compared with patients who had plain film imaging. ❑Inconsistent test e.g. SLR with distraction ❑A meta-analysis (Chou et al) found no clinically significant difference in patient outcomes between ❑Unexplainable neurologic deficits (non dermatomal sensory loss, sudden giving away on motor) those who had immediate lumbar imaging versus usual care. ❑Pain on simulated axial load (pressure on top of head) Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. NEJM. 1994:331;69-73. WHEN TO DO IMAGING TYPE OF IMAGING FOR SUSPECTED DISORDER ❑Red Flags ❑Failed conservative treatment options (for minimum 6 weeks) ❑Surgery consideration ❑Therapeutic injection ❑NOT FOR DIAGNOSIS ❑Communicate: “The good news is that based on your history and your normal physical examination I do not think that you need an x-ray.” ❑Empathy, partnership, legitimation: “I want to reassure you that your symptoms are very different from those of your brother or someone with a herniated disc causing issues” 3 2020-09-25 TREATMENT - ACUTE TREATMENT – ACUTE PHARMACOTHERAPY Goal of Care- Short-term Symptomatic relief 1. Non-Pharmacologic Treatment: Massage (dec spasm), Heat (dec spasm), ❑NSAIDs (Usually Ibuprofen 400 QID or Naproxen250-500BID) acupuncture (dec pain), spinal manipulation (increase ROM and dec pain) ❑Acetaminophen-2016 Cochrane review, similar to placebo (B evidence), use if no 2. NO Bed Rest: Bed=slower recovery, more pain safe alternatives 3. Gradual return to work/activity as tolerated – individualized ❑NON-BENZODIAZEPINE muscle relaxants: ➢Cylobenzaprine-2003 Cochrane review (A) 4. ? PT – not any more effective than NSAIDs, education ➢Methocarbamol, Tizanidine, Baclofen 5. Poor evidence: Cold (poor penetration), Muscle energy technique (contraction vs ❑OPIOIDS – Only if refractory, severe, contraindications to non-opioids (CDC 2016) assisted stretching), Traction, Lumbar supports, Yoga, Mattress changes, Paraspinal injections (Epidural, trigger points, facet) GRADES OF RECOMMENDATION: TREATMENT – SUBACUTE AND CHRONIC A: Good evidence (Level I studies with consistent findings) for or against ❑Self care: Maintain activity as tolerated, heat + stretching (20min q2h), self care recommending intervention. education B: Fair evidence (Level II or III studies with consistent findings) for or against ❑Exercise: ROM, Core strengthening, Core stabilization, directional preferences (eg recommending intervention. McKenzie), aerobics, Pilates, exercises that have a mind-body component (yoga and Tai Chi) C: Poor quality evidence (Level IV or V studies) for or against recommending ❑Avoidance of getting to chronic LBP: help preexisting psychological conditions, intervention. somatization, maladaptive pain coping behaviors (eg, fear avoidance or catastrophizing), high level of functional impairment, the presence of other types of I: Insufficient or conflicting evidence not allowing a recommendation for or against chronic pain, job dissatisfaction or stress, and dispute over compensation issues intervention. ❑Spinal Manipulation (Chiropractors, PT, Osteopaths): short term benefits ❑Acupuncture 4 2020-09-25 TREATMENT – SUBACUTE/CHRONIC PARASPINAL INJECTIONS: EPIDURAL INJECTIONS PHARMACOTHERAPY ❑“Leg pain dominant” pain-indicate lumbosacral nerve root irritation or entrapment 1St Line ❑NSAIDs (Ibuprofen and Naproxen) (B) ❑Inhibition of the synthesis or release of pro-inflammatory substances ❑Acetaminophen (esp. in NSAID allergy or other intolerance, chronic kidney disease, hypertension, peptic ulcer disease, or with cardiovascular disease) ❑12 randomized trials : 50% helped with pain, NNT 6 for short nd term benefit and NNT 11 for long term benefit 2 ➢Non-benzo muscle relaxants (Cyclobenzaprine, Tizanidine, Baclofen, Robaxin) Line ❑Cochrane review (April 2020): ➢Long-term-TCA/SNRIs (Duloxetine, Amitriptyline, gabapentin) [B] ➢25 clinical trials, 2470 participants, 0-100 pain scale, minor SEs ➢Pain-slightly effective MD 4.9 (95%CI 8.7-1.09) If all fails – Opioids for short-term only, less than 50MME (Morphine milligram ❖ ➢Disability – slightly effective MD 4.18 (95% CI 6.04-2.17) Equivalent) ➢Evidence inconclusive, Clinical experience drives practice ❖NOT RECCOMENDED [C]: Herbs (Except Capsicum frutescens), glucosamine, ❑Not cost effective (Leah et.al, 2018)-Quality adjusted life years Benzodiazepines (abuse, AEs and dependency), Lumbar supports gained Samanta, A., & Samanta, J. (2004). Is epidural injection of steroids effective for low back pain?. BMJ (Clinical research ed.), 328(7455), 1509–1510. PARASPINAL INJECTIONS: MBB AND RFA SPINAL CORD STIMULATOR ❑Concept of gate control theory (Wall and Melzack, 1965): ❑Radiofrequency ablation (RFA), a procedure using heat to Control pain by activating large, rapidly conducting fibers interrupt pain signals in spinal nerves ❑“Gate” is in the dorsal horn of spinal cord ❑Systematic review 1063 abstracts: ➢Small fibers=pain fibers. Impede inhibitory interneurons, allowing pain ➢Patients had back pain for at least 3 months information to travel up to the brain ➢Pain assessed 1 month after RFA ➢Large fibers= touch, pressure and other skin senses. Excites the inhibitory neurons, which diminishes the transmission of pain information ➢Improvement in pain for lumbar