A Syndrome Approach to Low Back Pain

Hamilton Hall MD FRCSCHamilton Hall MD FRCSCProfessor, Department of Surgery, University of TorontoProfessor, Department of Surgery, University of Toronto

Executive Director, Canadian Spine SocietyExecutive Director, Canadian Spine Society

Faculty/Presenter Disclosure

• Faculty: Hamilton Hall

• Relationships with commercial interests:• Consultant: Stryker Spine USA• Consultant: Medtronic• Consultant: rti Surgical• Medical Director, Pure Healthy Back• Medical Director, CBI Health Group

Disclosure of Financial Support

• This program has received no financial support.

• This program has received no in-kind support

• Potential for conflict of interest:• Hamilton Hall receives compensation as Medical

Director of CBIHG.

Mitigating Potential Bias

• This program does not discuss or recommend surgical devices.

• CBIHG acknowledges that the Pattern Approach to Low Back Pain was developed by Dr. Hall during his time with CBIHG and that its development included contributions for many CBIHG staff members over many years.

Our current approach isn’t working

• The medical paradigm hasn’t solved the problem of low back pain.

• Guideline: discordant indicators 23,918 primary care visits for back pain

Jan 1999 – Dec 2010

• MRI increase use 7.2% to 11.3%

Mafi J et al. JAMA 2013Mafi J et al. JAMA 2013

Our current approach isn’t working

Our current approach isn’t working

• Guideline: discordant indicators 23,918 primary care visits for back pain

Jan 1999 – Dec 2010

• MRI increase use 7.2% to 11.3% • NSAID/acetaminophen decrease use 36.9% to

24.5%• Narcotic increase use 19.3% to 29.1% • Specialist referrals increase 6.8% to 14.0%

Mafi J et al. JAMA 2013Mafi J et al. JAMA 2013

Specialist referrals increase 6.8% to 14.0%

• Less than 30% of referrals to a spine surgeon are appropriate for spine surgery.

Our current approach isn’t working

Wai E et al. Can J Surg 2009Wai E et al. Can J Surg 2009

Our current approach isn’t working

• Back pain remains an enormous social burden.

• More than 13 types of health care provider with over 30 treatment approaches.

• Still the commonest cause of recurrent lost time from work.

Our current approach isn’t working

• There is no correlation between degenerative changes on plain x-ray and back pain.

• CT has a 30% false positive rate.

• MRI has a 60-90% false positive rate.

Webster BS et al. Spine 2013Webster BS et al. Spine 2013

Early MRI without indication has a strong iatrogenic effect in acute LBP… it provides no benefits,

and worse outcomes are likely.

Our current approach isn’t working

• With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.

• Everything else is labeled “non-specific” back pain.

Our current approach isn’t working

• With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.

• Everything else is labeled “non-specific” back pain. It is treated “non-specifically”,

Our current approach isn’t working

• With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.

• Everything else is labeled “non-specific” back pain. It is treated “non-specifically”, which doesn’t work.

Our current approach isn’t working

• In most cases it doesn’t give the patient what the patient needs:

• immediate pain relief• reassurance• a clear prognosis• a method of control

And our current approach is wrong

• Most back pain is not the result of

• tumour• infection• major trauma• or any medical problem

• Most back pain begins spontaneously.• In a study of over 11,000 patients, 2/3rds of the

subjects could not recall any cause for the pain.

Hall et al. Clin J Pain 1998Hall et al. Clin J Pain 1998

But we still memorize the Red Flags• Sphincter disturbance: bowel or bladder• History of cancer• Unexplained weight loss• Immunosuppression• Intravenous drug use• Recent onset of structural deformity• Recent or on-going infection• Fever • Night sweats • Non-mechanical pattern of pain• Constant pain• Wide spread neurological signs or symptoms• Disproportionate night pain• Lack of treatment response• Thoracic dominant pain• Under 20 and over 55

• Over 90% of back pain is caused by minor altered mechanics.

• Most back pain is mechanical.

So why don’t we look there first?

There is another way

• Over 90% of back pain is caused by minor altered mechanics.

• Mechanical back pain is pain• related to movement• related to position• related to a physical structure

It means there is a sore thing in the back.

There is another way

We can all recognize there is a sore thing.

We just can’t agree on which sore thing.

And for all the non-invasive treatmentslocating the sore thing isn’t even necessary.

There is another way

There is another way

“Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and

subsequent treatment.”

Patterns of back pain

“Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and

subsequent treatment.”

Syndromes of back pain

“Distinct syndromes of reliable clinical findings are the only logical basis for back pain categorization and

subsequent treatment.”

What is a syndrome?

A syndrome is a constellation of signs and symptoms that appear together in a consistent

manner

A syndrome is a constellation of signs and symptoms that appear together in a consistent

mannerand respond to treatment in a predictable

fashion.

A syndrome is a constellation of signs and symptoms that appear together in a consistent

mannerand respond to treatment in a predictable

fashion.

What is the difference between a disease and a syndrome?

The only difference is that we know the etiology of a disease.

• A disease has an etiology.• Does a syndrome have an etiology?• Do you think that constellation of signs and

symptoms just appears in exactly the same way every time merely by chance?

• Of course, a syndrome has an etiology.• We just don’t know what it is yet.

Syndrome recognition

• The key to syndrome recognition is the history.

and that begins with three questions.

Where is your pain the worst?

Where is your pain the worst?

• Is it back or leg dominant?

• Back dominant pain is referred pain from a physical structure.

• Back dominant:• back• buttocks• coccyx• greater trochanters• groin

Where is your pain the worst?

• Is it back or leg dominant?

• Back dominant pain is referred pain from a physical structure.

• Sites of referred pain can become locally tender.

• Trochanteric bursitis

• Piriformis syndrome

Where is your pain the worst?

• Is it back or leg dominant?

• Leg dominant pain is radicular pain from nerve root involvement.

• Leg dominant:• Around or below the gluteal fold, to the:

• thigh• calf• ankle• foot

Where is your pain the worst?

• Is it back or leg dominant?

• The patient will often report both.

• But it must be one or the other.

• “ If I could stop only one pain, which one do I stop?

• “I have a back pill and a leg pill, which one do you want?”

Syndrome recognition

• The key to syndrome recognition is the history.

and that begins with three questions.

Where is your pain the worst?

Is your pain constant or intermittent?

Part A

Is there ever a time when you are in your best position, in your best time of your day and everything is going well when your pain stops even for a moment?

I know it comes right back but is there ever a

time, even a short time when the pain is gone?

Part B

When your pain stops does it stop completely?

Is it all gone?

Are you completely without your pain?

When the pain is constant consider:

• Malignancy

• Systemic conditions

• Pain disorder

• Constant mechanical pain

Syndrome recognition

• The key to syndrome recognition is the history.

and that begins with three questions.

Where is your pain the worst?

Is your pain constant or intermittent?

Does bending forward make your typical pain worse?

1. Where is your pain the worst?

2. Is your pain constant or intermittent?

3. Does bending forward make your typical pain worse?• What are the aggravating movements/positions?

1. Where is your pain the worst?

2. Is your pain constant or intermittent?

3. Does bending forward make your typical pain worse?

4. Has there been a change in your bowel or bladder function

• since the start of your pain?

1. Where is your pain the worst?

2. Is your pain constant or intermittent?

3. Does bending forward make your typical pain worse?

4. Has there been a change in your bowel or bladder function

5. What can’t you do now that you could do before you were in pain and why?

1. Where is your pain the worst?

2. Is your pain constant or intermittent?

3. Does bending forward make your typical pain worse?

4. Has there been a change in your bowel or bladder function

5. What can’t you do now that you could do before you were in pain and why?

6. What are the relieving movements/ positions?

1. Where is your pain the worst?

2. Is your pain constant or intermittent?

3. Does bending forward make your typical pain worse?

4. Has there been a change in your bowel or bladder function

5. What can’t you do now that you could do before you were in pain and why?

6. What are the relieving movements/ positions?

7. Have you had this same pain before?

1. Where is your pain the worst?

2. Is your pain constant or intermittent?

3. Does bending forward make your typical pain worse?

4. Has there been a change in your bowel or bladder function

5. What can’t you do now that you could do before you were in pain and why?

6. What are the relieving movements/ positions?

7. Have you had this same pain before?

8. What treatment have you had? Did it work?

History takes precedence over physical examination.

But the physical examination must support the history.

Physical Examination1. Observation

• general activity and behaviour• back specific:• contour• colour• scars• palpation (if you must)

Physical Examination1. Observation

2. Movement• flexion• extension

Physical Examination1. Observation2. Movement

3. Nerve root irritation tests• straight leg raising

A positive straight leg raise:

• Passive test - the examiner lifts the leg

• Reproduction/exacerbation of typical leg dominant pain

• Back pain is not relevant

• Produced at any degree of leg elevation

To reduce confusion with hamstring tightness, flex the opposite hip and knee.

Physical Examination1. Observation2. Movement

3. Nerve root irritation tests• straight leg raising• femoral stretch test-when history indicates

Physical Examination1. Observation2. Movement3. Nerve root irritation tests

4. Nerve root conduction tests• L4• L5

• S1

Physical Examination1. Observation2. Movement3. Nerve root irritation tests4. Nerve root conduction tests

5. Upper motor test• plantar response• clonus

Physical Examination1. Observation2. Movement3. Nerve root irritation tests4. Nerve root conduction tests5. Upper motor test

6. Saddle sensation• lower sacral nerve roots (2,3,4) test

Physical Examination1. Observation2. Movement3. Nerve root irritation tests4. Nerve root conduction tests5. Upper motor test6. Saddle sensation

Physical Examination1. Observation2. Movement3. Nerve root irritation tests4. Nerve root conduction tests5. Upper motor test6. Saddle sensation

7. Sensory testing (if indicated)

Physical Examination1. Observation2. Movement3. Nerve root irritation tests4. Nerve root conduction tests5. Upper motor test6. Saddle sensation7. Sensory testing (if indicated)

8. Ancillary testing (if indicated)• hip, abdomen, peripheral pulses

Three questions – two teststo rule out the Red Flags

• Where is your pain the worst?

• Is your pain constant or intermittent?

• Has there been a change in your bowel or bladder function?

• Test upper motor function.

• Test lower sacral sensation.

There are four mechanical patterns

Pattern 1 Pattern 2 Pattern 3 Pattern 4

Pattern 1 PENPattern 1

PEP

Pattern 4 PEP Pattern 4

PEN

Pattern 1

History

• Back dominant pain

• Worse with flexion

• Constant or Intermittent

Physical Examination

• Back dominant pain

• Worse with flexion

• Neurological examination is normal or unrelated to the pattern

Physical Examination

• Back dominant pain

• Worse with flexion

• Neurological examination is normal

• Better with 5 prone passive extensions Pattern 1 Prone Extension Positive

PEP

The patient has a directional preference.

Physical Examination

• Back dominant pain

• Worse with flexion

• Neurological examination is normal

• No change/worse with 5 prone passive extensions Pattern 1 Prone Extension Negative

PEN

The patient has no directional preference.

Pattern 1

Pattern 1 PENPattern 1

PEP

Pattern 2

History

• Back dominant pain

• Worse with extension

• Never worse with flexion

• Always intermittent

History

• Back dominant pain

• Worse with extension

• Never worse with flexion

• Always intermittent

If the pain is constant or if there is any pain on flexion the patient is Pattern 1

Physical Examination

• Back dominant pain

• Worse with extension

• Neurological examination is normal or unrelated to the pattern

• No effect or better with flexion

Pattern 1 Pattern 2

Pattern 1 PENPattern 1

PEP

Pattern 3

History

• Leg dominant pain

• Always constant

• Affected by back movement/position

Physical Examination

• Leg dominant pain

• Leg pain affected by back movement

• Positive irritative test• and/or conduction loss

Pattern 1 Pattern 2 Pattern 3

Pattern 1 PENPattern 1

PEP

Pattern 4

History

• Leg dominant pain

• Always intermittent

• Worse with flexion

Physical Examination

• Rarely a positive irritative test and/or conduction loss

• Always better with unloaded back extension movement or position

Leg dominant pain that responds to mechanical treatment.

Pattern 4

History

• Leg dominant pain

• Always intermittent

• Worse with activity in extension

• Better with rest in flexion

• May have transient weakness

Physical Examination

• Negative irritative tests

• Possible permanent conduction loss

Pattern 1 Pattern 2 Pattern 3 Pattern 4

Pattern 1 PENPattern 1

PEP

Pattern 4 PEP Pattern 4

PEN

Back dominant Leg dominant

Constant /Intermittent Intermittent Constant Intermittent

That’s all there is

There are only four Mechanical Syndromes

That’s all there is

Start with the patterns

• There will be a pattern in ninety percent of your patients.

• If it responds as expected, you have your solution.

• If there is no syndrome or it doesn’t respond as anticipated, that is the group that needs to be investigated.

• That is the time to consider the Red Flags.

Red Flags• Sphincter disturbance: bowel or bladder• History of cancer• Unexplained weight loss• Immunosuppression• Intravenous drug use• Recent onset of structural deformity• Recent or on-going infection• Fever • Night sweats • Non-mechanical pattern of pain• Constant pain• Wide spread neurological signs or symptoms• Disproportionate night pain• Lack of treatment response• Thoracic dominant pain• Under 20 and over 55

Red Flags• -• History of cancer• Unexplained weight loss• Immunosuppression• Intravenous drug use• Recent onset of structural deformity• Recent or on-going infection• Fever • Night sweats • Non-mechanical pattern of pain• Constant pain• Wide spread neurological signs or symptoms• Disproportionate night pain• Lack of treatment response• Thoracic dominant pain• Under 20 and over 55

Red Flags• -• History of cancer• Unexplained weight loss• Immunosuppression• Intravenous drug use• Recent onset of structural deformity• Recent or on-going infection• Fever • Night sweats • Non-mechanical pattern of pain• Constant pain• Wide spread neurological signs or symptoms• Disproportionate night pain• Lack of treatment response• Thoracic dominant pain• Under 20 and over 55

Red Flags• -• History of cancer• Unexplained weight loss• Immunosuppression• Intravenous drug use• -• Recent or on-going infection• Fever • Night sweats • Non-mechanical pattern of pain• Constant pain• Wide spread neurological signs or symptoms• Disproportionate night pain• Lack of treatment response• Thoracic dominant pain• Under 20 and over 55

Red Flags• -• History of cancer• Unexplained weight loss• Immunosuppression• Intravenous drug use• -• Recent or on-going infection• Fever • Night sweats • Non-mechanical pattern of pain• Constant pain• Wide spread neurological signs or symptoms• Disproportionate night pain• Lack of treatment response• Thoracic dominant pain• Under 20 and over 55

Red Flags• -• History of cancer• Unexplained weight loss• Immunosuppression• Intravenous drug use• -• Recent or on-going infection• Fever • Night sweats • Non-mechanical pattern of pain• Constant pain• Wide spread neurological signs or symptoms• Disproportionate night pain• Lack of treatment response• Thoracic dominant pain• Under 20 and over 55

Red Flags• -• History of cancer• Unexplained weight loss• Immunosuppression• Intravenous drug use• -• Recent or on-going infection• Fever • Night sweats • -• Constant pain• -• -• Lack of treatment response• -• Under 20 and over 55

Red Flags• -• History of cancer• Unexplained weight loss• Immunosuppression• Intravenous drug use• -• Recent or on-going infection• Fever • Night sweats • -• Constant pain• -• -• Lack of treatment response• -• Under 20 and over 55

Red Flags• -• History of cancer• Unexplained weight loss• Immunosuppression• Intravenous drug use• -• Recent or on-going infection• Fever • Night sweats • -• Constant pain• -• -• Lack of treatment response• -• Under 20 and over 55

Red Flags• -• -• -• Immunosuppression• Intravenous drug use• -• -• -• - • -• -• -• -• Lack of treatment response• -• Under 20 and over 55

Red Flags• -• -• -• Immunosuppression• Intravenous drug use• -• -• -• - • -• -• -• -• Lack of treatment response• -• Under 20 and over 55

Red Flags• -• -• -• Immunosuppression• Intravenous drug use• -• -• -• - • -• -• -• -• -• -• Under 20 and over 55

Red Flags• -• -• -• Immunosuppression• Intravenous drug use• -• -• -• - • -• -• -• -• -• -• -

Start with the Pattern. If it responds as anticipated you have your solution.

Further investigation is unnecessary.