Jim Messerly, DO

Disclosures

No conflicts to disclose

Do we, Can we make a difference? 90% of episodes (of acute low back

pain) resolve within 6 weeks regardless of treatment. Advise that minor flare-ups may occur in the subsequent year. (Level C= Observational studies)

From the Aspirus Network: Acute Low Back Pain Management Guideline. Approved by ANI Medical Management Committee May 2013

Categories of Low Back Pain

Acute (less than 3 months) vs Chronic (more than 3 months)

Mechanical/Axial low back pain vs Neurogenic/Radicular pain

Red Flags Cauda Equina Syndrome: Mainly bladder dysfunction;

Retention more common than incontinence. Infection: Fevers, Chills, Night Sweats Tumor: Weight loss, History of Cancer Inflammation: Morning stiffness; Spondyloarthropathies-

Ankylosing Spondylitis, Reiters, Psoriatic Others: Intra-abdominal- AAA, Kidney pathology

Acute Low Back Pain Acute low back pain is

often nonspecific and therefore, frequently cannot be attributed to a definite cause/source.

From Diagnosis and Treatment of Acute Low Back Pain; American Family Physician February 15, 2012

Acute Low Back Pain- Goals of Treatment Reassurance: based on thorough exam Develop management strategies through

education Relieve Pain: Meds, Ice, Manipulation, PT,

Others Improve Function: Avoid bedrest, Reduce

time off work Attempt to minimize the development of

chronic low back pain ?Identify Pain Generator: Radicular/ Disc

protrusion pain

Low Back Pain- History

Mechanism: Lifting, Twisting (Work Comp)

First Episode vs Recurrence Location: Axial vs Radicular (Dermatonal

pattern) What makes it worse?

Sitting: Disc protrusion Standing: Facet vs Foraminal disc protrusion Coughing/Sneezing: Disc Protrusion

Low Back Pain History Continued

What makes it better? Sitting: Foraminal disc protrusion/ Facet pain Standing/ Walking: Lateral disc protrusion

Bladder control issues? Retention and saddle anesthesia probably more

common sign of Cauda Equina Syndrome than incontinence

Night Pain/ Unrelenting Pain Fevers, Chills, Night Sweats, Weight Loss,

Cancer History

Low Back Pain- Physical Exam Inspection: Look at the low back- Lordosis, Lateral Shift, etc. Palpation: Location of tenderness- lumbar, SI’s, Sciatic notch Motion Testing: Flexion, Extension, Lumbar Spurling’s; Note back and/or radicular

pain Heel (L4/5 footdrop) and Toe (S1)Walk DTR’s: Patella-L4, Achilles-S1 Manual Muscle Testing: Hip flexor-L3, Quad/Anterior Tib-L4, Extensor Hallicus-L5,

Flexor Hallicus-S1 Sensation: Medial leg and foot-L4, Lateral leg/Dorsal foot-L5, Lateral foot-S1 Sitting and Supine Straight Leg Raises: Sensitive for disc protrusion- Low back pain

with bilateral sitting straight leg raise think central disc protrusion; Radicular pain with supine straight leg raise (positive cross straight leg raise) think lateral disc protrusion

Hip Range of Motion Testing: Sitting and supine to look for hip pathology Patrick’s Testing: SI pathology contralateral Femoral Nerve Stretch Test: Thigh pain with passive hip extension- tests for L1-4

radicular pain

Low Back Pain Exam- X-Rays

“Radiography may be helpful to screen for serious conditions, but usually has little diagnostic value because of its low sensitivity and specificity.” American College of Radiology ACR Appropriateness criteria. May 2, 2011

Low Back Pain Exam- Lab Work

Lab- CBC, ESR, CRP for suspected infectious or inflammatory etiologies. ?HLA B27

Acute Low Back Pain Diagnoses “Low Back Pain”:

Mechanical/ Axial low back pain

“Lumbar Radiculitis” or “Radiculopathy”: Component of leg pain with nerve root involvement

Avoid “Lumbar Strain”: Does low back muscle injury really occur? Rarely if ever seen on MRI scan of lumbar spine. Clinical observation Jim Messerly DO

Acute Low Back Pain Treatment Reasurrance: A good history and exam can help to rule out significant Red

Flags or neurologic pathology. No urgent need for MRI scan because “It’s not going to change our treatment”

?Discussion of Possible Low Back Pain Generator: Disc protrusion vs Facet pain

Active rather than Passive Treatments: Avoid bedrest to avoid deconditioning

Medications: Steroid burst (Medrol pack, Prednisone), NSAID’s, Tylenol, Muscle Relaxants, Tramadol, Narcotic Pain meds, Nerve Stabilizers (Gabapentin/Lyrica) for radicular pain

Ice/Heat Physical Therapy: Flexion/Extension/Stabilization exercises, Modalities,

Mobilization Manipulation: DC, DO, PT Traction, Accupunture Injections: Interlaminar, Transforaminal, Caudal, Epidural Steroid injections

for disc protrusions with or without radicular pain. Medial Branch blocks to diagnose facet pain

Surgery: Usually discectomy for acute/subacute low back pain- rarely needed

Evaluation of Acute Low Back Pain Treatment: Medication Naproxen with Cyclobenzaprine,

Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain. A Randomized Clinical Trial. JAMA, 2015; 314(15):1572-1580.

Conclusions and Relevance: Among patients with acute, nontraumatic, nonradicular low back pain presenting to the ED, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone did not improve functional outcomes or pain at 1 week follow-up. These findings do not support the use of these additional medications in these settings.

Evaluation of Acute Low Back Pain Treatment: NSAIDs “Low quality evidence suggests that

NSAIDs are effective for short-term symptom relief of acute low back pain compared with placebo. Consider switching NSAID if the first one is not effective.”

Diagnosis and Treatment of Acute Low Back Pain; American Family Physician; Feb 12,2012; Vol 85, #4

Evaluation of Acute Low Back Pain Treatment: NSAIDs FDA Drug Safety Communication: FDA

strengthens warning that non-aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes, 07/09/2015.

“The risk of heart attack or stroke can occur as early as the first weeks of using an NSAID. The risk may increase with longer use or higher doses of NSAIDs. NSAIDs can increase the risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease, but still greater in heart disease patients. There is also increased risk of heart failure with NSAID use.”

Evaluation of Acute Low Back Pain Treatment: NSAIDs NSAID Use and Renal Function: “In

addition to blunting the hypotensive effects of diuretics, ACE inhibitors and Angiotensin Receptor Blockers (ARBs) , there is an increased risk of patients developing acute renal failure when an NSAID is coadministered.” Pharmacy Times; April 18, 2013.

Acute Low Back Pain Treatment: Muscle Relaxants “Moderate quality evidence shows that

non-benzodiazepine muscle relaxants (cyclobenzaprine and others) are beneficial in the treatment of acute low back pain. Most pain reduction from these medications occurs in the first 7-14 days, but the benefit may continue for up to 4 weeks. However, disability status is not improved.”

Diagnosis and Treatment of Acute Low Back Pain; American Family Physician; February 15,2012; Vol 85, #4.

Acute Low Back Pain Treatment: Narcotic Pain Medications “Opioids are commonly prescribed for patients

with severe acute low back pain, however, there is little evidence of benefit. 3 studies showed no difference in pain relief or time to return to work between oral opioids and NSAIDs or acetaminophen and there is risk of harmful dose escalation over time with opioids, especially with pure formulations.”

Diagnosis and Treatment of Acute Low Back Pain; American Family Physician; February 15,2012; Vol 85, #4.

Acute Low Back Pain Treatment: Oral Steroids Prednisone for Emergency Department

Low Back Pain: A Randomized Controlled Trial. Journal Emergency Medicine; Jul 2014; 47(1)65-70.

79 patients given prednisone 50 mg daily for 5 days.

Conclusion: We detected no benefit from oral corticosteroids in our ED patients with musculoskeletal low back pain.

Acute Low Back Pain Treatment: Oral Steroids “A short course of oral corticosteroids

has questionable benefit for patients with acute radicular leg pain.”

Journal American Board Family Medicine; 2008; 21(5):469-474.

Acute Low Back Pain Treatment: Physical Therapy Early Physical Therapy vs Usual Care in Patients

with Recent-Onset Low Back Pain. A Randomized Clinical Trial. JAMA; 2015; 314(14):1459-1467.

108 patients treated with 4 physical therapy sessions (mobilization/manipulation and range of motion exercises) vs 112 involved in no additional interventions during the first 4 weeks.

Conclusions and Relevance: Among adults with recent onset low back pain, early physical therapy resulted in a statistically significant improvement in disability, but the improvement was modest and did not achieve the minimum clinically important difference compared with usual care.

Acute Low Back Pain Treatment: My Approach- Suspected Disc Protrusion Mechanical/Axial Low Back Pain (without radicular symptoms):

If concerns for central disc protrusion, i.e. pain worse with sitting, bending and coughing/sneezing, then would try Medrol Dosepak with aggressive extension exercises/stabilization program in physical therapy. In my experience, manipulation seems to aggravate low back central disc protrusion pain.

Low back pain with Radicular Symptoms: Radicular symptoms may be related to lateral or foraminal disc protrusion or spinal stenosis with neural foraminal stenosis. Can try Medrol Dosepak followed by gradual increasing dose of Gabapentin with physical therapy for extension exercises for lateral disc protrusion and stabilization exercises for far lateral disc protrusion with neural foraminal narrowing. Chiropractic care can also be helpful.

Low Back and Radicular Pain Treatment with Gabapentin Gabapentin 100 mg- Start with 1 at bedtime

for 1 week, then increase to 2 at bedtime for 1 week, then 3 at bedtime for 1 week if tolerating well. Could consider 1 in a.m. and 3 at bedtime increasing to 300 mg bid if higher doses needed.

Warn patient of possible sedation side effects even at 100 mg. If side effects occur at a given dose, then decrease to the previous tolerable lower dose.

Gabapentin seems to be very safe for neurogenic pain with no significant GI, cardiac or renal side effect concerns.

Low Back Pain Treatment: MRI Scan

Indications for MRI scanning of the lumbar spine: Presence of Red Flag. Concerning for Cauda

Equina, tumor or infection Progressive neurologic deficit which is usually

weakness. (Footdrop, Quad weakness with knee giving way)

Lack of improvement with conservative care for 4-6 weeks

Spinal Fracture Need to correlate MRI scan findings with

clinical symptoms

Low Back Pain Treatment: Understanding Nerve Root Anatomy

Low Back Pain Treatment: MRI Central Disc Protrusion

Low Back Pain- Central Disc Protrusion MRI Description: Central disc protrusion contacting or

indenting the thecal sac usually with some associated central canal narrowing.

Symptoms: Mainly mechanical/axial low back pain which is worse with prolonged sitting or repetitive bending and lifting. Frequently worse with coughing or sneezing.

Treatment: Pain is frequently decreased with the use of a Medrol Dosepak and extension/stabilization exercises. Important to maintain lumbar lordosis/proper posture with bending and lifting. Manipulation seems to aggravate the pain. Lumbar epidural steroid injections (Caudal or Transforaminal) frequently provide some relief.

Low Back Pain Treatment: MRI Lateral Disc Protrusion

Low Back Pain- Lateral Disc Protrusion MRI Description: Lateral disc protrusion with lateral

recess stenosis displacing the specific nerve root. Lateral disc protrusion at L4-5 contacts the L5 nerve root and L5-S1 contacts the S1 nerve root.

Symptoms: Usually right or left low back pain with associated buttock and lower extremity radicular pain in a specific nerve root/dermatomal pattern. Pain is usually worse with bending, sitting and coughing/sneezing.

Treatment: Trial of Medrol Dosepak adding Gabapentin 100 mg for the neurogenic pain. Physical therapy for extension exercises/stabilization exercises as tolerated. Caudal or Transforaminalepidural steroid injections are frequently helpful for the pain.

Low Back Pain Treatment: MRI Far Lateral/Foraminal Disc Protrusion

Low Back Pain- Far Lateral/ Foraminal Disc Protrusion MRI Description: Far lateral/Foraminal disc

protrusion with associated neural foraminalnarrowing contacting the exiting L4 nerve root at L4-5 or L5 nerve root at L5-S1.

Symptoms: Usually neurogenic/radicular pain with prolonged standing or walking in a specific nerve root/dermatomal pattern. Can be aggravated by extension.

Treatment: Medrol pack and Gabapentin 100 mg. Physical therapy for an aggressive stabilization program. Extension exercises may aggravate radicular pain. Transforaminal epidural steroid injections are frequently helpful.

MRI Disc Protrusions

Low Back Pain: Facet Mediated Pain

Usually confined to the low back, but can refer pain to the buttocks and rarely lower extremities

Usually worse with extension X-rays may show facet

arthritis/degenerative spondylolisthesis

Physical therapy is important for core stabilization

Spinal manipulation can be helpful

Short course of NSAIDs may be helpful

Spinal medial branch block injections can be diagnostic followed by Radiofrequency Ablation treatment

Low Back Pain Treatment: Spinal Injection Therapy The Efficacy of Lumbosacral Transforaminal

Epidural Steroid Injections: A Comprehensive Review; Journal Back Musculoskeletal Rehabilitation; 2011; 24(2):67-76.

Conclusion: This systemic review included prospective, retrospective and randomized clinical trials showing that there was strong evidence for transforaminal injections in the treatment of lumbosacral radicular pain for both short-term and long-term relief.

Low Back Pain Treatment: Spinal Injection Therapy Viewpoint: Spinal Injection Therapy for

Low Back Pain; JAMA; June 19, 2013; Vol 309; #23 (The Netherlands)

“(Spinal) Injection of any kind may be beneficial in individual cases or subgroups. Nevertheless, given the weak scientific evidence base and the availability of noninvasive and more effective alternatives, physicians and policy makers should not recommend the use of injection therapy for patients with low back pain and sciatica.”

Acute Low Back Pain Treatment Summary Nothing works great all the time. Perform a good history and physical examination

reassuring the patient that there are no signs for significant ongoing neurologic damage.

Identify possible pain generator with optimism that treatment will help the pain.

Reassure the low back pain patient that low back pain is very common and most patients do not have chronic pain.

Try to use lumbar spine x-rays appropriately. Use “Low Back Pain” as diagnosis rather than “Lumbar

Strain”. Physical therapy can be helpful to equip patients with

appropriate low back pain rehab exercises and management techniques for self-care.

Spinal manipulation can be helpful for pain.

Acute Low Back Pain Treatment Summary Continued Cautious use of NSAIDs- consider cardiovascular, renal and GI

side effects. Cautious use of narcotic pain medications- they may still be

helpful for short-term management of pain. Cautious use of muscle relaxants due to sedation especially in

the elderly. Consider short course of oral steroids especially for discogenic

pain which seems to be generally safe. Consider a trial of gabapentin for any neurogenic or radicular

pain warning about sedation side effects. Use MRI scans appropriately. Try to correlate MRI scan findings

with clinical presentation especially for disc protrusions. Consider referral for spinal injection therapy especially for disc

protrusions with radicular pain, but can also help sort out possible facet mediated pain.

Thank You

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