Approach To Patient With Back Pain PDF

Approach to patient with back pain • Dr.Ebtehaj Almughais • MBBS, SBFM, Assistant Professor & Consultant Family Physician • Department of Family & Community Medicine Objectives 1. Define common cause of back pain. 2. Differentiate acute from chronic back pain. 3. know the red flag symptoms and whe...

Approach to patient with back pain • Dr.Ebtehaj Almughais • MBBS, SBFM, Assistant Professor & Consultant Family Physician • Department of Family & Community Medicine Objectives 1. Define common cause of back pain. 2. Differentiate acute from chronic back pain. 3. know the red flag symptoms and when to refer to a specialist. 4. formulate differential diagnosis and identify mechanical low back pain. 5. outline investigation and management. Introduction • Back pain is one of the most common medical problems in the worldwide, pain may be acute or chronic, constant or intermittent. • It usually occurs in the lower back, or lumbosacral area. • Up to 84 percent of adults have low back pain at some time in their lives Acute pain : less than 6 weeks Subacute pain : 6 – 12 weeks Chronic pain : more than 12 weeks AAFP Risk factors • Smoking • Obesity • Older age • Female gender • Physically strenuous work • Sedentary work • Psychological factors such as somatization disorder, anxiety, and depression HOW TO APPROACH PATIENTS WITH BACK PAIN? History 1 Personal Data 2 SOCRATES 3 Red Flags! 4 PMH 5 Past Surgical Hx 6 Medications 7 Family, Social & Systemic Review 1 Personal Data Age? Residence? History taking Occupation? 2 SOCRATES Site? Associated? Onset? Timing? Character? Exacerbating? Radiation? Severity? History taking 3 Red Flags! 4 PMH Hx taking Trauma? Cancer? 5 Past Surgical Hx 6 Medications Psychotic? Steroid? 7 Family, Social & Systemic Review Inherited disease? Social? Smoking? Alcohol? One More thing Idea Concern Expectation How does it affect him/her Emotionally/Functionally Physical examination • Proper exposure • Inspection of back and posture • Range of motion • Palpation of the spine • Straight leg raising • Neurologic assessment of L5, S1 roots (patients with leg symptoms) • Evaluation for malignancy (breast, prostate, lymph node exam) when persistent pain or history strongly suggests systemic disease Inspection Palpation Movement Neurological Inspection • Inspection of the Gait • Inspection is focused on alignment of major bony landmarks and assessment of the normal spinal curves. • Back for scoliosis , lordosis, swelling, scars and muscle wasting . Palpation The examination should include palpation of spines process, para-vertebral muscle and sacroiliac joint Checking for significant tenderness and swelling Movement 1. Range of motion (ROM) should be tested in Flexion 2. Extension 3. Lateral bending 4. Rotation Special test Straight-leg raise • The patient is supine with the legs straight. The leg on the symptomatic side is lifted with the knee in extension. • Tests for lumbar disc herniation. • A positive test result is pain between 30 and 70 degrees in the low back or leg. Patrick’s test (FABER) Provocative test ✓ Femoral stretch test: 1. Knee flexion hip extension while the patient is lying in prone position. 2. Positive if pain felt in ipsilateral anterior thigh. 3. Positive test mean that the L3 and L4 nerve roots are involved. Power • • • • • • Knee flexion L5-S1 Knee extension L3-L4 Foot planter flexion L4-L5 Foot eversion L5-S1 Foot inversion L4-L5 Big Toe Dorsi flexion Neurological examination 1.Motor 2.Sensory: • Medial side of foot L4 • Dorsum of foot L5 • Lateral side of foot S1 3.Tone: Normal, Flaccid or rigid. 4.Reflexes: • Knee • ankle jerks. Physical examination Physical examination Mechanical ▹ Tends to get better or worse depending on your position – for example, it may feel better when sitting or lying down. ▹ Typically feels worse when moving ▹ Can develop suddenly or gradually ▹ Might sometimes be the result of poor posture or lifting something awkwardly, but often occurs for no apparent reason ▹ May be due to a minor injury 4 Inflammation ▹ Age at onset of back pain <45 years ▹ Back pain lasting > 3 months ▹ Night pain ▹ Early morning pain and stiffness lasting more than one hour ▹ Insidious onset ▹ Tenderness/inflammation over the joint ▹ Increased by Rest and Relived by activity 4 Root Nerve Compression ▹ Characterized by radicular pain arising from nerve root impingement due to herniated discs. ▹ Radicular pain: Pain that radiates into the lower extremity directly along the course of a spinal nerve root. 4 Malignancy ▹ Metastatic tumors are found mostly in patients older than 50 years . ▹ Metastatic disease is more common than primary tumors of the spine, and thoracic spine metastatic lesions are more common than lumbar ▹ Patient usually has constitutional symptoms such as fever ,Wight loss, loss of appetite and N\V 4 Case 1 A 38-year-old man with no significant history of back pain developed acute LBP when lifting boxes 2 weeks ago. The pain is aching in nature, located in the left lumbar area, and associated with spasms. He describes previous similar episodes several years ago, which resolved without seeing a doctor. He denies any leg pain or weakness. He also denies fevers, chills, weight loss, and recent infections On examination, there is decreased lumbar flexion and extension secondary to pain, but a neurologic exam is unremarkable. Mechanical Inflammation Malignancy Root Nerve Compression Case 2 A 20-year-old man presents to his primary care physician with low back pain and stiffness that has persisted for more than 3 months. There is no history of obvious injury but he is a very avid sportsman. His back symptoms are worse when he awakes in the morning, and the stiffness lasts more than 1 hour. His back symptoms improve with exercise. He has a desk job and finds that sitting for long periods of time exacerbates his symptoms. His back symptoms also wake him in the second half of the night. He normally takes an anti-inflammatory drug during the day, and finds his stiffness is worse when he misses a dose. He has had 2 bouts of iritis in the past. Mechanical Inflammation Malignancy Root Nerve Compression Case 3 9-year-old male patient who had a history of low back pain for about a year and was reporting severe, constant, and aching lower back pain of 8-9 on a scale of 10. as well as radicular right leg pain, decreased sensation on the right, difficulty straightening his right leg making it difficult to walk. An MRI showed a rather large L5-S1 herniated disc on the right side with severe degenerative disc disease. Mechanical Inflammation Malignancy 31 Root Nerve Compression Case 4 A man aged 78 years presented to his general practitioner with newonset low back pain. The patient had metastatic prostate cancer, which was diagnosed 2 years ago. He reported a 6-week history of constant, burning pain in the lower lumbar region, which was worse at night and was 7/10 in severity on the Numeric Pain Rating Scale. He had no relief with regular paracetamol or ibuprofen. He had not had lower limb weakness, numbness, lower urinary tract symptoms . Mechanical Inflammation Malignancy 32 Root Nerve Compression INDICATIONS FOR INVESTIGATIONS? • • • • • • • • • • • Progressive neurological findings Constitutional symptoms History of traumatic onset History of malignancy Age ≥50 years Infectious risk such as injection drug use Immunosuppression Indwelling urinary catheter Prolonged steroid use Skin or urinary tract infection Osteoporosis Blood tests not necessary for most patients with back pain. CBC, UA, calcium, phosphorus, (ESR), and alkaline phosphatase may be considered in patients with suspected systemic disease, older individuals, and those who fail conservative treatment. Patients who may require long-term NSAIDs may require baseline renal and liver function tests. IMAGING For most patients x-rays are not recommended unless the pain persists beyond 6 weeks. Both MRI and CT are more sensitive than plain films for detecting spinal infections, cancers, herniated disks, and spinal stenosis. Management Plan TREATMENT non-mechanical causes of low back pain— such as infection, malignancy, or fracture—require treatment of the underlying problem mechanical low back pain—conservative treatment of pain control, education, reassurance, and appropriate activity. About 80% to 90% will recover within 6 weeks. Bed rest is generally not recommended unless the pain is severe enough to preclude normal activities; even then, it should be limited to 2 to 3 days. Longer periods of bed rest result in deconditioning. Cont. acute phase— the patient should be encouraged to continue normal activities, including work as tolerated, but told to avoid heavy lifting (>25 lb), twisting, prolonged sitting, driving for long periods, and heavy vibration. Traction and analgesic injection are usually not helpful in the acute stage. Cont. Pharmacological treatment : • Initiate trial of NSAIDs . (NSAIDs caution in patients with a history of gastritis, asthma, hypertension, chronic renal failure, or CHF) • Consider a muscle relaxant based on pain severity. • Consider a short course of opioid therapy if pain is severe. Surgical treatment surgery may be of benefit to those who do not respond to conservative care and have disabling symptoms: cauda equina syndrome worsening of neurologic deficits herniated disks spinal stenosis Patients with persistent more than 6 months or frequent recurrences of back pain — referral physiatrist or chronic pain management specialist Physical therapy or epidural steroid injections benefit some patients. When to refer ? • Urgent/Emergency referrals : 1. Cauda equina 2. Sever radiculopathy. 3. Fractures. • Other referrals 1. Recalcitrant spinal canal stenosis 2. Neoplasia or infection 3. Undiagnosed back pain 4. Continuing pain of 3 months’ duration without a clearly definable cause 5. erectile dysfunction Prevention and education • Losing weight: too much upper body weight can strain the lower back. • Posture: How you sit, stand and lie down can have an important effect on your back. The following tips should help you maintain a good posture. • Standing: Stand upright, with your head facing forward and your back straight. Balance your weight evenly on both feet and keep your legs straight Prevention and education • Sitting and driving: Sit up with your back straight and your shoulders back. Your knees and hips should be level and your feet should be flat on the floor. Prevention and education • Sleeping: Your mattress should be firm enough to support your body while supporting the weight of your shoulders and buttocks, keeping your spine straight. Prevention and education • Lifting and carrying: ✓ One of the biggest causes of back injury is lifting or handling objects incorrectly. ✓ Push rather than pull – if you have to move a heavy object across the floor, it is better to push it rather than pull it. ✓ Don't lift heavy objects by bending over at the waist ‫ـــــ‬ Bending hips and knees and then squat to pick up the object. ✓ The back should be straight and hold the object close to the body. ✓ Don't twist your body while you are lifting. Prevention and education • Exercise: ✓ Exercise is both an excellent way of preventing back pain and of reducing it but should seek medical advice before starting an exercise programs if you've had back pain for six weeks or more. ✓ Regular exercise will improve core muscles strength that support the back. TAKE HOME MESSAGE • A focused history and physical examination are sufficient to evaluate most patients with low back pain. • Without findings suggestive of serious pathology, imaging is not indicated in patients with low back pain. Thank you References • Up to date • AAFP Khalid, VD