Causes of low back pain student rev S2023 PDF(1).pdf

CAUSES OF LOW BACK PAIN PRECISE AND ACCURATE DIAGNOSIS LOW BACK PAIN: GENERAL INFORMATION Functions of the low back, or lumbar area, include structural support, movement, and protection of certain body tissues. Pain in the low back can be a result of conditions (musculoskeletal/viscera...

CAUSES OF LOW BACK PAIN PRECISE AND ACCURATE DIAGNOSIS LOW BACK PAIN: GENERAL INFORMATION Functions of the low back, or lumbar area, include structural support, movement, and protection of certain body tissues. Pain in the low back can be a result of conditions (musculoskeletal/visceral/ systemic conditions) affecting the bony lumbar spine, intervertebral discs, ligaments around the spine, spinal cord/nerves, lumbar musculature, internal organs of the pelvis/abdomen, and the skin covering the lumbar area. Treatment of low back pain is optimally directed toward a diagnosed or suspected specific cause. ORIGINS OF LOW BACK PAIN Anatomic & Physiologic Musculoligamentous injuries Degenerative changes in the IVD and facets IVD herniation with nerve root irritation Spinal stenosis Anatomic anomalies Underlying systemic disease Visceral disease PT. HISTORY: RED FLAGS FOR LOW BACK PAIN Unsteady when standing or walking Difficulties passing/controlling bladder or bowels or numbness in either area A previous history of cancer or osteoporosis Back pain accompanied by unexplained weight loss or fever Bleeding disorder MUSCULO-LIGAMENTOUS INJURIES Lumbar strain/sprain (acute/chronic) One of the M/C cause of LBP Muscles, tendons, fascia, ligaments, joint capsule, etc. Partial tearing/stretching of soft tissues above due to: Trauma/overuse/improper use (poor posture) Diagnosis based on: MOI (___________), location of pain, & exclusion of nervous system injury and other systemic diseases Research shows that prolonged bedrest slows recovery MUSCULO-LIGAMENTOUS INJURIES Low Back Pain due to soft tissue injury: Local Pain on Palpation (POP) mild to severe No paresthesia (exceptions) No muscle weakness in legs or feet Paraspinal muscle spasm (may be excruciating) Usually relieved by rest / Exacerbated by motion May begin immediately or gradually after trauma (usually w/in 24hrs) MUSCULOLIGAMENTOUS INJURIES May begin immediately or gradually after trauma (usually w/in 24hrs) Acute Trauma Repetitive/micro trauma Everyday stresses / poor biomechanics X-rays may be indicated to rule out fracture (esp. high velocity trauma) MRI to visualize soft tissues https://www.spine-health.com/video/lower-back-strain-video  MUSCULOLIGAMENTOUS INJURIES Chiropractic Care: HVLA may be contraindicated if severe/acute Although exacerbated by motion, preventing motion is counterproductive Limiting motion  decreases muscle strength and flexibility & circulation Gentle stretching and exercise preferred treatment Resolve the injury more efficiently by using motion to increase circulation and flexible healing If gentle stretching/exercise increase pts symptoms STOP IVD & FACET DEGENERATION May cause radiating pain if degeneration causes nerve root impingement IVD bulging/herniated into IVF Facet hypertrophy (severe expanding into IVF) https://www.spine-health.com/video/facet-joints-video Facet pain referral to: Buttocks and posterior thighs NERVE ROOT IRRITATION Direct Compression (mechanical pressure) Chemical changes Neuroischemia (spinal stenosis) Viral infection: ______ causes inflammation of the nerves NERVE ROOT IRRITATION Direct Compression (mechanical pressure) Disc degeneration/Lumbar radiculopathy (usually unilateral) Bony encroachment (arthritic hypertrophy/ spondylolisthesis / spinal stenosis) Spinal nerve rootlets exiting IVF more susceptible to pressure/ischemia (no epineurium)2 Chemical changes Nucleus pulposis inflammatory to n. roots Dermatome – an area of skin innervated by a single spinal nerve LUMBAR RADICULOPATHY: Pathology of a lumbar nerve root Herniated disc (degeneration/trauma/both) Facet arthritis / bone spurs Spondylolisthesis ABSOLUTE CONTRAINDICATIONS to HVLA which may cause raciculopathy: SOL’s: spinal cord or meningeal tumors & cysts, hematomas (cord or spinal canal), spinal malignancies, Aggressive benign tumors (aneurysmal bone cyst, giant cell, osteoblastoma, osteoid osteoma) Disc herniation with progressive neurological degeneration CES Fracture or dislocation LUMBAR RADICULOPATHY: Need to determine level involved Patient history EMG / NCV nerve testing Surgery may be necessary Unrelenting pain Severe functional impairment Incontinence (CES-SURGICAL EMERGENCY) https://www.spine-health.com/video/lumbar-radiculopathy-video RADIATING PAIN & DERMATOMAL PATTERNS Sciatica (S1-S5): buttocks  posterior legs  lateral ankles https://www.spine-health.com/video/sciatica-interactive-video https://www.spine-health.com/video/sciatic-nerve-anatomy- video L5: postero-lateral thighs wrapping around to the anterior foreleg L4: lateral-anterior thighs wrapping around to antero-medial foreleg MYOTOMES AND MUSCLE STRENGTH TESTING Myotome – Group of muscles stimulated by a single spinal nerve Upper Extremities: C5 – Deltoid and Biceps (C6 too) C6 – Wrist Extensors C7 – Triceps / Wrist Flexors / Finger Extensors C8 – Finger Flexors T1 – Finger ABduction / Finger ADduction MYOTOMES AND MUSCLE STRENGTH TESTING Myotome – Group of muscles stimulated by a single spinal nerve Lower Extremities: L3 – Hip Flexors L4 – Knee Extensors L5 – Knee Flexors S1 – Plantar Flexors SPINAL STENOSIS Central Canal Stenosis: Narrowing of the central spinal canal and/or… Foraminal Stenosis (lateral): Narrowing of the lateral recesses of the spinal canal (n. roots run inferiorly) May present with compensatory hypolordosis Can result from hypertrophic degenerative changes: IVD, ligamentum flavum, and facets (synovial cyst), etc. Prevalence unknown DDX LBP: https://www.youtube.com/watch?v=P8DG0B6MEzw ANATOMIC ANAMOLIES: ABSOLUTE OR RELATIVE CONTRAINDICATIONS? Some of the more serious anomalies are not in the L-P region Dens hypoplasia, unstable os odontoideum, basilar invagination, Arnold Chiari, etc4 Most lumbopelvic anamolies cause relative contraindications or none Scoliosis – asymptomatic or symptomatic (severe) Spondylolisthesis - asymptomatic or symptomatic (severe) No HVLA on grade 3-4 No P-A on involved segment EVER (any grade) Spatulated TVPS Sacralization of L5 Spina Bifida/ diastematomyelia (split cord) depends on severity4 SYSTEMIC DISEASE Cancer – primary or metastatic Spinal Infections Ankylosing Spondylitis VISCERAL DISEASES May refer pain to the low back from abdominal & pelvic organs: Bowel/bladder Uterus/ovaries & prostate cancer/cysts/prostatitis (may cause difficulty/painful urination) Kidneysreferred LBP may be sharp if kidney stones/painful/ difficult urination GI Gallbladder- A 2006 Scandinavian study questioned 220 patients with gallstones and found that 63% had referred back pain related to this condition.3 The survey also found that for 5% of participants, the back pain was their most pronounced symptom. Aorta- sudden onset severe abdominal/back pain Other symptoms not typically experienced with mechanical back pain: dizziness, clammy skin, loosing consciousness, nausea, vomiting, rapid heart rate, shock Lymph nodes/tissue PREVALENCE OF DISEASES CAUSING LOW BACK PAIN Compression Fractures 4% Spondylolisthesis 3% Malignant Neoplasm of the Spine 0.7% Ankylosing Spondylitis 0.3% Spinal Infections combined 0.01% Spinal Stenosis prevalence unknown (M/C older adults) Ref. 8,14,15 DIAGNOSING CAUSES OF LBP- BIG PICTURE Evidence of systemic disease or visceral disease, anatomic anomolies? Pt. history/exam Constitutional Symptoms Evidence of neurologic compromise (lumbar disc herniation, stenosis, CES)? Assess motor, reflex, and sensory function Evidence of social/psychological stress that could amplify/prolong pain Decrease pain inhibition Somatic amplification serves the patients needs for economic survival and maintenance of self-esteem Illness behavior  DIAGNOSING CAUSES OF LBP Evidence of social/psychological distress that could amplify/prolong pain “5 categories of innapropriate/non-organic signs correlating to other indicators of psychological distress:” * 1. Innappropriate tenderness + superficial/widespread pain 2. Pn on simulated axial loading (S-I pressure on pts head) & spinal rotation (shoulders and hips move together) 3. “Distraction Signs” (ex. Inconsistent performance b/w seated and supine SLR) 4. Regional strength and sensation disturbances inconsistent with nerve root innervation patterns 5. Overreaction during the physical exam NOTE: Positive findings in at least 3/5 categories suggests psychological distress5 *5. Waddell G, McCulloch JA, Kummel E, Verner RM. Nonorganic physical signs in low back pain. Spine. 1980:5(2):117-125 EVIDENCE OF SYSTEMIC DISEASE - CANCER Cancer is the M/C systemic disease affecting the spine Accounts for 50yoa History of cancer *consider cancer until proven otherwise Unexplained weight loss Pain lasting longer than one month/fail to improve with conservative therapy Pain not relieved by bed rest CANCER RED FLAGS: SENSITIVITY AND SPECIFICITY How likely a patient is to have or not have a condition based on test is dependent on the accuracy of the test In this case, the test is a question regarding the patient’s health history If a test is positive it indicates the patient has the condition (current cancer) Positive Test= LBP + Hx Cancer If a test is negative it indicates the patient does NOT have the condition (current cancer) Negative Test= LBP + NO Hx Cancer CANCER (RED FLAGS) CONTINUED 80% of patients with a malignant spinal neoplasm are >50yoa History of cancer – *consider the cause of back pain to be cancer until proven otherwise Specificity = likelihood that a positive test is really positive Specificity=.98 Sensitivity=.31 M/C source of spinal malignancy= breast, lung, and prostate SPECIFICITY & SENSITIVITY Highly sensitive test: more likely a – test is really – for a condition Highly specific test: more likely + test is really + for condition For example: Temp > 98.6o  sick patient High sensitivity (less false negatives) / Low specificity (more false positives) Temp >102o  sick patient Low sensitivity: for example sick pts with a temp of 101o (more false negatives) High specificity: for example most pts with a temp >102o are really sick (less false +) CANCER (RED FLAGS) CONTINUED Unexplained weight loss Pain > 1 month Failure to improve with conservative therapy CANCER (RED FLAGS) CONTINUED Pain not relieved by bed rest High Sensitivity – Neg test rules out (SNOUT) If a patient’s pain IS relieved by bedrest = Neg test High sensitivity = good at identifying patients WITHOUT the Dz = more true negatives Pain that IS relieved by bedrest (neg test) good at predicting no cancer High sensitivity means a negative test more accurate (than if test had low sensitivity) Low Specificity – Positive test rules in (SPIN) If a patient’s pain is NOT relieved by bedrest = Positive test Low specificity = not as good at identifying patients WITH the Dz = More false + pain not relieved by bedrest is experienced by many pts w/o Cancer Low specificity means that a positive test is less accurate (than if the test had high specificity) CANCER SUMMARY Patient history is most useful in detecting underlying cancer (compared to PE) >50 yoa History of Cancer - M/C metastases from breast lung and prostate Unexplained weight loss Pain > one month Pain not improved by conservative therapy Pain not relieved by bed rest CANCER SUMMARY **” In a study of nearly 2000 patients with back pain, no cancer was identified in any patient younger than 50 years & without a (NO) history of cancer, unexplained weight loss, or a failure of conservative therapy (combined sensitivity 100%)1 Sensitivity 100% = zero false negatives  ABSOLUTE CONTRAINDICATIONS4 WHO Guidelines list of ABSOLUTE CONTRAINDICATIONS for HVLA adjusting: Some anomalies (dens hypoplasia, unstable or os odontoideum, etc) Acute fracture Acute infection Spinal malignancies, meningeal & spinal cord tumors, soft tissue/muscle neoplasia Hematomas (cord or canal) “Frank disc herniation with accompanying signs of progressive neurological deficit”4 Basilar invagination or Arnold Chiari malformation (upper cervical) Vertebral dislocation  ABSOLUTE CONTRAINDICATIONS4 CONTINUED WHO Guidelines list of ABSOLUTE CONTRAINDICATIONS for HVLA adjusting (continued): Aggressive benign tumors Internal stabilization/fixation devices Positive Kernig’s (meningitis) or Lhermitte’s sign (MS) Congenital, generalized hypermobility Signs or patterns of instability Syringomyelia Hydrocephalus (unknown etiology) Diastematomyelia CES cauda equina syndrome SPINAL INFECTIONS Acute spinal infections are absolute contraindications to HVLA thrusts. Ex: Osteomyelitis Septic discitis TB of the spine LBP caused by spinal infection – incidence.01% Usually bloodborne (pt w/ discogram) Presence of fever: high specificity (SPIN: specificity + rules in) SPINAL INFECTIONS Look for a history of: UTI Catheters Skin infections Injection sites IV drug users ** One of these sites identified in 40% of pts presenting with spinal infection SPINAL INFECTIONS Specificity (high)- Positive test rules in –”SPIN” Presence of fever (+) confirming (rules in) spinal infection 2% of pts. with mechanical LBP have fever w/o spinal infection10 Sensitivity (varies)- Negative rules out – “SNOUT” Absence of fever (-) ruling out spinal infection False negative - no fever, but does have spinal infection COMPRESSION FRACTURES Common in patients with osteoporosis (included under ‘systemic diseases’) Red Flags Osteoporosis Corticosteroid usage >70yoa >50yoa History of trauma HISTORY OF TRAUMA: SLED VS. TREE 17 yo male was sledding backwards when the sled hit a tree stump Patient stood up immediately after the accident (momentarily) before he fell to the ground Severe pain at T8/9 with no radiating symptoms Arrived at Pagosa Springs Medical Center via ambulance CT Scan with contrast revealed 5 burst/compression fractures: T8,T9,T10,T12,L1with microfractures of the trabeculae at T11 HISTORY OF TRAUMA: CT SCAN HISTORY OF TRAUMA / COMPRESSION FRACTURES  COMPRESSION FRACTURES Specificity = positive rules in Patient > 70yoa? Yes + LBP= 96% specific for compression fracture Patient > 50yos? Yes + LBP = 61% specific for compression fracture COMPRESSION FRACTURES Long term corticosteroid usage?- very high specificity (.99) Treat as a compression fracture until proven otherwise Is there a history of trauma? Yes + LBP = 85% specific for comp fracture Low sensitivity –Most patients with a history of compression fracture do not have history of trauma high specificty + rules in Low sensitivity – does not rule out ANKYLOSING SPONDYLITIS 5 SCREENING QUESTIONS FOR AS: Morning stiffness? Discomfort improves with exercise? Onset before 40yoa? Did symptoms begin slowly? Has the pain persisted for a minimum of 3 months? ***4 or more yes answers = + screening test result (warrants further investigation) + Screening test result warrants further investigation, NOT + for AS ANKYLOSING SPONDYLITIS If the pt answers ‘yes’ to at least 4/5 of the screening questions+ for AS Predictive value of a + screening test is typically low for very rare conditions Sensitivity and specificity vary from one study to another How accurate is the screening? Accurate enough to look for signs of AS during the physical examination ANKYLOSING SPONDYLITIS Physical Examination Schober test: to quantify decrease in flexion Decreased flexion is equally common in pts w/ chronic LBP/spine tumors Spine flexion is of limited diagnostic value (for AS) Spinal ROM very useful in locating spinal fixations, planning, & monitoring physical therapy EVIDENCE OF NEUROLOGIC COMPROMISE Causes of neurologic compromise: Herniated disc may compromise neurological structures: cauda equina, sc, n. roots Nerve Root Entrapment in the IVF Bony/ligamentous hypertrophy Spinal stenosis Spinal/paraspinal infections SOL SYMPTOMS OF NEUROLOGICAL COMPROMISE Caused by irritation of the s.c./nerve roots/nerves Motor dysfunction Reflex dysfunction Sensory dysfunction Rarely bowel/bladder dysfunction (consider CES) SYMPTOMS OF NEUROLOGICAL COMPROMISE Peak incidence 30-55 yoa Sciatica: sharpburning pn in posteriorlateral leg to the foot May be associated with numbness/tingling/paresthesia May be aggravated by coughing/sneezing/valsalva  Another good video on stenosis https://www.youtube.com/watch?v=XwgmzhuTev8 REFERENCES 1. The Rational Clinical Examination Evidence Based Clinical Diagnosis, David Simel, MD, MHS Drummond Rennie, MD 2. Bergmann & Peterson. Chiropractic Technique. 3rd ed., Elsevier Health Sciences, 2010. 3. Berhane T, Vetrhus M, Hausken T, Olafsson S, Søndenaa K. Pain attacks in non-complicated and complicated gallstone disease have a characteristic pattern and are accompanied by dyspepsia in most patients: the results of a prospective study. Scand J Gastroenterol. 2006;41(1):93-101. doi:10.1080/00365520510023990 4. WHO Guidelines on Basic Training and Safety in Chiropractic. 2005. 5. Waddell G, McCulloch JA, Kummel E, Verner RM. Nonorganic physical signs in low back pain. Spine. 1980:5(2):117-125