Evaluation and Management of Low Back Pain

Dr H.M.P.S.Herath

Acting Consultant in Sport and Exercise Medicine

Teaching Hospital - Kalutara

Outline

• Introduction and epidemiology
• Evaluation – History, Examination, Investigations
• Classification
• Systemic/serious pathology
• LBP with specific pathology
• Non-specific LBP
• Genral overview of non-operative treatment modalities

Specific LBP

Introduction

• Low back pain (LBP) is the most common cause of disability in those under the age of 45 years
• In developed countries it’s said to be the most expensive healthcare problem in those between the ages of 20-50 yrs
• Estimated annual cost of LBP in US said to be over USD 40 billion

Epidemiology

• Back pain affect up to 85% of the population at some time in their lives.
• It is rare before age of 10 yrs
• Majority (70-80%) will improve from an acute episode over a 3-month period
• 50-80% will have at least one recurrent episode
• Up to 20-30% LBP can become persistent and disabling (affecting ADL, quality of life)

Evaluation

• History
• Examination
• Investigation

History

• Personal information
• Gender
• Age
• Sport/s – type, level

History

• Evaluation of pain
• SOCRATES
• Site – Midline, L/S, R/S, mixed
• Onset – acute, insidious (in acute – presence of injury, mode of injury)
• Character – aching, burning, spasms, sharp, shooting, throbbing
• Radiation 🡪 sciatic pain
• Associated symptoms – e.g. neurological symptoms
• Time/Duration – acute, subacute, chronic, acute on chronic
• Exacerbating/relieving factors – movements/activities, time of day, rest pain
• Severity – pain score

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Mechanical vs inflammatory pain

History ctd.

• Red flags
• LOA, LOW, night pain
• Inflammatory type pain
• Fever, night sweats
• Cauda equina syndrome features
• Saddle back anaesthesia
• LL motor weakness
• B/L LL pain
• Urinary retention
• Fecal incontinence
• Presence of severe trauma
• Steroid / immunosuppression use

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History ctd.

• Family history – e.g inflammatory arthritis, malignancies
• Past medical history – e.g. TB, tumours
• Past surgical history – spinal surgeries
• Medication history – e.g. corticosteroids, immunosuppresants
• Occupational history/sport and training history
• IV drug use, smoking
• Differential diagnosis
• GU symptoms
• GI symptoms
• Gyaenocological & obstetric symptoms

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Examination

• Gait
• Inspection – posture, scoliosis, kyphosis, features of inflammatory arthritis
• Palpation
• Tenderness
• midline – spinous process/ intervertebral space
• Paraspinal muscles
• Facet joints
• Other muscles – latissimus dorsi, oblique muscles
• SI joint
• Muscle spasms/trigger points
• Step off sign/low midline sill sign - indicative of spondylolisthesis
• Sensitivity - 60-88%
• Specificity - 87-100%

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Examination ctd.

• ROM
• 3 planes
• Sagittal plane – Flexion, extension
• Coronal plane – Lateral flexion
• Horizontal plane – Lateral rotation
• Observations
• Pain
• limitations

Examination ctd.

• Lumbar quadrant test/ kemp test/extension-rotation test
• For assessment of useful for diagnosing pain related to facet joint pathology, lumbar spinal stenosis
• Low back pain predominant – facet joint pathology
• Neurogenic claudication type pain – lumbar spinal stenosis
• Sensitivity – 50-70%
• Specificity - 65-70%

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• Stork standing test
• For assessment of pars interarticularis fracture
• Sensitivity – 50-70%
• Specificity – 17-30%

Examination ctd.

• Neuroprovacative tests
• SLRT
• To detect lumbar radiculopathy - Usually L4, L5 nerve root involvement
• Sensitivity – 90%
• Specificity – 25%

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• Cross SLRT
• Sensitivity – 30%
• Specificity – 90%

Examination ctd.

• Neuroprovacative tests
• Reverse SLRT/Femoral nerve stretch test
• L2, L3 nerve root (can be an positive in femoral nerve irritation too)
• Sensitivity, Specificity – no consensus

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Examination ctd.

• Neuroprovacative tests
• SLUMP test
• Indicate disc herniation or nerve root entrapment
• Sensitivity - 44-87%
• Specificity - 23-63%

Examination ctd.

• Neurological evaluation
• Lower limb neurology
• Motor – tone, power, reflexes
• Sensory – pain, touch, proprioception
• Spinal shock
• DRE
• Absent bulbocavernosus reflex
• Other
• Examination related to suspecting pathology (General examination and specific examination)
• e.g. Neoplasms, inflammatory arthritis

Examination ctd.

• Other musculoskeletal examinations
• SI joint, sacrum
• Gluteal musculation
• Hip joint
• Functional tests – squats, lunges, hops, step-ups, eccentric drop squats,
• Sorensen test
• Higher spinal levels – cervical, thoracic

Investigations

• Radiographs
• Indications
• Red flag features
• History of significant trauma
• Pain > 1 month and not responding to non-operative management
• Views – AP views, lateral views, oblique views, flexion/extension views
• Useful in,
• Diagnosing fractures
• Identify degenerative changes, malignant changes
• Changes in spinal alignment, diagnosing spondylolisthesis
• etc.

Investigations

• Bone scans/scintigraphy
• Indications
• Suspicious for osteomyelitis, bone malignancy, stress injuries or occult fracture when radiographs are normal
• Relatively low radiation risk

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• Limitations
• High sensitivity but poor specificity
• hypersensitivity to contrast
• Unsafe for pregnant and breastfeeding women
• Interfere by some medications – corticosteroids, bisphosphonates, iron, nifedipine, methotrexate, oestrogens, androgen antagonists, drugs that interfere osteoblast activity

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Investigations

• CT scans
• Evaluation of bony pathologies, structural stability
• Pre-surgical planning

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Investigations

• MRI scan
• Gold standard in most clinical pathologies
• Indications – neurological deficits, suspecting systemic cause (infection, malignancy), not responding to treatment, pre-surgical planning
• High sensitivity and specificity
• High rate of abnormal findings in the normal population (esp. with ageing)

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Investigations

• Electrophysiological studies (NCS and EMG)
• Useful in differentiating radiculopathy from peripheral neuropathy or myopathy
• Legal purposes
• Limitations – need patient cooperation, a limited number of muscles & nerves can be studied, timing (findings may not present until 2-4 weeks after the onset of symptoms)

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• Myelogram
• Discography

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Investigations

• USS
• Limited use in LBP
• Muscular pathologies

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• Serology and other investigations
• Neoplasms
• Inflammatory arthritis
• Infections
• Other differential diagnosis

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General Overview

General Overview

• Other
• Renal disease
• Gynaecological
• Etc.

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Serious or Systemic pathology

• Accounts for 1-2% of all low back pain

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• These include
• Malignancies
• Systemic inflammatory disorders
• Infections
• Cauda equina symptoms
• Severe trauma

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• Diagnosis should made with clinical evaluation and investigations

• Red flag symptoms
• Related examination and investigation findings

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• Refer to specific specialty

LBP with specific pathology

• Accounts for 5-10% of all LBP
• Includes
• Fractures – (traumatic/stress)
• Disc prolapse
• Spondylolisthesis
• Degenerative disease entities
• Spinal canal stenosis
• Type 1 modic changes (vertebral end plate oedema)
• Definitive diagnosis can be made after clinical evaluation and radiological investigations

Fractures

• Broadly divided into traumatic, pathological and stress fractures

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• Management
• Acute setting – ATLS protocol
• Orthopedic referral
• Pain relief
• Conservative vs operative management
• Age, comorbidities
• Presence of cauda equina symptoms and signs
• Presence of motor weakness
• Presence of segmental instability

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Lumbar disc herniation

• Peak incidence in 4^th and 5^th decade
• Lifetime prevalence in 10%, but only ≈ 5% become symptomatic
• Male: Female = 3:1
• Around 95% involve L5/S1 (most common) and L4/L5 levels

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Pathophysiology

• Usually due to recurrent torsional strain leading to tear of annulus fibrosis
• Herniated nucleus pulposus causes both mechanical compression and chemical irritation (inflammation) on nerve roots leading to classic sciatic pain
• Commonest site to herniate – posterolateral (paracentral)

Lumbar disc herniation

• Acute onset severe pain – usually after lifting a heavy object
• May preceded by a history of low-grade on-and-off back pain
• Usually have an occupational or sport-related exposure to prolonged sitting with lateral bending and/or rotation
• Symptomatic improvement with lying supine with knees and hips flexed
• Presentation
• Axial back pain (may be discogenic or mechanical in nature)
• +/- Radiculopathy features
• Usually worse with sitting and improves with standing
• Valsalva test - radicular pain may worsen
• Cauda equina syndrome (1-10%)

Classifications - Location Classification

• Central prolapse
• Often associated with back pain only
• May present with cauda equina syndrome which is a surgical emergency
• Posterolateral (paracentral)
• Most common (90-95%)
• PLL is weakest here
• Affects the traversing/descending/lower nerve root
• At L4/5 affects L5 nerve root
• Foraminal (far lateral, extraforaminal)
• Less common (5-10%)
• Affects exiting/upper nerve root
• At L4/5 affects L4 nerve root
• Herniated disc material directly compresses dorsal root ganglion
• Can manifest with more severe pain than traditional posterolateral disc herniation
• Axillary
• Can affect both exiting and descending nerve roots

Classifications - Location Classification

Classifications - Morphology classification

• Protrusion
• Eccentric bulging with an intact annulus
• Extrusion
• Disc material herniates through annulus but remains continuous with disc space
• Sequestered fragment (free)
• Disc material herniates through annulus and is no longer continuous with disc space
• Prone to proximal or distal migration

Classifications - Morphology classification

Classifications - Morphology classification

Classifications - Containment classification

• Contained
• Disc material is contained beneath the posterior longitudinal ligament
• Uncontained
• Disc material passes dorsal to the posterior longitudinal ligament

Classifications - Timing classification

• Acute
• Herniations present < 3-6 months
• Chronic
• Herniations present >6 months

Classifications – MSU classification

Disc prolapse - Investigations

• Radiographs
• To exclude other pathologies
• Non-specific features may present
• Reduce disc height, scoliosis, reduce lumbar curvature/loss of lordosis, degenerative changes of spine
• MRI
• Gold standard
• Indications – cauda equina features, motor deficit, worsening symptoms, no improvement after 6 weeks of treatment
• CT myelogram
• Indicated in patients who contraindicated to MRI
• Nerve conduction studies

Classification - MRI classification

Disc prolapse - Management

Non-operative management

• First-line treatment option for most patients
• 90% improve without surgery
• Positive predictors of good outcomes with nonoperative treatment
• higher level of education
• Factors associated with worse outcomes with nonoperative treatment
•  Obese patients (BMI >30)
• Symptoms present >6 months prior to starting treatment

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Disc prolapse - Management

1. Non-operative management
• Patient education and reassurance
• Active rest
• Medications
• Analgesics
• Paracetamol, paracetamol + codeine
• NSAIDS
• Neuropathic drugs – Pregabalin, gabapentin, amitriptyline
• Opioids – usually not recommended for the treatment of disc herniation due to the risk of addiction and side-effects. Can use if other medications failed to improve the pain.
• Muscle relaxants – can be used as an adjunct therapy
• Corticosteroids
• Oral corticosteroids – can be used as an adjunct therapy
• Selective nerve root injections

Indications – Severe disabling pain

No significant improvement after 6 weeks of treatments

• Physical therapy/Exercise therapy
• Postural correction/activity modifications

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Disc prolapse

2. Operative management (laminotomy and discectomy/microdiscectomy)
• Indications
• Failed non-operative management
• Presence of motor weakness
• Progressive symptoms
• Cauda equina syndrome – indication of emergent microdiscectomy within 48 hours

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• Better surgical outcomes if addressed within 2 months
• Surgery provides a faster improvement in pain and function compared to non-operative management
• Surgical treatment is equivalent to nonsurgical treatment in the long term

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Degenerative low back pain

• Includes facet joint arthropathy, degenerative disc pathologies (discogenic back pain), osteophytes related
• Discogenic back pain features
• Axial low back pain without radicular symptoms
• Pain exacerbated by
• Flexion
• Sitting
• Axial loading
• Neuroprovacative tests are negative�

Degenerative low back pain

Degenerative disease

• Management
• Non-operative management
• Analgesics, physical therapy, cognitive therapy, lifestyle modifications
• Operative management

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• For discogenic back pain, there is no statistically significant difference in short-term (1 year) or long-term (10 years) for patients treated with cognitive and exercise therapy compared to operative management

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1. Fritzell P, Hägg O, Wessberg P, Nordwall A; Swedish Lumbar Spine Study Group. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976). 2001 Dec 1;26(23):2521-32; discussion 2532-4. doi: 10.1097/00007632-200112010-00002.

2. Gibson JN, Waddell G. Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine (Phila Pa 1976). 2005 Oct 15;30(20):2312-20. doi: 10.1097/01.brs.0000182315.88558.9c.

3. Mannion AF, Brox JI, Fairbank JC. Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials. Spine J. 2013 Nov;13(11):1438-48. doi: 10.1016/j.spinee.2013.06.101. Epub 2013 Nov 5.

Spondylolysis – (Pars interaticularis fracture)

• Stress fracture (overuse injury)
• Usually in adolescents
• Commonly occurs in individuals with repetitive lumbar hyperextension

e.g. cricket fast bowlers, gymnasts, weight lifters

• Genetics may have a role

Spondylolysis – clinical presentation

• History
• Classic history 🡪 Healthy active adolescent who presents with acute onset of low back pain with athletic activity
• Symptoms
• Asymptomatic - many cases of spondylolysis are asymptomatic
• Low back pain - no association between radiologic grade and clinical presentation, symptoms include insidious onset of activity-related low back pain
• Lower limb symptoms
• Buttock pain
• Hamstring tightness (most common) and knee contracture
• Radicular pain (L5 nerve root)
• Listhetic crisis (in B/L spondylolysis)
• Severe back pain aggravated by extension and relieved by rest
• Neurologic deficit
• Hamstring spasm
• Bowel and bladder symptoms - rare
• Cauda equina syndrome - rare

Spondylolysis – clinical presentation

• Signs
• Palpation
• Tenderness may present
• ROM
• Limitation of lumbar extension
• Neurological evaluation
• Neuroprovacative tests may be positive
• Special tests
• Positive stork standing test

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Spondylolysis - Investigations

• Radiographs
• AP view - may see sclerosis of the stress reaction
• Lateral view - may show a defect in pars in 80%
• Oblique view - Scotty dog sign
• Bone scan
• Excellent screening tool for low back pain in children or adolescents
• High sensitivity, but poor specificity
• CT
• Best investigation mode to diagnose and evaluation
• MRI
• If neurological symptoms present

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Spondylolysis - Management

• Non-operative
• Observation alone (no activity limitations)
• Indications - asymptomatic patients
• Physical therapy & activity restriction
• Indication - symptomatic isthmic spondylolysis
• Bracing (TLSO) for 6 to 12 weeks
• Indications - acute spondylolysis
• Operative
• Pars interarticularis repair
• Multiple pars defects,
• L1 to L4 isthmic defect that has failed nonoperative management
• L5-S1 posterolateral fusion, +/- ALIF, +/- sacroiliac fusion
• L5 spondylolysis that has failed nonoperative treatment

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Spondylolisthesis

• Subluxation of one vertebral body to the adjacent inferior vertebral body

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• Depending on the direction of subluxation can divide into 2 presentations
1. Anterolisthesis (Spondylolisthesis) – anterior translation of superior vertebra
2. Retrolisthesis – posterior translation of superior vertebra

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Spondylolisthesis

• Symptoms
• Asymptomatic - many cases of spondylolysis are asymptomatic
• Low back pain - no association between radiologic grade and clinical presentation, symptoms include insidious onset of activity-related low back pain
• LL symptoms
• Buttock pain
• Hamstring tightness (most common) and knee contracture
• Radicular pain (L5 nerve root), neurogenic claudication
• Listhetic crisis
• Severe back pain aggravated by extension and relieved by rest
• Neurologic deficit
• Hamstring spasm
• Bowel and bladder symptoms - rare
• Cauda equina syndrome - rare

Spondylolisthesis

• Signs
• Inspection
• high grade/dysplastic patients may develop “heart-shaped buttocks" due to sacral prominence
• flattened lumbar lordosis
• Palpation
• Step off sign//low midline sill sign - palpable step off of spinous process
• ROM
• Limitation of lumbar flexion and extension
• Measure popliteal angle to evaluate for hamstring tightness
• Neurological evaluation
• Neuroprovacative tests may be positive
• DRE - if bowel and bladder symptoms present
• Radiculopathy features – sensory and/or motor
• Special tests
• Positive stork standing test
• Gait
• may have a crouched gait – in severely symptomatic patients

Spondylolisthesis - Classification

• Wiltse-Newman Classification – to classify the type
• Meyerding Classification – for grading

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Spondylolisthesis - Investigations

• Radiographs
• Lateral view – to measure slip grade, slip angles and pelvic incidence (pelvic tilt – sacral slope)
• Flexion and extension views – to evaluate stability
• CT
• Best investigation mode to diagnose and evaluation
• MRI
• If neurological symptoms present

Spondylolisthesis - Management

• Nonoperative
• observation alone (no activity limitations)
• Indications
• Asymptomatic patients
• Regardless of slip grade which does not correlate with clinical presentation
• Return to contact sports is controversial – need to individualize the decision
• Analgesics, physical therapy, activity restriction & lifestyle modifications
• Indications
• symptomatic low-grade spondylolisthesis
• Bracing for 6 to 12 week
• Indications
• Low-grade spondylolisthesis that has failed to improve with physical therapy
• May use in acute phase of isthmic spondylolisthesis
• Operative (fusion methods)
• Indications
• Low-grade spondylolisthesis (myerding grade I and II) that,
• Failed nonoperative treatment
• Is progressive
• Presence of neurologic deficits
• Dysplastic - high propensity for progression
• High-grade spondylolisthesis (meyerding grade III, IV, V)

Lumbar spinal canal stenosis

• Narrowing of the lumbar spinal canal
• Most common reason for lumbar spine surgery in patients > 65 years old

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• Mechanism – due to obstructed by
• Bony structures
• Osteophytes - Facet osteophytes, uncinate spur (posterior vertebral body osteophyte)
• Spondylolisthesis
• Displaced fractures
• Soft tissue structures
• Herniated or bulging discs
• Hypertrophy or buckling of the ligamentum flavum
• Synovial facet cysts

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Lumbar spinal canal stenosis - Aetiology

• Acquired
• Degenerative/spondylotic changes (most common)
• Post-surgical
• Post-traumatic (vertebral fractures)
• Inflammatory (ankylosing spondylitis)
• Secondary to systemic diseases (paget disease, acromegaly, fluorosis)
• Congenital
• Short pedicles with medially placed facets
• Due to,
• Idiopathic
• Developmental (achondroplasia)

Lumbar spinal canal stenosis - Anatomic classification

• Central stenosis
• Caused by
• Ligamentum hypertrophy
• Disc bulging
• Lateral recess stenosis (subarticular recess)
• Caused by
• Facet joint arthropathy and osteophyte formation
• Foraminal stenosis
• Caused by
• A substantial loss of disk height
• Foraminal disk protrusions or osteophytes
• Angulation in the setting of degenerative scoliosis
• Extraforaminal stenosis
• Caused by far lateral disc herniations

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Lumbar spinal canal stenosis - Presentation

• Symptoms
• Back pain
• Referred buttock pain
• Leg pain - often unilateral
• Neurogenic claudication
• Pain worse with extension (walking, standing upright)
• Pain relieved with flexion (sitting, leaning forward, sleeping in fetal position)
• Lower limb weakness
• Bladder disturbances
• Recurrent UTI present in up to 10% due to autonomic sphincter dysfunction
• Cauda equina syndrome (rare)

Lumbar spinal canal stenosis - Presentation

• Examination findings
• Kemp sign
• unilateral radicular pain from foraminal stenosis made worse by back extension
• straight leg raise (tension sign) - usually negative
• Valsalva test - radicular pain not worsened by Valsalva (unlike the a herniated disc)
• May have normal neurologic exam in seated position and symptoms may be reproducible or exacerbated only with lumbar extension or ambulation
• Other neurological findings

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Lumbar spinal canal stenosis – Investigations

• Radiographs
• AP view, lateral view, may need flexion/extension views
• Myelogram – invasive
• MRI – imaging modality of choice
• CT/CT myelogram

Lumbar spinal canal stenosis – Management

• Non-operative Rx
• First line of treatment
• Analgesics (NSAIDS), physical therapy, activity modification, and corticosteroid injections

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• Operative Rx
• Indicated in
• Failed non-operative management (3-6 months)
• Progressive neurological defect
• Segmental instability/surgical instability
• risk of adjacent segment degeneration >30% at 10 years

Non-specific LBP

• Accounts for ≈ 90%
• Dilemma – in both diagnosing and management
• No pathoanatomical diagnosis that correlates with clinical presentation
• Experienced clinicians can usually identify a clear pattern of tissue sensitisation linked to specific spinal structures
• Has multidimensional in nature

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Multidimensional nature of Non-specific LBP

1. Physical factors
• Increased ROM loading/strain, non-neutral postures, chronic ‘protective muscle guarding’
2. Lifestyle factors
• Sedentary behaviour, sudden increase in activities, obesity, sleep deficits, excessive alcohol, smoking
3. Neurophysiological factors
• Various sensorimotor changes due to loss of endogenous pain inhibition related to genetic/environmental interactions, changes in neuroimmune and neuroendocrine systems, sensorimotor cortex
• Can cause,
• Proportionate pain to mechanical loading
• Disproportionate pain to mechanical loading – due to central and widespread tissue sensitisation
4. Psychological factors
• Cognitive factors, emotional factors, social stresses
5. Individual factors
• Genetics, comorbidities, athlete’s goals & expectations

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Non-specific LBP

• Diagnosis based on the exclusion of specific pathologies and comprehensive clinical evaluation including multidimensional factors
• Non-specific LBP can be suspected in
• Patient with long-standing LBP, that not responding/minimally responding to treatments
• Signs of the presence of a functional component of back pain (Waddell Signs)

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Waddell Signs

• Nonorganic signs indicating the presence of a functional component of back pain
• Superficial, nonanatomic tenderness
• Pain with simulated testing (in axial loading or pelvic/acetabular rotation)
• Inconsistent responses with distraction (e.g., Straight leg raises while the patient is sitting)
• Nonorganic regional disturbances (e.g., Nondermatomal sensory loss)
• Overreaction

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• A score of 3 or more out of the 5 categories is considered significant and the test is positive.

Screening tools for non-specific LBP

• STarT Back Screening Tool (SBST)
• Orebro screening tool

Categorization of Non-specific LBP

• 3 categories
1. Low complexity profile
2. Medium complexity profile
3. High complexity profile

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Low complexity profile

• Features
• Acute pain resolves rapidly
• Low to moderate level of pain/disability
• Mechanical pain profile
• Pain associated with physical and lifestyle risk factors
• E.g. Training loads, motor control, conditioning, lifestyle factors

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• Good coping strategies, low level of psychological distress
• Low risk on screening questionnaires

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Low complexity profile

Management

• Patient education – about the risk factors
• Reassurance regarding spine’s resilience
• Pain relief/simple analgesics if needed
• Manual therapy if movement impairments persists
• Address issues relating to: motor control, conditioning, training loads, sports techniques, lifestyle
• Graduated return to sport

Moderate complexity profile

• Features
• Moderate level of pain/disability
• Mixed pain profile
• Pain associated with physical, lifestyle and cognitive risk factors
• E.g. Training loads, motor control, conditioning, lifestyle factors, stress, fear

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• Mixed coping strategies, moderate level of psychological distress
• Medium risk on screening questionnaires

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Moderate complexity profile

Management

• Patient education – about the multidimensional factors associated with LBP
• Reassurance regarding spine’s resilience
• Pain control and management if needed
• Manual therapy if movement impairments persists
• Address issues relating to: fear, distress, motor control, conditioning, lifestyle and sports-specific factors
• Graduated return to sport

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High complexity profile

• Features
• High level of pain/disability
• Mixed/non-mechanical pain profile
• Pain dominated by cognitive and psychosocial risk factors
• E.g. depression, anxiety, stress, fear, negative beliefs, poor coping, low-self-efficacy, protective motor control +/- physical, lifestyle risk factors

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• High risk on screening questionnaires

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High complexity profile

Management

• Patient education – about the biopsychosocial nature of LBP
• Reassurance regarding spine’s resilience
• Pain control and management
• Address issues relating to: fear, distress, mood, anxiety, social stressors, coping, motor control, conditioning, lifestyle and sports-specific factors
• Psychological management may also be required
• Manual therapy if movement impairments persists
• Graduated return to sport

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Don’t Forget

• Underpinned by a strong therapeutic relationship which emphasis person-centered care, active management planning and consideration of the patient’s “life” context goals and expectations

Non-operative treatment modalities

• Patient education and reassurance of spinal integrity
• Bed rest vs Active rest
• Analgesics
• Corticosteroids
• Muscle relaxants
• Physical therapy/Exercise therapy
• Posture correction/lifestyle modifications
• Cold and/or heat therapy
• Other complementary treatment options

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Bed Rest vs Active rest

• Historically bed rest was frequently prescribed for patients with back pain
• Now not recommended due to prolongation of symptom relief, leading to chronic back pain, other comorbidities (DVT & PE, depression)
• Indications – unstable spinal fractures awaiting surgery, severe disabling back pain
• Active rest is now the preferred recommendation for patients. With activity modification/activity restriction to avoid painful arcs of motion, tasks that exacerbate the back pain, posture corrections
• Gradually increase physical activities as tolerated

Bed Rest vs Active rest

• Historically bed rest was frequently prescribed for patients with back pain
• Now not recommended due to prolongation of symptom relief, leading to chronic back pain, other comorbidities (DVT & PE, depression)
• Indications – unstable spinal fractures awaiting surgery, severe disabling back pain
• Active rest is now the preferred recommendation for patients. With activity modification/activity restriction to avoid painful arcs of motion, tasks that exacerbate the back pain, posture corrections
• Gradually increase physical activities as tolerated

Analgesics

• Paracetamol
• Paracetamol + Codeine
• NSAIDS
• Topical analgesics – sprays, balms, patches (NSAIDS/MSA/Lidocaine)
• Adjuncts – Anticonvulsants or TCA
• Opioids (weak 🡪 strong)
• Interventional analgesia
• Nerve blocks/Epidural analgesia/ Neurolytic block therapy

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Corticosteroids

• Epidural or selective nerve root corticosteroids
• Indications
• After initial nonsurgical treatments have been tried with insufficient or no pain relief, but before surgery is considered.
• If the patient is in too much pain to progress with physical therapy. An epidural injection may provide enough pain relief to engage in rehabilitative therapy

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• Absolute contraindications
• Systemic infection or local infection at the site of injection
• Bleeding diathesis or full anticoagulation
• Significant allergic reaction/hypersensitivity to anesthetic, or corticosteroid
• Local malignancy
• Patient refusal
• Relative contraindications to epidural steroid injections:
• Uncontrolled diabetes mellitus
• Congestive heart failure
• Pregnancy (due to fluoroscopy)

Corticosteroids

• Oral corticosteroids
• Among patients with acute radiculopathy due to a herniated lumbar disk, a short course of oral steroids, compared with placebo, resulted in modestly improved function and no improvement in pain.

Goldberg H, Firtch W, Tyburski M, Pressman A, Ackerson L, Hamilton L, Smith W, Carver R, Maratukulam A, Won LA, Carragee E, Avins AL. Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. JAMA. 2015 May 19;313(19):1915-23. doi: 10.1001/jama.2015.4468. PMID: 25988461; PMCID: PMC5875432.

• Oral corticosteroids for the treatment of lumbar radiating pain can be more effective in pain relief than gabapentin or pregabalin. The satisfaction of patients and physicians with the drug and objective improvement status were not inferior to that with gabapentin or pregabalin.

Ko S, Kim S, Kim J, Oh T. The Effectiveness of Oral Corticosteroids for Management of Lumbar Radiating Pain: Randomized, Controlled Trial Study. Clin Orthop Surg. 2016 Sep;8(3):262-7. doi: 10.4055/cios.2016.8.3.262. Epub 2016 Aug 10. PMID: 27583108; PMCID: PMC4987309.

Corticosteroids

• For radicular low back pain:
• Systemic corticosteroids may have small benefits on pain and function in short-term follow-up and might improve function in long-term follow-up
• Benefits appear small. But may be useful as they have few side effects when used for a short period, are widely available, and have low costs
• Systemic corticosteroids probably do not help avoid surgery
• It is unclear whether the effectiveness of systemic corticosteroids varies according to the duration of symptoms as the optimal dose and duration of treatment for radicular low back pain is unknown; avoiding higher doses may reduce the risk of harms

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• For non-radicular back pain and spinal stenosis
• Benefits of systemic corticosteroids are unclear

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Chou R, Pinto RZ, Fu R, Lowe RA, Henschke N, McAuley JH, Dana T. Systemic corticosteroids for radicular and non-radicular low back pain. Cochrane Database of Systematic Reviews 2022, Issue 10. Art. No.: CD012450. DOI: 10.1002/14651858.CD012450.pub2

(Cochrane systematic review with 13 studies)

Muscle relaxants

• Muscle relaxants are effective for short-term symptomatic relief in patients with acute and chronic low back pain

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• However the incidence of drowsiness, dizziness and other side effects is high

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• Muscle relaxants must be used with caution and left to the physician’s discretion to weigh the pros and cons and determine whether a specific patient is a suitable candidate for a course of muscle relaxants

Physical therapy/Exercise therapy

• Benefits
• Improve pain
• Improve functional limitations
• Reduce recurrence rate

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• Benefits seen in both specific and non-specific LBP conditions

Posture correction/lifestyle modifications

• Correction of functional non-neutral postures
• Avoiding pain exacerbating activities, movements

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• Avoid smoking
• Reduction of overweight/obesity

• Have both preventive and therapeutic benefits

Complementary treatment options

• Cold and heat therapy
• Cold therapy
• Analgesic properties, limit oedema in acute MSK injury, increase tolerance to exercise therapy
• Heat therapy
• Analgesic properties in chronic pains, promotion of tissue healing

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• Chiropractic, Spinal manipulation and massage
• Was moderately effective for chronic low back pain in some patients
• Chiropractic treatment of the neck may cause strokes in rare cases.

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• Acupuncture/dry needling
• Although results are sometimes modest, acupuncture is effective

in relieving chronic back pain in some patients

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Take home messages

• LBP need comprehensive history taking, examination and targeted investigations
• Don’t forget to evaluate red flags
• In chronic LBP think about non-specific LBP
• Patient education, reassurance and adequate analgesia are critical components of the management
• At all times avoid bed rest, unless really indicated
• Timely referral

References

1. Low back pain – WHO. https://www.who.int/news-room/fact-sheets/detail/low-back-pain. Updated on 19.06.2023
2. GBD 2021 Low Back Pain Collaborators. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol 2023: 5: e316-29.
3. Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]Published: 30 November 2016 Last updated: 11 December 2020
4. Brukner P, Khan K, Clarsen B, Cook J, Cools A, Crossley K et al. Clinical Sports Medicine. 5th ed. McGraw-Hill Education; 2017.p. 521-566.
5. Wheeler S.G, Wipf J. E, Staiger T.O, Deyo R., Jarvik J.G. Evaluation of low back pain in adults [Internet]. Uptodate [2022] Available from: https://www.uptodate.com/contents/evalu ation-of-low-back-pain-in-adults
6. Patel AT, Ogle AA. Diagnosis and management of acute low back pain. Am Fam Physician. 2000 Mar 15;61(6):1779-86, 1789-90. PMID: 10750882.
7. Orthobullets

Thank you