LOW BACK PAIN Sign and symptom ANDALIB A

LOW BACK PAIN Sign and symptom ANDALIB. A. MD Orthopaedic surgeon and fellowship of spine surgery

Is This Really A Problem? • 80 % 0 f adults in industrial countries have at least one episode of disabling back pain. • By the 3 rd decade 50% of people have experienced an episode of LBP that required alteration in activity. • In spite of “optimal management” 5% of acute back pain progresses to a chronic and disabling endpoint. Spengler 1986

Is Back Pain a Problem? • 86 million Americans suffer from chronic pain • 66 million are partially disabled • 8 million are totally disabled from back pain • There are 65, 000 cases of pain related permanent disability diagnosed each year. Medical Data International 1998

Is Back Pain a Problem? Pai found in 20041 that in the U. S. low back pain was the • Second leading symptomatic cause for physician visits • Third most common cause for surgical procedures • Fifth most common reason for hospitalization. 1. Pai S, Sundaram LJ. Low back pain: an economic assessment in the united states. Orthop Clin N Am. 2004; 35: 1 -5.

Is Back Pain a Problem at Work? Absences from Work In 1999, back pain accounted for 40 percent of absences from work, second only to the common cold. Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in US industry and estimates of lost workdays. AM J Public Health. 1999; 89: 1029 -1035.

Clinical Evaluation • Test for Patient Malingering: – Malingering – medical and psychological terms that refers to an individual fabricating/exaggerating their level of symptoms • Financial compensation (fraud) • Avoiding work • Obtaining drugs • Attract attention or sympathy DR. ANDALIB 6

New Topic: Duration of symptoms It is generally useful to break back pain into three categories according to duration of symptoms: 1. 2. 3. Less than eight weeks duration Eight weeks-six months duration Greater than six months duration

Diagnoses we don’t want to miss • • Tumor (of bone or viscera) Infection Fracture Any process resulting in severe compromise of nervous tissue • Systemic illnesses affecting joints • Leaking abdominal aortic aneurysm

Back pain without radiculopathy 8 weeks - 6 months Further evaluation • Plain x-ray and ESR, with flexion extension in elderly patients and patients with significant sharp sudden pain with movement. – Fracture, instability, infection, tumor, inflammatory spondylitis

How not to miss them History: the nine red pain flags • Prominent neurological symptoms of weakness, numbness, loss of bowel or bladder control, difficulty walking • Pain is much worse at night • Fever • Other constitutional symptoms that always worry us • Patient cannot sit or stand due to pain

The nine red flags on history 2 • Pain following a fall in the elderly or in a patient at risk for osteoporosis • Leg pain is much worse than back pain • History of cancer in the last five years, particularly breast, lung, prostate, thyroid, renal • Polyarthralgias • Age<10 or >50

Historical aspects that increased suspicion for infection • Recent IV drug abuse • Immunosuppression • Diabetes

Common “benign” diagnoses in chronic back and leg pain

Predominantly back pain 1. Discogenic pain (annular tear) 2. Painful osteoarthritis of the facet joints 3. Structural pathology 1. Congenital or degenerative kyphosis/scoliosis 4. Compression fracture 5. Spondylolysis/spondylolisthesis 6. Inflammatory spondylitis 7. Visceral pathology Predominantly leg pain 1. Herniated nucleus pulposus 2. Spinal stenosis

Annular tear

Why might pain radiating down the legs to the feet occasionally, especially with heavy loads and activity?

• A Lasegue sign usually is positive on the involved side. • Contralateral leg pain produced by straight leg raising should be regarded as pathognomonic of a herniated intervertebral disc. DR. ANDALIB 20

Clinical Evaluation • Femoral Nerve Stretch Test: – Tests for nerve root impingement at L 2, L 3, L 4 – Test position: • Patient prone with a pillow under the abdomen; examiner at side of patient – Action: • Examiner passively extends hip while keeping knee flexed to 900 – Positive test: • Pain in anterior and lateral thigh DR. ANDALIB 21

All that radiates to the leg is not disease of the nerve root • Occasional, usually bilateral radiation to the feet with disc pain • Hip joint osteoarthritis can be confused with L 3 and L 4 radiculopathy • Trochanteric bursitis can be confused with L 5 radiculopathy • Sciatic nerve entrapment and S 1 radiculopathy can look identical

Pain arising from the hip joint • Always a groin component • Often lower outer buttock pain as well • Radiates to anterior thigh and knee • Worse with many of the activities that aggravate radiculopathy

Clinical Evaluation • Sacroiliac Dysfunction: – History: • Onset: – Acute or insidious • Pain characteristics: – One or both SI joints; possibly radiating pain in buttocks, groin, thigh • Mechanism: – Prolonged stress • Predisposing conditions: – Postpartum women (relaxin levels) – Hormonal levels during menstruation DR. ANDALIB 24

• Sacroiliac Joint Stress Test: – Test position: • Subject supine – Action: • Examiner applies outward and downward pressure with the heels of both hands – Positive finding: • Unilateral pain at SI joint or in gluteal/leg region is indicative of anterior SI ligament sprain DR. ANDALIB 25

• Sacroiliac Joint Stress Test: – Test position: • Subject side-lying; examiner stands next to patient and places both hands (one on top of the other) directly over the subject’s iliac crest – Action: • Apply downward pressure – Positive finding: • Increased pain indicative of SI pathology (possible involvement of posterior SI ligament) DR. ANDALIB 26

Clinical Evaluation • Patrick or FABER Test: – Test position: • Subject supine – Action: • Examiner passively flexes, abducts, and externally rotates the involved leg until the foot rests on the top of the knee of uninvolved lower extremity; examiner slowly abducts the involved lower extremity towards the table – Positive test: • Involved lower extremity does not abduct below level of uninvolved side – SI pathology, iliopsoas tightness DR. ANDALIB 27

Clinical Evaluation • Gaenslen’s Test: – Test position: • Subject supine, lying close to edge of table; examiner stands at side – Action: • Slide patient to edge of table; patient pulls far knee up to the chest; near leg allowed to hang over edge of table • Examiner applies downward pressure on near leg, forcing it into hyperextension – Positive finding: • Pain in SI region indicating SI joint dysfunction DR. ANDALIB 28

Spinal stenosis • The clinical presentation is neurogenic claudication

Spinal stenosis • However, claudication often coexists with back pain because they derive from the same process: degenerative disease of the spine

Spinal stenosis – Classical presentation: • Bilateral thigh and or lower extremity pain for canal stenosis • Unilateral dermatomal radicular pain foraminal stenosis – Variant presentation: • Buttock pain only with standing and walking

Plan ahead, don’t hurry Move in close when placing object on high shelf Lift with leg muscles 33 Tighten stomach muscles Bend knees Don’t twist Spread feet shoulder DR. ANDALIB distance apart 33

Thank you for attention