Introduction to Clinical Neurology

Acute Low Back and Neck Pain

Daniel Lowenstein, MD Andy Josephson, MD Wade Smith, MD, PhD

John Engstrom, M.D.

Professor of Neurology Adult Neurology Residency Program Director Betty Anker Fife Endowed Professor of Neurology Department of Neurology, UCSF School of Medicine Potential Conflicts of Interest
! None

Learning Objectives

Learning Objectives-Epidemiology
o! Be able to explain the impact of back and neck pain on public health o! Be able to list the risk factors by history and examination for serious causes of back and neck pain o! Be able to explain how the function of anterior spine differs from the posterior spine o! Be able to describe the course of lumbar nerve roots from the lower spinal cord to the exit of the spine

Learning Objectives-Patient Evaluation

o! Explain how the history and examination of a patient is used in clinical management o! Be able to describe the significance of: o! Straight-leg raising and reverse straight leg raising signs o! Focal palpation tenderness over the bony spine o! Pain with passive internal or external rotation of the leg at the hip o! Describe the utility of plain x-rays, CT scans, and MRI imaging of the spine

Learning Objectives-Neuro Evaluation

o! Describe the distribution of reflex, motor, and sensory findings for injury to the L4, L5, and S1 nerve roots o! Describe the distribution of reflex, motor, and sensory findings for injury to the C6, C7, and C8 nerve roots o! Describe initial non-pharmacologic and pharmacologic treatment of non-specific acute low back pain o! Describe the indications for surgical treatment of a herniated lumbar disk

Epidemiology and Risk Factors

Background: Importance
o! Back and neck pain are the second most common reason for neurologic consultation o! 1% of US adults are chronically disabled due to back or neck pain o! 70% of adults will experience back or neck pain during their lives

Scope Impact of Back/Neck Pain

o! Annual cost in USA > $100 billion/year o! Direct medical costs o! Indirect costs (e.g.-loss of work hours) o! Back pain is the most common reason for long term opioid use o! Need for an organized, rational approach to initial assessment and management

Use of Risk Factors and Algorithms

o! Risk factor assessment for serious causes of back or neck pain allow us to determine who needs detailed clinical assessment o! This initial assessment allows us to assign patients into those with symptoms likely to be of benign origin and those for whom a serious underlying cause needs further consideration

Risk Factors by Clinical History-I

o! Prior history of cancer o! Pain worse at rest or at night o! History of chronic infection-skin, lungs, urinary tract, poor dentition o! History of spine trauma

Risk Factors by Clinical History-II

o! Chronic corticosteroid use o! Intravenous drug use o! Rapidly progressive neurologic deficit o! Age > 70 years

Acute Low Back Pain-Natural History o! 85-90% of patients return to functional baseline in 12-16 weeks o! Treat symptoms o! Reassurance!

Anatomy

Basic Spine Anatomy

o! The spine is divided into 4 regions: cervical, thoracic, lumbar, and sacral o! Each region has a normal curvature o! Each vertebra of the spine is separated from its neighboring vertebra by a disk o! Sacral vertebra are fused as the sacrum

Segmental Spine Anatomy

o! Each vertebra protects a central spinal canal though which the spinal cord passes from the neck to the lower back o! The anterior spine (blue arrows)-absorbs the force of vertical body movements
! Disks act as shock absorbers ! Vertebra provide stability in the vertical plane

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Segmental Spine Anatomy

o! The posterior spine (blue arrows)-two transverse processes, spinous process, two lamina, two facet joints, two pedicles o! Tendon insertion sites for the paraspinal muscles-act as long pulleys for postural movements of the back o! Adjacent vertebrae meet posteriorly at the facet joints-fine postural movements

Special Clinical Lumbar Anatomy

o! Spinal cord normally ends (conus medullaris) at L1-2 level o! A cluster of lumbar nerve roots follow a long course within the lumbar spinal canal o! A lumbar puncture for spinal fluid examination (LP) is performed in the low lumbar regionthere is no danger of spinal cord injury

Pathophysiology

Pain From Injury to the Spine

o! Most benign causes of acute back pain resolve on their own o! Pain sensitive spine structures-periosteum, facet joints, outer disk, vessels, ligaments, dura (sac in the spinal canal that contains the spinal fluid) o! Nerve roots (radiculopathy)

Spine Pain: Serious Causes-Tumor o! Usually due to metastatic spread of tumor from the body to the vertebral body o! History-prior history of cancer, weight loss, fever, pain worse at rest or at night, pathologic spine fracture, age >70 years o! Focal spine tenderness o! Focal neurologic deficits by examination

Spine Pain: Serious Causes-Infection

o! Usually due to blood-borne spread of bacteria from a body source to the vertebral body o! Chronic infection sources-skin, urine, lungs o! History-weight loss, fever, pain worse at rest or at night, pathologic spine fracture, age >70 years, chronic corticosteroid use, intravenous drug use o! Focal spine tenderness o! Focal neurologic deficits by clinical examination

Spine Pain: Serious Causes-Fracture o! Obvious trauma-MVAs, falls o! Pathologic fractures with minor trauma but structurally weakened vertebra-infection, tumor, osteoporosis, chronic steroid use o! Associated focal neurologic deficits associated with findings of spinal cord injury, nerve root injury, or both

Back Pain-Focal Neurologic Deficits o! Focal neurologic deficits (FND) may indicate nerve root or central nervous system (e.g.-spinal cord or brain) injury o! FND from an unrelated peripheral nervous system injury (e.g.-peroneal neuropathy) o! Diagnosis is determined by associated history and examination, and some testing

Non-Spinal Causes of Back Pain

o! Not all back pain arises from the spine
! Cuts, trauma, burns, inflammation of the overlying skin or soft tissues can cause pain ! Referred pain from viscera of the abdomen or pelvis, or bones/joints of the pelvis ! Pain associated with paraspinal muscle, tendon, or ligament injury

Non-Spinal Low Back Pain: AAA

o! Abdominal aortic aneurysm (AAA) o! Classic: Back pain, abdominal pain, shock o! Presents as back pain only in 20% o! Misdiagnoses non-specific back pain, diverticulitis, renal colic, myocardial infarction o! Pulsatile abdominal mass on exam in 50-75% o! High risk: Older smokers with atherosclerosis

Back and Leg Pain-Significance

o! Nerve root injury-pain in a dermatomal distribution of a nerve root with or without focal neurologic deficits by examination o! Referred pain-pain often circumferential in the limb or crossing multiple dermatomes, but there are no focal neurologic deficits o! Combination of referred and nerve root injury pain can be difficult to assess

Clinical Presentation

Acute Back/Neck Pain: Assessment

o! Risk factor assessment determines how to proceed in the patient evaluation o! If no risk factors, then treat symptoms with primary goal of return to normal function o! History-prior cancer, trauma, fever, weight loss, pain at rest or night, focal neurologic deficit, chronic infections, IV drugs, chronic steroid use, age > 70 years

Acute Back Pain Risk Factors: Exam o! Unexplained, documented fever o! Unexplained, documented weight loss o! Abdominal, rectal, or pelvic mass o! Rapidly progressive focal neurologic deficit o! General examination findings o! Neurologic examination findings

Acute Back Pain Risk Factors: Exam o! Palpation tenderness over spine o! Straight-leg raise (SLR) or reverse straight leg raise (RSLR) examination signs o! Hip pain elicited by passive internal or external rotation of the leg at the hip

Exam Signs: Focal Spine Tenderness o! Palpation over spinous process transmits force through the posterior bony spine to the vertebral body anteriorly
! Pain-sensitive structures that are not normal may be affected to produce pain ! Control stimuli over parasp muscles or other spine levels shows if pain is genuinely focal

Exam Signs: Nerve Tissue Stretch

o! Straight-leg raising-Places traction on the L5 or S1 roots, or sciatic nerve by passive flexion of the entire leg at the hip (sciatic nerve and roots posterior to the hip) o! Reverse straight-leg raising-Places traction on the L2, L3, or L4 roots or femoral nerve by passive extension of the entire leg at the hip (femoral nerve and roots anterior to the hip)

Nerve/Root Stretch Signs: Interpretation

o! If the maneuver reproduces the typical back or leg pain, then the sign is present o! If the maneuver elicits back or leg pain of different quality or location, sign is absent o! If the maneuver elicits stretching of the hamstring or other muscles, sign is absent

Passive Leg Rotation at the Hip

o! Passive rotation of the leg at the hip can be performed in supine or seated positions o! If passive internal or external rotation reproduces the patients back or leg pain, then hip pathology must be considered

Demonstration of Root Findings

o! Common Cervical Roots (C6, C7, and C8) o! Common Lumbar Roots (L4, L5, and S1)

Lumbosacral Root- Neuro Exam Findings

Root L4 L5 Motor Quadriceps (knee extension) Peronei (foot eversion) Abductor hallucis (toe flexors) Reflex Knee None Sensory Medial calf Pain Distribution Medial calf

Lateral calf, Posterolat thigh; dorsal foot Lat calf, dorsal foot S1 Ankle Sole foot Posterior thigh/calf Sole foot

Cervical Root: Neuro Exam Findings

Root C6 C7 Motor Biceps brachii (arm flexion) Triceps (arm extension) Finger extensors Reflex Biceps Triceps Sensory Pain Distribution Lateral hand, Lateral hand, forearm forearm, arm Dorsal forearm, Posterior arm, dorsal hand, dorsal forearm, Third finger dorsal hand Medial hand, Medial arm, medial forearm medial forearm, medial hand

C8

Abductor pollicis brevis Finger (thumb abduction) flexors

Nerve Root Injury Caveats

o! Disk herniations are frequently asymptomatic o! The localization of nerve root injury only begins the process of finding a cause
! Disk herniation is one common cause ! Bony compression at the foramen is another ! Tumor, infection or fracture are others

Spinal Stenosis and Neurogenic Claudication o! Neurogenic claudication-exertional leg pain relieved by sitting and present when standing or walking
! Not present using a stationary bike like vascular claudication ! Improves when walking partially bent forward (e.g-shopping cart) ! Due to severe lumbar spinal stenosis

o! Lumbar spinal stenosis is an abnormally narrowed lumbar spinal canal

! Frequently asymptomatic, even when severe ! Rarely causes cauda equina syndrome

Diagnosis

Initial Approach to Acute LBP

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Role of Spine Imaging

o! Plain x-rays show bony integrity only, no soft tissue detail-good for fractures o! CT scans show bony anatomy in multiple planes-good for fracture, tumor, infection o! MRI shows soft tissue detail-excellent for tumor, infection; good for fracture o! CT or MRI can often distinguish between infectious, neoplastic, fracture, and other etiologies

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Role of Electromyography Studies

o! Stimulate nerves along their course and record over same nerve or muscles o! Assess electrical activity patterns in muscle to determine if muscle and nerve supply to the muscle are normal o! Semi quantitative measure of motor and sensory function o! Localize nerve tissue injury to root or nerve o! Assess severity of nerve tissue injury

Treatment

Acute Back Pain-Initial Drug Rx

o! Patients should consult their health care provider regarding the need for an office visit and to discuss medication choices, especially if other illnesses are present or other medications are being taken o! There is no evidence that narcotics are better than acetaminophen or non-steroidal drugs for the initial treatment of acute low back pain o! The approach I outline is based upon clinical evidence, mindful of cost, and based upon my experience o! Learn to tailor your approach to individual patient circumstances (e.g.-need for prompt return to work, tailoring dose to symptoms)

Acute Back Pain-Nonpharmacologic Rx

o! Limited bed rest not more than two days, then progressive ambulation o! Avoid heavy exertion or activities that clearly exacerbate symptoms o! Cold packs acutely x 15-20 minutes
! ! ! !

Temporary relief-useful at night to promote sleep Supine on cold pack with wet cloth between skin and pack Store 2-3 packs in a freezer and rotate Substitute frozen peas or plastic bag of ice

Acute Back Pain-Initial Drug Rx

o! Nocturnal skeletal muscle relaxants may relieve paraspinal muscle spasm and promote sleep
! Drowsiness limits daytime use ! Cyclobenzaprine 5-10mg by mouth at night only

o! Consider ibuprofen 400mg by mouth 3 times/day for 4 days

! Acute back pain is often inflammatory and justifies using non-steroidal medications as first-line agents ! If effective follow published guidelines for further dosing ! If ineffective proceed to acetaminophen

Acute Back Pain-Initial Drug Rx

o! Consider acetaminophen 650mg by mouth 3 times/day for 4 days
! If effective follow published guidelines for further dosing ! If ineffective begin acetaminophen + ibuprofen for 4 days

o! Opioid analgesics are best used for patients who do not tolerate acetaminophen or non-steroidals o! Steroids or neuropathic pain medications that treat nerve pain are not initial treatments for low back pain

Acute Back Pain-Patient Education

Provide reassurance about the usual favorable outcome! Anticipate 85% return to functional baseline at 12 weeks 2/3 seen in primary care first are better by 7 weeks! Avoid unnecessary diagnostic testing for patients without risk factors o! Establish a mechanism for follow-up if symptoms worsen o! The evolution of new symptoms or focal neurologic symptoms should prompt a follow-up physician visit o! o! o! o!

Disk Herniation: Surgical Indications

o! Spinal cord compression o! Progressive motor weakness by exam o! Cauda equina (the many roots that fill the lumbar spinal canal) or conus medullaris (distal spinal cord) syndromes o! Intractable Pain Most common and controversial reason

Summary

Acute Low Back/Neck Pain: Summary

o! Back and neck pain are costly public health issues and common problems for patients o! Use your understanding of spine anatomy and function to consider the many possible etiologies for back pain o! Use your knowledge of historical and exam risk factors for serious causes of back pain to decide who needs further assessment or symptomatic management

Acute Low Back/Neck Pain: Summary

o! Consider tumor, infection, or fracture as possible etiologies for patients with risk factors for a serious cause o! Not all disk herniations require surgery o! Have a simple and cost-effective initial approach to symptomatic management for patients lacking risk factors o! Educate these patients and reinforce the overall excellent prognosis in the absence of unnecessary testing