ACUTE BACK PAIN

EVIDENCE BASED APPROACH

BY DR MOHAMMAD NAEEM
 OBJECTIVES

REVIEW DIFFERENTIAL DIAGNOSIS OF THIS COMMON BUT MULTIFACTORIAL

COMPLAINT.
RECOGNIZE RED FLAGS-IMMEDIATE WORK UP.
YELLOW FLAGS FOR DELAYED RECOVERY THAT ACCOMPANY THE
COMPLAINT OF LOW BACK PAIN
 OBJECTIVES

PRIMARY CARE PHYSICIANS CAN PLAY AND ESSENTIAL ROLE IN MANAGING

SYMPTOMS & RETURN TO WORK AND FUNCTION.
EVIDENCED BASED GUIDELINES WILL ENHANCE
RECOVERY & AVOID IATROGENIC EXPENSE.
MULTIDISCIPLINARY APPROACH.
 BACK PAIN
INITIAL EVALUATION
PRIMARY CARE--50%

ORTHOPEDIST--33%

DC, PAIN
MGMT/OTHER-17%
 EPIDEMIOLOGY-NATURAL HISTORY

LIFETIME INCIDENCE OF ACUTE LOW BACK PAIN IS 60-90% OF THE

POPULATION ANNUAL INCIDENCE 5% OF POPULATION.
2ND TO 5TH CHIEF COMPLAINT SEEING PRIMARY CARE SPECIALISTS.
NATURAL HISTORY OF ACUTE LOW BACK PAIN FAVORABLE-90% RESOLVE
WITHIN IN 6-12 WEEKS.
VS. CHRONIC LOW BACK PAIN-13 MILLION PHYSICIAN VISITS ANNUALLY FOR-
PREVALENCE, DISABILITY & EXPENSE REMAIN HIGH.
 EPIDEMIOLOGY

EPIDEMIC OF BACK PAIN IN INDUSTRIALIZED COUNTRIES.

ONE OF THE MOST EXPENSIVE MEDICAL CONDITIONS, ESPECIALLY WHEN WORK DISABILITY
IS CONSIDERED.
2005 EXPENDITURES TO TREAT ~86 BILLION ANNUALLY.
AN ILLNESS IN SEARCH OF A DISEASE
MULTIPLE SYNONYMS-LUMBAR SPRAIN/STRAIN, LUMBAGO, REGIONAL BACK PAIN,
MUSCULOLIGAMENTOUS STRAIN, SPRAIN.

JAMA 2015
 NATURAL HISTORY

LBP/MUSCULOSKELETAL COMPLAINTS ARE THE SECOND TO FIFTH MOST

COMMON REASON FOR OUTPATIENT PRIMARY CARE PHYSICIAN VISITS.
MOST RESOLVE WITH CONSERVATIVE MEASURES.
HOWEVER, ONLY 14% HAVE LBP AS LONG AS 2 WKS.
1.5% PRESENT WITH SCIATICA.
98% OF CLINICALLY IMPORTANT DISC HERNIATIONS OCCUR AT L4-5 (THE L5
ROOT) OR L5-S1 (THE S1 ROOT).
 TOP 10 MOST
COMMON REASONS FOR SEEING THE DOCT
OR
WERE (14K PATIENTS).
1. SKIN DISORDERS, INCLUDING CYSTS, ACNE AND DERMATITIS.
2. JOINT DISORDERS, INCLUDING OSTEOARTHRITIS.
3. BACK PROBLEMS.
4. CHOLESTEROL PROBLEMS.
5. UPPER RESPIRATORY CONDITIONS.
6. ANXIETY, BIPOLAR DISORDER AND DEPRESSION.
7. CHRONIC NEUROLOGIC DISORDERS.
8. HIGH BLOOD PRESSURE.
9. HEADACHES AND MIGRAINES.
10. DIABETES.
ST. SAUVER, JL. J. MAYO CLINIC PROCEEDINGS. 2013. VOL 88, NO 1, PP. 56-7.
 GUIDELINES

AMERICAN COLLEGE OF PHYSICIANS AND THE AMERICAN PAIN SOCIETY

FORMED THE CLINICAL ANNALS OF INTERNAL MEDICINE (2012). TWO PRIMARY
PRINCIPLES:

1. MOST LOW BACK PAIN IMPROVES WITHOUT INTERVENTION, AND ALTHOUGH

THE HISTORY AND PHYSICAL ARE THE CORNER STONES OF MANAGEMENT
2. COSTLY RADIOLOGIC EVALUATION OF PATIENTS WITH LOW BACK PAIN WAS
STILL POPULAR IN 2012.
 PRIMARY DIFFERENTIAL

DETAILED HISTORY & PHYSICAL EXAMINATION TO DETERMINE:

1. THE PRESENCE OF RED FLAGS FOR URGENT CONDITIONS-

MUSCULOSKELETAL VS. OTHER ETIOLOGIES.
2. NON-SPECIFIC REGIONAL BACK PAIN-PAIN IS TYPICALLY AXIAL IN LOCATION
THAT PREDICTS FAVORABLE COURSE.
3. RADICULOPATHY/OTHER NEURO RELATED SPINE CONDITION.
 RED FLAGS

A FOCUSED MEDICAL HISTORY, WORK HISTORY AND PHYSICAL EXAM.

EVALUATION OF UNDERLYING CONDITIONS, INCLUDING SOURCES OF
REFERRED SYMPTOMS IN OTHER PARTS OF THE BODY.
FREQUENCY, INTENSITY AND DURATION OF COMPLAINTS.
AGGRAVATING AN RELIEVING FACTORS.
HISTORY AND PHYSICAL FINDINGS THAT RAISE SUSPICION FOR SERIOUS
UNDERLYING DISORDERS= RED FLAGS
 RED FLAGS-FOR BACK PAIN

AGE OVER 50.

UNEXPLAINED WEIGHT LOSS, HISTORY OF CANCER.
PERSISTENT FEVER; RECENT BACTERIAL INFECTION.
HISTORY OF INTRAVENOUS DRUG USE.
IMMUNOCOMPROMISED.
URINARY OR STOOL INCONTINENCE/URINARY RETENTION.
TRAUMA.
NEUROLOGIC DEFICIT, WEAKNESS.
Rule out red flag diagnoses, including diagnostic studies, for specialist
referral:
o Cauda Equina Syndrome (Schedule emergency procedure)

o Fracture, Compression fracture, Dislocation, Wound

o Cancer, Infection

o Dissecting/Ruptured Aortic Aneurysm

o Others (prostate problems, endometriosis/gynecological disorders,

urinary tract infections, & renal pathology)

LARGE CENTRAL L5-S1 DISC HERNIATION
Anterior compression fractures may present with
stiffness but no pain or tenderness of the spinous
processes.
 WHAT ARE YELLOW FLAGS?

RISK FACTORS FOR DELAYED FUNCTIONAL RECOVERY.

MULTIPLE PRIOR INJURIES, PROLONGED OR MULTIPLE ABSENCES, VICTIM OF
ABUSE IN THE PAST, SMOKING, ETOH ABUSE, FH OF DISABILITY,
DEPRESSION, CHEMICAL DEPENDENCY, STRESS, JOB DISSATISFACTION,
ADVERSARIAL RELATIONSHIP, SEVERITY OF SYMPTOMS, DELAYED
PRESENTATION, CHRONIC PAIN SYMPTOMS, MULTIPLE DIAGNOSES, MULTIPLE
PERSONAL OR OCCUPATIONAL/PERSONAL INJURY BACK/NECK CLAIMS,
EXCESSIVE PHYSICAL MEDICINE TREATMENT, ECONOMIC, LEGAL FACTORS,
SUBJECTIVE> OBJECTIVE FINDINGS.
 PAIN

ACCORDING TO THE INTERNATIONAL ASSOCIATION FOR THE STUDY OF PAIN (IASP):

PAIN IS AN UNPLEASANT SENSORY AND EMOTIONAL EXPERIENCE ASSOCIATED WITH ACTUAL OR POTENTIAL
TISSUE DAMAGE. BASED ON THIS DESCRIPTION, A FEW THINGS BECOME APPARENT.
PAIN IS BY DEFINITION SUBJECTIVE; PAIN HAS AN EMOTIONAL COMPONENT; AND PAIN MAY OR MAY NOT BE
CAUSED BY ANY ACTUAL DAMAGE. HOW DOES THIS RELATE TO THE APPROACH TO PATIENTS WITH LOW BACK
PAIN? WHEN PHYSICIANS TRY TO UNDERSTAND A PATIENTS SUBJECTIVE EXPERIENCE OF PAIN, THEY NEED TO
ADDRESS THE EMOTIONAL COMPONENT OF PAIN FIRST AND FOREMOST, AND ONLY THEN TRY TO UNDERSTAND
WHAT THE ACTUAL OR POTENTIAL TISSUE DAMAGE WAS THAT CAUSED THE PAIN.
PAIN BY DEFINITION IS SUBJECTIVE. A VARIETY OF NEURAL PATHWAYS ARE INVOLVED IN THE GENERATION AND
PROPAGATION OF PAIN. PAIN IS EMOTIONAL. PAIN PATHWAYS INTERACT WITH THE LIMBIC SYSTEM, AND THIS
INTERACTION MODULATES PAIN. THE EXPERIENCE OF PAIN IS RELATED TO THE EXPERIENCE OF PAST PAIN. MANY
POTENTIAL PAIN GENERATORS ARE PRESENT IN THE LOW BACK. THE MOST LIKELY SOURCE OF PAIN IS THE
INTERVERTEBRAL DISC. TREATING PAIN REQUIRES A MULTIFACTORIAL APPROACH, BECAUSE PAIN IS VERY
COMPLEX AND THIS IS WHAT WE ARE DOING IN KKT.
 WHAT TO DO?

What to do.? involve a multidisciplinary approach?

follow closely..? see what else is going on?
 WHAT TO DO?

DETAILED HISTORY-GOOD INVESTMENT OF TIME INITIALLY.

HANDS ON PHYSICAL EXAMINATION. OBSERVATION, MANUAL MOTOR TESTING, DETAILED NEURO
EXAM, UNDERSTAND MECHANISM OF INJURY.
PATIENT PARTICIPATION.
ADDRESS CONCERNS, DISCUSS EXPECTATIONS.
WORK STATUS-COMPLIANCE. MULTIDISCIPLINARY APPROACH.
PHYSICAL/OCCUPATIONAL THERAPY-TO TEACH HOME PROGRAM.
ERGONOMIC ASSESSMENT/ADJUSTMENT OF WORK STATION.
EXERCISE PRESCRIPTION-WALKING, SWIMMING, ETC.
NURSE CASE MANAGER/PMA.
EARLY FOLLOW UP, LIMIT DETAILED WORK UP.
 CONCLUSIONS

INTERNISTS AND OTHER PRIMARY CARE PHYSICIANS WILL NEED EXPERTISE IN THE
E & M OF ACUTE BACK PAIN.

PROVIDERS MAY HAVE A POSITIVE IMPACT ON IMPROVING OUTCOMES, REDUCING

SYMPTOMS, AND IMPROVING FUNCTIONAL RECOVERY.

EXCESSIVE OVER-MEDICALIZATION, AND DISABILITY ARE NOT SUPPORTED BY THE

EVIDENCE IN THE MAJORITY OF CASES. THESE OUTCOMES CAN BE PREVENTED
WITH CLOSE ATTENTION TO PATIENTS HISTORY, DETAILED EXAM, AND
MULTIDISCIPLINARY APPROACH TO MANAGEMENT.
 CONCLUSIONS

LESS COMMON RED FLAG CONDITIONS WILL BE ENCOUNTERED BY ALL OF

US-ON BOARDS & WARDS.
A HIGH INDEX OF SUSPICION IN RED FLAG CLINICAL SCENARIOS THAT ARE
UNUSUAL IS INDICATED, SO AS TO PROCEED WITH PROMPT EVALUATION,
SELECTIVE DIAGNOSTIC TESTING AND REFERRAL IN THESE CASES.
WE CAN EXPECT THE UNEXPECTED AND KEEP OUR EYES AND EARS OPEN!
 Chronic LBP is a disease, not a symptom.
Progress is focused on targeting treatment at
the mechanisms that produce pain rather than ameliorating the
symptoms.
Biopsychosocial approach is critical for the successful
management of chronic LBP.
Promising treatments for chronic LBP include:
new agents
new uses of agents
new combinations of agents
Thank you