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Back Pain Basics:
When Back Pain Keeps Coming Back
The Diagnostic Approach to Back Pain
Allan D. Corpuz, MD, FPCP, FPRA
Section of Rheumatology
Department of Medicine
LORMA Medical Center
Ilocos Training and Regional Medical Center
May 5, 2021
Objectives
1. To discuss the diagnostic approach to back pain.
2. To discuss the different arthritides and systemic conditions that can cause
back pain and illustrate these by presenting 3 uncommon but potentially
permanently disabling and possibly fatal causes of low back pain (that need
immediate recognition, treatment and/or referral)
DISCLOSURES
•I have received honoraria for speakership and module
design from
• Pfizer,J&J, Lilly, Novartis, Mylan, MSD,Takeda, Multicare,
Corbridge, Medichem, LRI-Therapharma,Taisho, Menarini
WHY ARE WE TALKING ABOUT
THIS?
The Burden of LBP
84%of adults will have low
back pain at some point in their lives
Deyo, et al. Spine (Phila Pa 1976).
1987;12(3):264
Cassidy, et al. Spine (Phila Pa 1976).
1998;23(17):1860
A Old Condition of New
“Pandemic” Proportions
• Kakar, R. S., & Lomond, K. (2020). Can COVID-19
Lead to Another Pandemic of Back Pain? Archives of
Physical Medicine and Rehabilitation, 101(12),
e132. doi:10.1016/j.apmr.2020.10.019
Abrupt shift to social
distancing = increased
remote work
Prolonged sitting behaviors
Computer Use
Detrimental effects on spine
posture
4 out 5 develop MSK pain
due to WFH status • 89% with back (50%), shoulder
(28%) and neck pain (36%) did
not inform employer
• 23% had MSK symptoms most
or all the time
• 46% taking painkillers more
than they would like
• 35-45% received no equipment,
support or advice
https://www.personneltoday.com/hr/working-from-home-four-in-five-develop-musculoskeletal-pain/
Epidemiology
• 65-80%: during entire lifetime
• Most prevalent chronic pain syndrome
• Leading cause of limitation: <45 y/o
• 2nd most frequent reason for MD visit
• 3rd most common surgical indication
Epidemiology
• Pain and function improve
substantially within 1 month
• >90% are better at 8 weeks (but are
susceptible to future brief relapses)
• 7-10% chronic LBP
Diagnosing Back Pain
This exercise can be a pain in the neck or a back-breaking activity (pun
intended)
Classification by Duration
ACUTE SUBACUTE CHRONIC
<4 weeks 4-12 weeks ≥12 weeks
Chou, R. Ann Intern Med. 2014 Jun 3;160(11):ITC6-1
For many patients, episodes of low back pain are self-limited
Rarely, it is a harbinger of serious medical condition
Risk Factors
Age >=30
Female Gender
Obesity
Pregnancy
Arthritis or Osteoporosis
Bad posture
Physically strenous work (heavy lifting, bending and
twisting, or whole body vibration such as truck driving)
Smoking
Sedentary work
Psychologically strenous work
Low Educational attainment
Worker’s compensation insurance
Job dissatisfaction
Psychologic factors: somatization disorder, anxiety,
depression
Katz, J Bone Joint Surg Am. 2006;88 Suppl 2:21.
Steffens D. et al., Arthritis Care Res (Hoboken). 2015 Mar;67(3):403-10.
PSYCHOSOCIAL
ORGANIZATIONAL
FACTORS
INDIVIDUAL
FACTORS
PHYSICAL
FACTORS
PCP AC 2021 - Back Pain Basics
Algorithm and Differential
Diagnosis
90-
95%of
Low Back
Pain is
Mechanical
The Key in Initial
and Subsequent
Evaluation is
finding the
5-10% that
can be
permanently
disabling or fatal
RED FLAGS
for potentially serious
underlying causes of LBP
Differential Diagnosis
Common History and Physical Examination Features
for Back Pain Causes
Disease Characteristics on
History
Physical Examination
Findings
Notes
Degenerative disk
disease
Nonspecific Nonspecific Common radiologic
abnormality that may be
related to symptoms
Degenerative disk
disease with
herniation
Sciatic pain Impaired ankle or patella reflex;
positive ipsilateral or crossed
straight-leg raising test result;
great toe, ankle, or quadriceps
weakness; lower extremity
sensory loss
Common cause of nerve
root impingement and
radicular symptoms, most
commonly at L5 and S1
levels
Common History and Physical Examination Features
for Back Pain Causes
Disease Characteristics on
History
Physical Examination
Findings
Notes
Spinal stenosis Severe leg pain;
pseudoclaudication; no
pain when patient is seated
Wide-based gait;
pseudoclaudication; thigh pain
after 30 s of lumbar extension
More common with
advancing age;
uncommon before age 50
Ankylosing
spondylitis
Gradual onset; morning
stiffness; improves with
exercise; pain for >3 mo;
pain not relieved when
patient is supine
Decreased spinal range of
motion
Usual onset before age 40
Common History and Physical Examination Features
for Back Pain Causes
Disease Characteristics on
History
Physical Examination
Findings
Notes
Osteomyelitis,
spinal abscess,
epidural abscess
Recent infection or history
of intravenous drug use
Fever and localized tenderness Can cause cord
compression
Cancer in the spine
or surrounding
structures
Weight loss or other cancer
symptoms; known past or
current cancer diagnosis;
failure to improve after 4
wk; no relief with bed rest
Localized tenderness Metastatic disease,
commonly from prostate,
breast, and lung cancer;
can cause cord
compression; more
common in patients aged
≥50
Common History and Physical Examination Features
for Back Pain Causes
Disease Characteristics on
History
Physical Examination
Findings
Notes
Intra-abdominal
visceral disease
Depends on affected viscera Depends on affected viscera Gastrointestinal: peptic
ulcer or pancreatitis
Genitourinary:
nephrolithiasis,
pyelonephritis, prostatitis,
pelvic infection, or tumor
Vascular: aortic dissection
All of these illnesses can
cause back pain
Common History and Physical Examination Features
for Back Pain Causes
Disease Characteristics on
History
Physical Examination
Findings
Notes
Metabolic bone
disease with or
without
compression
fracture
Nonspecific pain;
osteoporosis or
osteoporosis risk factors
Trauma; corticosteroid use
Localized tenderness if vertebral
fracture
Best example is
osteoporosis with
compression fracture
Herpes zoster Unilateral pain in
distribution of dermatome
Unilateral dermatomal rash Most common in elderly
or immunocompromised
patients
Common History and Physical Examination Features
for Back Pain Causes
Disease Characteristics on
History
Physical Examination
Findings
Notes
Psychosocial
distress
Symptoms do not follow a
clear clinical or anatomical
pattern; psychological and
emotional distress
Physical examination findings
that do not follow a clear clinical
or anatomical pattern
Patients with psychosocial
distress and low back pain
are at high risk for delayed
recovery, chronic pain, and
poor functional outcomes
When do you order imaging?
VOMIT
Victims of Medical Imaging Technology
Radiographic exams are usually of limited use unless the Hx or PE suggests a specific
underlying cause.
IMAGING
• Weak association between imaging abnormalities and symptoms
• Up to 85%: cannot make precise pathoanatomic Dx with identification of the
pain generator
• Reinforce suspicion of serious disease, magnify the importance of non-specific
findings, and label patients with spurious diagnosis
Deyo RA, Weinstein DO: Low back pain, N Engl J Med 344(5):363– 370, 2001.
Disk Herniation is Prevalent in Pain-Free Individuals
Brinjikji W, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations,
AJNR Am J Neuroradiol. 2015 Apr; 36(4): 811–816.
The demonstration of
anatomical abnormality
should notautomatically
lead the clinician to
assume that it is the cause
of pain
Earlier use of imaging for low back pain
without associated symptoms is not associated
with improved outcomes but increases the
medical costs and the use of
invasive procedures
Chou R. et al. Clinical Guidelines Committee of the ACP.Ann Intern Med. 2011;154:181-9
IMAGING
Imaging is NOT required UNLESS significant symptoms PERSIST BEYOND 6-8
weeks
Dixit RK: Approach to the patient with low back pain. In Imboden J, Hellmann D, Stone J, editors. Current diagnosis and
treatment in rheumatology, ed 2, New York, 2007, McGraw-Hill
NEITHER MRI NOR PLAIN RADIOGRAPHS taken EARLY in the course of LBP
evaluation improves clinical outcome, predicts recovery course, or reduces
overall cost of care
Chou R, Fu R, Carrino JA, Deyo RA: Imaging strategies for low back pain: systematic review and meta-analysis, Lancet
373:463–472, 2009.
ACP and APS
(2007)
Imaging
Guidelines
Chou r, et al. Clinical Efficacy Assessment
Subcommittee of the ACP.Ann Intern Med
2007;147:478-91
Imaging is useful as the
pretest probability of
underlying serious disease
requiring surgical or other
intervention increases.
What about other diagnostic tests
• Additional diagnostic and lab tests are not indicated in most patients with
(low) back pain
• ELEVATED ESR: think of systemic problems like infection, malignancy,
autoimmune/inflammatory diseases
• EMG-NCV
• Considered if with diagnostic uncertainty about the relationship of leg symptoms to
anatomical findings on advanced imaging
• Assess myelopathy, radiculopathy, neuropathy, myopathy
• Do NOTTest if duration of symptoms <4 weeks (unreliable in limb muscles until
significant symptoms seen >3-4weeks)
CASES
Case 1
A 66-year-old man was referred for left upper quadrant pain and mid to low back pain. The pain
started about 3 months prior to referral as pain that awakens him at night. The pain was described as
shooting/stabbing. He also experienced pleuritic chest pain. He was under the care of an internist
who was treating him for Diabetes with Metformin, Empagliflozin and Insulin. The latest FBS was
230mg/dl. He reported numbness around the middle back and also on the left calf area for about 5
months. He has no fever, anorexia, weight loss, bowel or bladder issues. He was started by his internist
with Pregabalin, Vitamin B complex and Tramadol + Paracetamol but had minimal relief.
On physical examination, vital signs are normal. Body mass index is 30 kg/m 2 . Gait is normal.
Straight-leg–raising test on both the left and right side was normal. The ankle reflexes are likewise
normal. No motor or sensory deficits are observed. Saddle anesthesia is not present. Rectal tone is
normal.
Chest Xray showed a right hilar mass.
ESR was mildly elevated at 35. Sputum AFB x 2 samples were negative.
CBC showed: Hb 112 Hct 0.34 WBC 11.2 (Seg 0.65 Lym 0.35) Plt 435
Which of the following is the most appropriate diagnostic test to
perform next in this patient?
A. Analgesics
and mobilization
as tolerated
B. Thoracic
MRI/Chest CT
Scan
C. Epidural
corticosteroid
injection
D. Lumbar spine
MRI
E. Lumbar spine
radiograph
Which of the following is the most appropriate diagnostic test to
perform next in this patient?
A. Analgesics
and mobilization
as tolerated
B. Thoracic
MRI/Chest CT
Scan
C. Epidural
corticosteroid
injection
D. Lumbar spine
MRI
E. Lumbar spine
radiograph
Case 1
Thoracic MRI:
The T7-T8 disc is abnormally bright on T2WI with associated subchondral irregularities of the apposing endplates which
extends posteriorly to the epidural region more to the left, causing spinal canal stenosis and compression of the
adjacent thoracic cord. Focal hyperintense cord signal on T2WI are seen relating to edema. Bilateral neural foraminal
narrowing is also seen, mild on the right and severe on the left, possibly compressing the left exiting nerve root. Pre
and paravertebral mass is seen from T6 down to T9. There is mild compression at T7 and T8 with diffuse marrow
edema.
Chest CT Scan
Findings in the T7-8 regions may relate to spondylodiscitis with mild indentation of the ventral thecal sac and probable
paravertebral abscess formations. These may be secondary to to an infectious/inflammatory process. However, a
neoplastic process has to be ruled out. MRI and/or histopathologic correlation is suggested.
Minimal bilateral pleural effusion
Diagnosis
•An initial diagnosis of PTB with Pott’s Disease was made.The
patient was then referred to Spine Surgery. He opted to go Manila
where he underwent spinal surgery. Samples taken from the
lesion came out negative for TB.
•The final dx was Bacterial Paravertebral Abscess s/p Debridement
and Decompression with spinal fusion.
Key Takeaways
• Red Flags: Uncontrolled Diabetes, Nocturnal Pain,Age >50 y/o, ESR elevation
• Uncontrolled comorbid diseases like DM can cause immunocompromise,
which may explain the only slightly elevated ESR as well as the absence of
fever and indolent presentation (mimicking TB) despite having a bacterial
abscess
• Other potential causes of immunocompromised state: RA, SLE, HIV,
Chemotherapy, use of steroids
Case 2
An 80 year old male, previously diagnosed with prostate adenocarcinoma in 2010, underwent cTURP and received “injections” as chemotherapy under his
attending MD. Did not have any followup after “completing “ the injections since he was already feeling well. The patient did not have any lower urinary tract
symptoms since 2010.
Recently started to have persistent, progressive low back pain for 2 months, not alleviated by rest, worse at night.
There is minimal relief with Paracetamol and NSAIDs. There was anorexia and weight loss. Recently, there was acute
weakness of both LE (MMT 2/5, bilateral). There was also urinary retention with overflow incontinence.
Laboratory studies reveal: ESR 45; CBC Hb 88 Hct 0.28 WBC 4.0 (Seg 0.55 Lym 0.45) Plt 150
PSA 1000
Which of the following is the most appropriate diagnostic test to
perform next in this patient?
A. Bone
Scintigraphy
Scan
B. Bone
Densitometry
C.
Radiographs
of the Spine
D. Lumbar
MRI
Which of the following is the most appropriate diagnostic test to
perform next in this patient?
A. Bone
Scintigraphy
Scan
B. Bone
Densitometry
C.
Radiographs
of the Spine
D. Lumbar
MRI
Case 2
CXR: Osteoblastic metastasis is considered.
Thoracic APL: Osteoblastic metastasis is considered.
Lumbosacral APL: Osteoblastic metastasis is considered.Osteodegenerative changes. Levoscoliosis.
Bone Scintigraphy Scan:
1. Increased activity in the skull, bilateral clavicles, manubrium-sterni, bilateral glenohumeral junctions and coracoid processes,
bilateral humerii, bilateral scapulae, ribcage, almost the entire vertebral column, sacrum, pelvis, and bilateral femora is indicative of
widespread metastatic bone disease.
2. Consider an osteolytic process in the proximal shaft of the left humerus,T4-T5,T11, and lumbar vertebrae.
3. Suggest fracture risk assessment in bilateral humeral shafts (especially the left), thoracolumbar vertebrae, bilateral hips, and bilateral
femoral shafts.
Key Takeaways
• Red Flags: Hx of malignancy, nocturnal pain, weight loss, anorexia, elevated
ESR, bladder dysfunction
• Prostate Ca is a common cause of vertebral metastasis. Others (Breast, Lung,
Thyroid, Kidney = 80%; MM =60%)
Always ask for history of malignancy (or in
males, prostate problems)
• Asking about the History for Malignancy is important because the
malignancy may have occurred at a distant past and the patient may
not be able to remember mentioning it or correlate it with their
current illness.
• Oftentimes, the presentation is less clear. Some patients with
metastatic bone lesions may only have mild LBP without
constitutional symptoms.
Diagnosis: Vertebral Metastasis from Prostate
Ca
• The patient improved with Zoledronic acid weekly infusions
• Chemotherapy with anti-androgenic hormones was initiated.
Case 3
A 27/M was referred for history of chronic back pain and knee pain. He noted that the onset
of his back pain came on gradually when he was in college. He was working as a barista, but
his pain progressively limited his ability to bend over while preparing drinks for his clients. He
saw a doctor at the time, who obtained an x-ray of his lumbosacral spine and hips. This x-ray
was read as normal, and the patient was diagnosed with “chronic back strain.” It was
recommended that he take Mefenamic Acid for the pain. He recalls that he typically took 1 to
2 tablets when the pain was particularly bad.
Case 3
The patient noted that his discomfort was worse when he woke up in the morning, and was associated with
stiffness that lasted for up to 2 hours after getting out of bed. The pain and stiffness improved as the day went by
and he participated in his normal activities. He also had pain on his heel on 1st step which improves with
ambulation and recurs after a period of rest.
By the age of 24, this patient also noted pain in his right hip, left knee, and right foot. At this time, he stopped his
work due to this pain. He denies history of any inflammatory eye disease, bloody diarrhea or other signs of
inflammatory bowel disease, or psoriasis.
He had repeated consults with different doctors/specialists who prescribed different drugs ranging from NSAIDs
PRN, Colchicine, Allopurinol; as well as physical therapy.
Case 3
A physical exam was performed, and the patient was noted to have diminished internal
rotation of his right hip, which caused him to wince in pain. His left knee was warm and
swollen, and he had tenderness at the plantar fascial insertion at the right foot. Anterior
spinal flexion (Schober’s) testing was 3.5 cm, lateral spine mobility was 15 cm, occiput-to-wall
distance was 0 cm, and chest expansion was 3 cm (all normal).
Which of the following is the most appropriate diagnostic test to
perform next in this patient?
A. LSV Xray B. Pelvic Xray
C.
Rheumatoid
Factor
D. Uric Acid
Which of the following is the most appropriate diagnostic test to
perform next in this patient?
A. LSV Xray B. Pelvic Xray
C.
Rheumatoid
Factor
D. Uric Acid
Case 3
LABS: CBC: Hb 120 Hct 0.35 WBC 8.0 Plt 212
Creatinine 89 SGOT 23 SGPT 35 Na 135 K 4.0 HbsAg NR
CRP 3.5mg/dl (NV <0.5mg/l); ESR 45
HLA B27 positive
IMAGING: Xrays:
AP pelvis: Sclerosis and erosions at both sacroiliac joints compatible
with grade III sacroiliitis; osteophyte formation in the Right hip
APL LS and Lat Cervical Spine: Joint space narrowing,
CXR: normal
Diagnosis: Ankylosing Spondylitis
• The diagnosis is Axial Spondyloarthritis, with this patient having reached later-stage
disease diagnosable as AS
• The doctor who saw the patient prescribed Celecoxib PRN and physical therapy only
Key Takeaways
• Red Flags: young patient, elevated ESR, CRP, severe morning stiffness, pain that
improved with activity (not with rest)
Spondyloarthritis
Assessments in SpA International Society (ASAS)
Criteria
HISTORY
MECHANICAL LBP INFLAMMATORY LBP
>95% Less common
Usually seen in elderly people,
postmenopausal women
Seen in men <40y/o (sPA)
Typically increases with physical
activity and upright posture
Marked morning stiffness >30mins
Worse during 2nd half of the night
Alternating buttock pain
Relieved by rest and recumbency Improves with exercise but not rest
Most common cause is degenerative
change in the LS
Spondyloarthritides
PCP AC 2021 - Back Pain Basics
For this patient, an AxSpA diagnosis
can be made based on
• presence of inflammatory back pain (IBP)
• in conjunction with
• enthesitis (in this patient, plantar fasciitis)
• peripheral lower extremity arthritis
• elevated inflammatory markers (erythrocyte sedimentation rate[ESR]and CRP
• radiographic sacroiliitis
• HLA-B27
Treatment
IL-17 inhibitors, JAK-inhibitors
SUMMARY
TAKEAWAYS
• No substitute for good history taking and complete PE. Sometimes we don’t
have enough time but we have to take time
• Ask for red flags, prompt patient as they have oftentimes inability to correlate
past problems/symptoms (or overcorrelate).
TAKEAWAYS
• Never base diagnosis on imaging.Just because it’s there, doesn’t mean it’s the
culprit. Correlate always.
• Image only when pain is persistent or when there are red flags
TAKEAWAYS
• In patients with red flags, the ESR/CRP will clue you in to a more systemic
problem. But just because the ESR is low or normal, doesn’t mean there is no
systemic problem.Absence of evidence is not evidence of absence
TAKEAWAYS
• In young males (or even females) with chronic LBP, it is wise to consider early
referral, or workup for Spondyloarthritis, esp if the presentation of back pain is
inflammatory in nature.
TAKEAWAYS
• Use NSAIDs continuously (rather than PRN) for axial Spondyloarthritis. Use
DMARDs for peripheral arthritis. Screen for TB and Hepa B before initiating.
Refer to Rheumatologist for possible biologic DMARDs early in the course to
prevent disease progression.
ROLE OF WELLNESS
in LBP DISORDERS
• Taking care of all the parameters in your life
oSocial
oOccupational
oSpiritual
oPhysical
oIntellectual
oEmotional
oEnvironmental
oFinancial
oMental
oMedical
Love is a lot
like backache.
It doesn’t
show up on
Xrays, but you
know it’s
there.
George Burns
Have a love-filled, backache-
free day!
rayuma.doktor@gmail.com
www.allancorpuzmd.com
https://seriousmd.com/doc/rayumadoktor

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PCP AC 2021 - Back Pain Basics

  • 1. Back Pain Basics: When Back Pain Keeps Coming Back The Diagnostic Approach to Back Pain Allan D. Corpuz, MD, FPCP, FPRA Section of Rheumatology Department of Medicine LORMA Medical Center Ilocos Training and Regional Medical Center May 5, 2021
  • 2. Objectives 1. To discuss the diagnostic approach to back pain. 2. To discuss the different arthritides and systemic conditions that can cause back pain and illustrate these by presenting 3 uncommon but potentially permanently disabling and possibly fatal causes of low back pain (that need immediate recognition, treatment and/or referral)
  • 3. DISCLOSURES •I have received honoraria for speakership and module design from • Pfizer,J&J, Lilly, Novartis, Mylan, MSD,Takeda, Multicare, Corbridge, Medichem, LRI-Therapharma,Taisho, Menarini
  • 4. WHY ARE WE TALKING ABOUT THIS?
  • 5. The Burden of LBP 84%of adults will have low back pain at some point in their lives Deyo, et al. Spine (Phila Pa 1976). 1987;12(3):264 Cassidy, et al. Spine (Phila Pa 1976). 1998;23(17):1860
  • 6. A Old Condition of New “Pandemic” Proportions • Kakar, R. S., & Lomond, K. (2020). Can COVID-19 Lead to Another Pandemic of Back Pain? Archives of Physical Medicine and Rehabilitation, 101(12), e132. doi:10.1016/j.apmr.2020.10.019 Abrupt shift to social distancing = increased remote work Prolonged sitting behaviors Computer Use Detrimental effects on spine posture
  • 7. 4 out 5 develop MSK pain due to WFH status • 89% with back (50%), shoulder (28%) and neck pain (36%) did not inform employer • 23% had MSK symptoms most or all the time • 46% taking painkillers more than they would like • 35-45% received no equipment, support or advice https://www.personneltoday.com/hr/working-from-home-four-in-five-develop-musculoskeletal-pain/
  • 8. Epidemiology • 65-80%: during entire lifetime • Most prevalent chronic pain syndrome • Leading cause of limitation: <45 y/o • 2nd most frequent reason for MD visit • 3rd most common surgical indication
  • 9. Epidemiology • Pain and function improve substantially within 1 month • >90% are better at 8 weeks (but are susceptible to future brief relapses) • 7-10% chronic LBP
  • 10. Diagnosing Back Pain This exercise can be a pain in the neck or a back-breaking activity (pun intended)
  • 12. ACUTE SUBACUTE CHRONIC <4 weeks 4-12 weeks ≥12 weeks Chou, R. Ann Intern Med. 2014 Jun 3;160(11):ITC6-1
  • 13. For many patients, episodes of low back pain are self-limited Rarely, it is a harbinger of serious medical condition
  • 15. Age >=30 Female Gender Obesity Pregnancy Arthritis or Osteoporosis Bad posture Physically strenous work (heavy lifting, bending and twisting, or whole body vibration such as truck driving) Smoking Sedentary work Psychologically strenous work Low Educational attainment Worker’s compensation insurance Job dissatisfaction Psychologic factors: somatization disorder, anxiety, depression Katz, J Bone Joint Surg Am. 2006;88 Suppl 2:21. Steffens D. et al., Arthritis Care Res (Hoboken). 2015 Mar;67(3):403-10. PSYCHOSOCIAL ORGANIZATIONAL FACTORS INDIVIDUAL FACTORS PHYSICAL FACTORS
  • 18. 90- 95%of Low Back Pain is Mechanical The Key in Initial and Subsequent Evaluation is finding the 5-10% that can be permanently disabling or fatal
  • 19. RED FLAGS for potentially serious underlying causes of LBP
  • 21. Common History and Physical Examination Features for Back Pain Causes Disease Characteristics on History Physical Examination Findings Notes Degenerative disk disease Nonspecific Nonspecific Common radiologic abnormality that may be related to symptoms Degenerative disk disease with herniation Sciatic pain Impaired ankle or patella reflex; positive ipsilateral or crossed straight-leg raising test result; great toe, ankle, or quadriceps weakness; lower extremity sensory loss Common cause of nerve root impingement and radicular symptoms, most commonly at L5 and S1 levels
  • 22. Common History and Physical Examination Features for Back Pain Causes Disease Characteristics on History Physical Examination Findings Notes Spinal stenosis Severe leg pain; pseudoclaudication; no pain when patient is seated Wide-based gait; pseudoclaudication; thigh pain after 30 s of lumbar extension More common with advancing age; uncommon before age 50 Ankylosing spondylitis Gradual onset; morning stiffness; improves with exercise; pain for >3 mo; pain not relieved when patient is supine Decreased spinal range of motion Usual onset before age 40
  • 23. Common History and Physical Examination Features for Back Pain Causes Disease Characteristics on History Physical Examination Findings Notes Osteomyelitis, spinal abscess, epidural abscess Recent infection or history of intravenous drug use Fever and localized tenderness Can cause cord compression Cancer in the spine or surrounding structures Weight loss or other cancer symptoms; known past or current cancer diagnosis; failure to improve after 4 wk; no relief with bed rest Localized tenderness Metastatic disease, commonly from prostate, breast, and lung cancer; can cause cord compression; more common in patients aged ≥50
  • 24. Common History and Physical Examination Features for Back Pain Causes Disease Characteristics on History Physical Examination Findings Notes Intra-abdominal visceral disease Depends on affected viscera Depends on affected viscera Gastrointestinal: peptic ulcer or pancreatitis Genitourinary: nephrolithiasis, pyelonephritis, prostatitis, pelvic infection, or tumor Vascular: aortic dissection All of these illnesses can cause back pain
  • 25. Common History and Physical Examination Features for Back Pain Causes Disease Characteristics on History Physical Examination Findings Notes Metabolic bone disease with or without compression fracture Nonspecific pain; osteoporosis or osteoporosis risk factors Trauma; corticosteroid use Localized tenderness if vertebral fracture Best example is osteoporosis with compression fracture Herpes zoster Unilateral pain in distribution of dermatome Unilateral dermatomal rash Most common in elderly or immunocompromised patients
  • 26. Common History and Physical Examination Features for Back Pain Causes Disease Characteristics on History Physical Examination Findings Notes Psychosocial distress Symptoms do not follow a clear clinical or anatomical pattern; psychological and emotional distress Physical examination findings that do not follow a clear clinical or anatomical pattern Patients with psychosocial distress and low back pain are at high risk for delayed recovery, chronic pain, and poor functional outcomes
  • 27. When do you order imaging?
  • 28. VOMIT Victims of Medical Imaging Technology Radiographic exams are usually of limited use unless the Hx or PE suggests a specific underlying cause.
  • 29. IMAGING • Weak association between imaging abnormalities and symptoms • Up to 85%: cannot make precise pathoanatomic Dx with identification of the pain generator • Reinforce suspicion of serious disease, magnify the importance of non-specific findings, and label patients with spurious diagnosis Deyo RA, Weinstein DO: Low back pain, N Engl J Med 344(5):363– 370, 2001.
  • 30. Disk Herniation is Prevalent in Pain-Free Individuals Brinjikji W, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations, AJNR Am J Neuroradiol. 2015 Apr; 36(4): 811–816. The demonstration of anatomical abnormality should notautomatically lead the clinician to assume that it is the cause of pain
  • 31. Earlier use of imaging for low back pain without associated symptoms is not associated with improved outcomes but increases the medical costs and the use of invasive procedures Chou R. et al. Clinical Guidelines Committee of the ACP.Ann Intern Med. 2011;154:181-9
  • 32. IMAGING Imaging is NOT required UNLESS significant symptoms PERSIST BEYOND 6-8 weeks Dixit RK: Approach to the patient with low back pain. In Imboden J, Hellmann D, Stone J, editors. Current diagnosis and treatment in rheumatology, ed 2, New York, 2007, McGraw-Hill NEITHER MRI NOR PLAIN RADIOGRAPHS taken EARLY in the course of LBP evaluation improves clinical outcome, predicts recovery course, or reduces overall cost of care Chou R, Fu R, Carrino JA, Deyo RA: Imaging strategies for low back pain: systematic review and meta-analysis, Lancet 373:463–472, 2009.
  • 33. ACP and APS (2007) Imaging Guidelines Chou r, et al. Clinical Efficacy Assessment Subcommittee of the ACP.Ann Intern Med 2007;147:478-91 Imaging is useful as the pretest probability of underlying serious disease requiring surgical or other intervention increases.
  • 34. What about other diagnostic tests • Additional diagnostic and lab tests are not indicated in most patients with (low) back pain • ELEVATED ESR: think of systemic problems like infection, malignancy, autoimmune/inflammatory diseases • EMG-NCV • Considered if with diagnostic uncertainty about the relationship of leg symptoms to anatomical findings on advanced imaging • Assess myelopathy, radiculopathy, neuropathy, myopathy • Do NOTTest if duration of symptoms <4 weeks (unreliable in limb muscles until significant symptoms seen >3-4weeks)
  • 35. CASES
  • 36. Case 1 A 66-year-old man was referred for left upper quadrant pain and mid to low back pain. The pain started about 3 months prior to referral as pain that awakens him at night. The pain was described as shooting/stabbing. He also experienced pleuritic chest pain. He was under the care of an internist who was treating him for Diabetes with Metformin, Empagliflozin and Insulin. The latest FBS was 230mg/dl. He reported numbness around the middle back and also on the left calf area for about 5 months. He has no fever, anorexia, weight loss, bowel or bladder issues. He was started by his internist with Pregabalin, Vitamin B complex and Tramadol + Paracetamol but had minimal relief. On physical examination, vital signs are normal. Body mass index is 30 kg/m 2 . Gait is normal. Straight-leg–raising test on both the left and right side was normal. The ankle reflexes are likewise normal. No motor or sensory deficits are observed. Saddle anesthesia is not present. Rectal tone is normal. Chest Xray showed a right hilar mass. ESR was mildly elevated at 35. Sputum AFB x 2 samples were negative. CBC showed: Hb 112 Hct 0.34 WBC 11.2 (Seg 0.65 Lym 0.35) Plt 435
  • 37. Which of the following is the most appropriate diagnostic test to perform next in this patient? A. Analgesics and mobilization as tolerated B. Thoracic MRI/Chest CT Scan C. Epidural corticosteroid injection D. Lumbar spine MRI E. Lumbar spine radiograph
  • 38. Which of the following is the most appropriate diagnostic test to perform next in this patient? A. Analgesics and mobilization as tolerated B. Thoracic MRI/Chest CT Scan C. Epidural corticosteroid injection D. Lumbar spine MRI E. Lumbar spine radiograph
  • 39. Case 1 Thoracic MRI: The T7-T8 disc is abnormally bright on T2WI with associated subchondral irregularities of the apposing endplates which extends posteriorly to the epidural region more to the left, causing spinal canal stenosis and compression of the adjacent thoracic cord. Focal hyperintense cord signal on T2WI are seen relating to edema. Bilateral neural foraminal narrowing is also seen, mild on the right and severe on the left, possibly compressing the left exiting nerve root. Pre and paravertebral mass is seen from T6 down to T9. There is mild compression at T7 and T8 with diffuse marrow edema. Chest CT Scan Findings in the T7-8 regions may relate to spondylodiscitis with mild indentation of the ventral thecal sac and probable paravertebral abscess formations. These may be secondary to to an infectious/inflammatory process. However, a neoplastic process has to be ruled out. MRI and/or histopathologic correlation is suggested. Minimal bilateral pleural effusion
  • 40. Diagnosis •An initial diagnosis of PTB with Pott’s Disease was made.The patient was then referred to Spine Surgery. He opted to go Manila where he underwent spinal surgery. Samples taken from the lesion came out negative for TB. •The final dx was Bacterial Paravertebral Abscess s/p Debridement and Decompression with spinal fusion.
  • 41. Key Takeaways • Red Flags: Uncontrolled Diabetes, Nocturnal Pain,Age >50 y/o, ESR elevation • Uncontrolled comorbid diseases like DM can cause immunocompromise, which may explain the only slightly elevated ESR as well as the absence of fever and indolent presentation (mimicking TB) despite having a bacterial abscess • Other potential causes of immunocompromised state: RA, SLE, HIV, Chemotherapy, use of steroids
  • 42. Case 2 An 80 year old male, previously diagnosed with prostate adenocarcinoma in 2010, underwent cTURP and received “injections” as chemotherapy under his attending MD. Did not have any followup after “completing “ the injections since he was already feeling well. The patient did not have any lower urinary tract symptoms since 2010. Recently started to have persistent, progressive low back pain for 2 months, not alleviated by rest, worse at night. There is minimal relief with Paracetamol and NSAIDs. There was anorexia and weight loss. Recently, there was acute weakness of both LE (MMT 2/5, bilateral). There was also urinary retention with overflow incontinence. Laboratory studies reveal: ESR 45; CBC Hb 88 Hct 0.28 WBC 4.0 (Seg 0.55 Lym 0.45) Plt 150 PSA 1000
  • 43. Which of the following is the most appropriate diagnostic test to perform next in this patient? A. Bone Scintigraphy Scan B. Bone Densitometry C. Radiographs of the Spine D. Lumbar MRI
  • 44. Which of the following is the most appropriate diagnostic test to perform next in this patient? A. Bone Scintigraphy Scan B. Bone Densitometry C. Radiographs of the Spine D. Lumbar MRI
  • 45. Case 2 CXR: Osteoblastic metastasis is considered. Thoracic APL: Osteoblastic metastasis is considered. Lumbosacral APL: Osteoblastic metastasis is considered.Osteodegenerative changes. Levoscoliosis. Bone Scintigraphy Scan: 1. Increased activity in the skull, bilateral clavicles, manubrium-sterni, bilateral glenohumeral junctions and coracoid processes, bilateral humerii, bilateral scapulae, ribcage, almost the entire vertebral column, sacrum, pelvis, and bilateral femora is indicative of widespread metastatic bone disease. 2. Consider an osteolytic process in the proximal shaft of the left humerus,T4-T5,T11, and lumbar vertebrae. 3. Suggest fracture risk assessment in bilateral humeral shafts (especially the left), thoracolumbar vertebrae, bilateral hips, and bilateral femoral shafts.
  • 46. Key Takeaways • Red Flags: Hx of malignancy, nocturnal pain, weight loss, anorexia, elevated ESR, bladder dysfunction • Prostate Ca is a common cause of vertebral metastasis. Others (Breast, Lung, Thyroid, Kidney = 80%; MM =60%)
  • 47. Always ask for history of malignancy (or in males, prostate problems) • Asking about the History for Malignancy is important because the malignancy may have occurred at a distant past and the patient may not be able to remember mentioning it or correlate it with their current illness. • Oftentimes, the presentation is less clear. Some patients with metastatic bone lesions may only have mild LBP without constitutional symptoms.
  • 48. Diagnosis: Vertebral Metastasis from Prostate Ca • The patient improved with Zoledronic acid weekly infusions • Chemotherapy with anti-androgenic hormones was initiated.
  • 49. Case 3 A 27/M was referred for history of chronic back pain and knee pain. He noted that the onset of his back pain came on gradually when he was in college. He was working as a barista, but his pain progressively limited his ability to bend over while preparing drinks for his clients. He saw a doctor at the time, who obtained an x-ray of his lumbosacral spine and hips. This x-ray was read as normal, and the patient was diagnosed with “chronic back strain.” It was recommended that he take Mefenamic Acid for the pain. He recalls that he typically took 1 to 2 tablets when the pain was particularly bad.
  • 50. Case 3 The patient noted that his discomfort was worse when he woke up in the morning, and was associated with stiffness that lasted for up to 2 hours after getting out of bed. The pain and stiffness improved as the day went by and he participated in his normal activities. He also had pain on his heel on 1st step which improves with ambulation and recurs after a period of rest. By the age of 24, this patient also noted pain in his right hip, left knee, and right foot. At this time, he stopped his work due to this pain. He denies history of any inflammatory eye disease, bloody diarrhea or other signs of inflammatory bowel disease, or psoriasis. He had repeated consults with different doctors/specialists who prescribed different drugs ranging from NSAIDs PRN, Colchicine, Allopurinol; as well as physical therapy.
  • 51. Case 3 A physical exam was performed, and the patient was noted to have diminished internal rotation of his right hip, which caused him to wince in pain. His left knee was warm and swollen, and he had tenderness at the plantar fascial insertion at the right foot. Anterior spinal flexion (Schober’s) testing was 3.5 cm, lateral spine mobility was 15 cm, occiput-to-wall distance was 0 cm, and chest expansion was 3 cm (all normal).
  • 52. Which of the following is the most appropriate diagnostic test to perform next in this patient? A. LSV Xray B. Pelvic Xray C. Rheumatoid Factor D. Uric Acid
  • 53. Which of the following is the most appropriate diagnostic test to perform next in this patient? A. LSV Xray B. Pelvic Xray C. Rheumatoid Factor D. Uric Acid
  • 54. Case 3 LABS: CBC: Hb 120 Hct 0.35 WBC 8.0 Plt 212 Creatinine 89 SGOT 23 SGPT 35 Na 135 K 4.0 HbsAg NR CRP 3.5mg/dl (NV <0.5mg/l); ESR 45 HLA B27 positive IMAGING: Xrays: AP pelvis: Sclerosis and erosions at both sacroiliac joints compatible with grade III sacroiliitis; osteophyte formation in the Right hip APL LS and Lat Cervical Spine: Joint space narrowing, CXR: normal
  • 55. Diagnosis: Ankylosing Spondylitis • The diagnosis is Axial Spondyloarthritis, with this patient having reached later-stage disease diagnosable as AS • The doctor who saw the patient prescribed Celecoxib PRN and physical therapy only
  • 56. Key Takeaways • Red Flags: young patient, elevated ESR, CRP, severe morning stiffness, pain that improved with activity (not with rest)
  • 58. Assessments in SpA International Society (ASAS) Criteria
  • 59. HISTORY MECHANICAL LBP INFLAMMATORY LBP >95% Less common Usually seen in elderly people, postmenopausal women Seen in men <40y/o (sPA) Typically increases with physical activity and upright posture Marked morning stiffness >30mins Worse during 2nd half of the night Alternating buttock pain Relieved by rest and recumbency Improves with exercise but not rest Most common cause is degenerative change in the LS Spondyloarthritides
  • 61. For this patient, an AxSpA diagnosis can be made based on • presence of inflammatory back pain (IBP) • in conjunction with • enthesitis (in this patient, plantar fasciitis) • peripheral lower extremity arthritis • elevated inflammatory markers (erythrocyte sedimentation rate[ESR]and CRP • radiographic sacroiliitis • HLA-B27
  • 64. TAKEAWAYS • No substitute for good history taking and complete PE. Sometimes we don’t have enough time but we have to take time • Ask for red flags, prompt patient as they have oftentimes inability to correlate past problems/symptoms (or overcorrelate).
  • 65. TAKEAWAYS • Never base diagnosis on imaging.Just because it’s there, doesn’t mean it’s the culprit. Correlate always. • Image only when pain is persistent or when there are red flags
  • 66. TAKEAWAYS • In patients with red flags, the ESR/CRP will clue you in to a more systemic problem. But just because the ESR is low or normal, doesn’t mean there is no systemic problem.Absence of evidence is not evidence of absence
  • 67. TAKEAWAYS • In young males (or even females) with chronic LBP, it is wise to consider early referral, or workup for Spondyloarthritis, esp if the presentation of back pain is inflammatory in nature.
  • 68. TAKEAWAYS • Use NSAIDs continuously (rather than PRN) for axial Spondyloarthritis. Use DMARDs for peripheral arthritis. Screen for TB and Hepa B before initiating. Refer to Rheumatologist for possible biologic DMARDs early in the course to prevent disease progression.
  • 69. ROLE OF WELLNESS in LBP DISORDERS • Taking care of all the parameters in your life oSocial oOccupational oSpiritual oPhysical oIntellectual oEmotional oEnvironmental oFinancial oMental oMedical
  • 70. Love is a lot like backache. It doesn’t show up on Xrays, but you know it’s there. George Burns
  • 71. Have a love-filled, backache- free day! rayuma.doktor@gmail.com www.allancorpuzmd.com https://seriousmd.com/doc/rayumadoktor