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Low Back Problems 

Low back pain is very common. Everyone is going to have low back pain eventually and low back pain is almost always self limiting. No matter what we do, low back pain in 95-99% of the cases is going to go away on its own, no matter what medicine, what therapies, back pain, sciatica, herniated disk, arthritis, siatica, sitica

There are only a very small number of patients that are associated with really disabling low back problems or that account for the bulk of the dollars spent in treating low back problems and a conservative approach to diagnosis and treatment is almost always indicated. Weíre going to talk about some of the red flags or reasons why weíd want to really be more aggressive. But in the

So, weíre going to talk a little bit about the general evaluation, weíre going to talk about the history and physical, weíre going to talk a little bit about the treatment and what has and hasnít been proven to be effective. Finally, weíll say a few words on prevention. As I mentioned, about 50% each year are going to get low back pain. 90%+ of Americans say theyíve had low

Availability of disability. Itís real interesting here. If you look at a country like Sweden where they have a disability system much like ours, low back pain is rampant. There are all sorts of visits to the hospital, to physicianís offices and a lot of expense. If you

Pregnancy. Almost everybody during pregnancy will have low pain and we will talk a little bit about that. Finally, we know that smoking is an important risk factor for having low back pain and persistent low back problems.

Masqueraders. Some non-spinal causes of pain. Youíre pretty embarrassed if someone goes out of your office with an abdominal aortic aneurysm thatís leaking. You probably donít want to miss that or a pelvic tumor or so on.

Other serious causes of low back pain. In particular, we want to make sure that a person doesnít have cauda equina syndrome. We want to look at nerve root entrapment and weíll talk about radiculopathy or nerve root entrapment, not because the treatment is so much different except in the very few cases, but because the natural history is a little more protracted.

Letís start out with the underlying occupational and psychosocial issues. We want to find out about their work environment. What are they doing? Are they a baggage handler for United? Do they sit all day in front of a CRT or monitor? What is the functional impact at work? Can they do their job? Are they trying at age 45 to use their back as a crane, digging ditches all day? Probably not realistic. What are the psychosocial issues including things like depression, substance use. Again, for many of your patients youíre going to know all this by the time they come in. If you are working in an Emergency Room or acute care center, itís going to take you a little longer to get this information. Is there a question of workersí compensation or disability? This by far and away tends to predict those with chronicity until we have resolution of those issues.

Masqueraders or non-spinal causes of back pain. I probably donít have to dwell on this but, again, keep in the back of your mind if someone comes in with low back pain itís not necessarily related to the spine. The person who ends up with an intra-abdominal process, a leaking aneurysm, an ulcer, etc, you want to make sure that we make those

We want to consider serious causes like systemic rheumatologic conditions. Does this person have Reiterís syndrome? Do they have something else going on? Infection. So spinal cord infection would be something. Diskitis. Tumor or myeloma, particularly as we get into our older population. Trauma or fractures. So we want to find out did this person sustain some sort of injury. Were they in a car accident. Then finally cauda equina syndrome.

Signs of infection. So fever, chills. Do they have a source, potentially, for infection. Bowel or bladder dysfunction that might point to cauda equina syndrome. So do they have overflow incontinence or problems with urinary retention? Is there a history of

Intravenous drug use. So obviously the person who is a user is going to be at risk for infections. Likewise, the individual who has some form of being immunocompromised. So the person with AIDS or who is on steroids who has a significant underlying

The history can be gotten in a relatively simple fashion and youíre all going to have your own ways of doing this. "Tell me about your back pain" may be all you need to do to elicit the information you need to know. "Where does it hurt?" Especially down below the knee which signifies true radiculopathy. "How does your back problem affect your job, school, household

What sort of physical exam? Obviously you look for fever. If someone has a temperature of 103.6ļ, thatís going to cause me to click in a bunch of other different things there besides just simple back sprain. Extreme stiffness or tenderness. You know, people are stiff and tender of all different varieties. Straight leg raise test and letís talk a little bit about that.

What is a positive straight leg raise? What we want to do with the straight leg raise is weíre looking for stretch on the nerve which is going to cause a radicular pain Ė not just back pain. Because, you know, if you raise somebody whoís got a back strain and you go bopping around with their leg, theyíre going to say, "Oh, yeah. That hurts." "Tell me about it. Where does it hurt?" "Well, it feels like thereís an electric shock down my leg." "Okay. And where does that go?" So get them to be specific. So to really have a positive straight leg raise as opposed to a meaningless, "Iíve got pain in my lower back when you do that, Doc."

We do reflexes. If you think about which disks are involved and what neurological levels are involved, you probably wouldnít, in this age of cost effective medicine, waste two seconds in doing a patellar reflex but since it takes two seconds you probably should. I mean, how long does it take to tap on it? Ankle is S1. L3 and 4 probably not really a very frequent occurrence.

Look at motor. So quadriceps. Wasting or atrophy. How long does it take you to get wasting or atrophy? How many of you have seen somebody with a wasted or atrophied quadriceps? I mean, this takes a long time. This is a missed diagnosis. This is someone who hasnít come in for a long time. Measuring quadriceps size. I think thatís worthless. I mean, youíre not going to have the accuracy and there have been no studies that have ever been shown that you can really tell much of anything with that so I donít do it. Great toe extensor weakness of the hallucis longus, L5, and a heel walk.

Now, Iíll put this together in a few moments but if you look at it, the gastrocnemius and soleus, so a toe walk. You can have them hop and theyíll have a flat footed landing and weíll demonstrate this in a moment. I think itís worth looking for pathologic reflexes that might make you think, "Wait a minute. This really isnít just a garden variety sciatica."

The sensory exam. Looking for L4, L5 and S1.

Here you go. A nice little simple thing to do. If you are thinking about this now, before we get into the actual nerve by nerve look at this, you can have someone walk into your room or walk around, see how disabled they seem to be, you can do a straight leg raise, you can palpate their back, you can look at their vital signs, you can have them do a heel and toe walk, you can do your thing on three parts of their foot and tap on some reflexes. Five minutes. Five minutes to do an exam for most people.

Now, clearly there are going to be a few people youíre going to do a more extensive evaluation on or itís going to be puzzling or hard to do but if you get this routine down, you are going to know, probably by the end of the history, let alone the physical, whether you are going to need to do anything further and you are going to be able to do that as well as any neurosurgeon or orthopedist or anyone else out there. This isnít rocket science.

Then we are going to try to put it together. Particularly for those people who we think might have radiculopathy, who might have sciatica, who might have some nerve root entrapment we think about L3-4 disk or the 4th lumbar roots. So remember the difference there and weíre going to look at pain, numbness, weakness, atrophy and reflexes in each of the nerve root entrapments and you have this in your handout.

So, pain. Maybe some numbness, weakness of the quadriceps. Again, that atrophy if itís been long standing and diminished patellar or knee jerk. Thatís the fourth lumbar root. You can test the tibialis anterior or here Ė the L4 neurologic level, sensation, reflex and motor exam.

Fifth lumbar root. Letís keep going downward now. Remember the pain, the numbness, motor and reflex changes. But there are no reflex changes here. Again, extensor hallucis longus. If we were to put this together, in the 5th neurologic level, motor, extensor hallucis longus weakness, no reflex changes and the dorsum of the foot.

Finally, the first sacral nerve root. Pain, numbness. You may see some changes with prolonged time period of the gastrocnemius and soleus. Then ankle jerk. You can have the person hop and see some flat landings so they canít keep on their toes, they hop. You can test the peroneae muscle unit. Putting it together, peroneus, the reflex changes and then sensation changes.

Well, you do see some of those patients and they may be looking for the green poultice treatment to relieve their symptoms. The point, unfortunately, is that weíre not going to be able to solve everyoneís problem but weíre not going to help by exacerbating them. Weíre not going to help by being angry with people or by setting up a confrontation.

So some of the things we need to look at. Non-organic tenderness. Iíll talk a little bit about pain drawings Ė nondermatomal distribution of sensory or motor findings and the Hoover test. This is a pain diagram or pain drawing. What you can do is have patients mark where their pain is with an "X", numbness with an "O" and "Z" for a numb feeling and then use that. You know, youíll have people that have one leg, in the back, that is totally numb or people that, "Well, my arm is numb from here and then my buttock is numb there and it hurts in my eyeballs when I urinate." Then youíve got a pretty good idea that maybe this person isnít quite on the level. Donít get fooled, though. You donít want to miss someone with cauda equina or a syrinx or some other serious neurologic problem. So make sure you followup and take them seriously.

Hoover test. Have many of you heard of that? Basically, if you are asking someone to try to raise their leg and you are trying to test their strength, most of us, if we had a significant deficit, are going to try to get counterforce or counterleverage by pressing down on the other leg. If you imagine the person laying down, youíre going to try to use that leverage. So if you have the individual trying to raise their one leg and you are trying to figure out of they are really trying or not, they will be applying force down where as the malingerer will give the opposite response. So here, again, the person trying to lift the leg will try to get a little leverage or purchase by pushing down.

The one I like a lot is the straight leg raise when they are sitting. They havenít even undressed yet. Iíll say, "You know, one of the things I really like to look at is the wear on your shoes. Oh, gosh, yes. Uh-huh." Youíve done a straight leg raise, right? It doesnít matter what position theyíre in. Then when you get them laying down theyíre smart enough and they say, "Oh gosh,

Letís talk about pharmacotherapeutics. It turns out that the most effective, or at least as effective as anything else, medication is right in that patientís medicine chest. Acetaminophen or aspirin. There is no evidence that anything is better than those two agents. There is evidence that things like nonsteroidals are effective and there may be some psychologic advantage to say, "Oh, yes, Iím going to go get you a sample of Daypro" or whatever the case may be but there is no evidence that any of those things are better than Tylenol or acetaminophen.

Muscle relaxants. There is no good evidence that muscle relaxants do anything and there is certainly a risk for things like driving off the road, falling asleep at machinery and work and so on. So I generally donít prescribe muscle relaxants. I donít prescribe benzodiazepines or anything else for my typical patient with low back pain. If I do, this is the type of person basically Iím just trying to snow for a day or two, let them get over their real acute pain and get them back activated. But I donít see a role for these.

Opioid analgesics. Very controversial. I will very rarely give an opioid analgesic or narcotic to someone I know who has significant discomfort and they have to do whatever they have to do for that next day or two. I think we probably all make some of those personal decisions one way or the other but as a rule there is no evidence that they are any better and I donít generally give them.

Steroids. Antidepressants. Any other medications that you might have heard of, Hulchisene, etc. There is no evidence that they work and, in fact, some evidence that they may make things worse.

How about the copper wrist band? Well, I mean if you can get one for $18 bucks or the gold plated one. I bet that really works well.

How many of you use chiropractic care or manipulation in your practice? How many refer? So some of you. Iím talking about for back pain. A lot of patients refer themselves just like alternative therapies which I see you will be hearing about later on. Well, the bottom line is that there is as good evidence that manipulation is effective for nonradicular back pain as for any of our

Physical agents or modalities. Hot and cold, you can apply at home. You donít need a physical therapist to do it. Traction. TENS, lifts, belts. There is no evidence that any of these things work well for acute low back pain and the evidence for chronic low back pain is darn iffy. The Support All Back Support Back Pain relief. Again, I just love collecting all these ads. Iíve got a

Injections. No evidence they work. No evidence at all. The only type of injection might be some epidural steroids when a person has radiculopathy and they are considering surgery. Thatís about the only time that I think about giving a person an injection and

Workersí comp. What do we do? I think we do all those things that we as family physicians have been taught to do. We make sure we havenít missed something on a good history and physical. If we want to refer that patient, we talk to our consultant and say, "Hey, look. Iíve got this person. I really donít think they have anything else going on but I appreciate you doing a good