www.medicaleducator.co.uk Evidence based Clinical Assessment of Low Back Pain for Medical Students: Evidence, Clinical examination, Imaging & Guidelines

www.medicaleducator.co.uk Overview Causes of LBP Case as an example Discussion around imaging of LBP

www.medicaleducator.co.uk Low Back Pain Ideopathic (“strain”) Degenerative disease disk/facet Spinal Stenosis Herniated disc Fracture (osteoporotic) Trauma Instability Malignancy Primary: Osteosarcoma/ cord tumour Secondary (commoner): Myeloma/ prostate/ breast/lung/renal Local Invasion of tumour Infection (disc/bone etc) Inflammatory: Ank Spond/ Seronegative arthritis Paget’s Disease Pelvic Renal AAA Small bowel Large Bowel

www.medicaleducator.co.uk Hypothetical Case Miss X 36 year old female presenting with a 15 day history of acute low back pain. Doesn’t want to see the GP. History of “Post Viral Fatigue” syndrome Extensive investigations have proved to be NAD at GP surgery. (bloods/x-rays) Examination previously normal

www.medicaleducator.co.uk PMHx DHx PRN NSAID, Codeine, tramadol, paracetamol SHx Lives Alone Works in Fast Food Restaurant Previous IVDU / Jail term Non smoker No ETOH S/E No other symptoms

www.medicaleducator.co.uk History Onset of pain (e.g., time of day, activity) Location of pain (e.g., specific site, radiation of pain) Type and character of pain (sharp, dull, radicular etc.) Aggravating and relieving factors (flexion/ extension) Medical history, including previous injuries. Systemic enquiry Psychosocial stressors at home or work. "Red flags"

www.medicaleducator.co.uk Evidence: From the history is she likely to have something sinister?

www.medicaleducator.co.uk Red flags include Age <20 or >55 for first onset Nocturnal pain W. loss Other high risk (IVDU/ Steroids/ Osteoporosis/ previous #/ malignancy) Motor / Sensory disturbance (bladder and bowels) Severity

www.medicaleducator.co.uk Evidence: History Predicting Lumbosacral Radiculopathy Kerr et al The value of accurate clinical assessment in the surgical management of disc protrusion. Neurol Neurosurg 1998 l51:169-173

www.medicaleducator.co.uk Does the examination predict disease?

www.medicaleducator.co.uk *Lauder et al. Effect of History and Exam in predictins Electrodiagnostic outcome on patients with suspected lumbosacral radiculopathy. Am J Rehabil. 2000;79:60-68 (N=170) **Kerr et al The value of accurate clinnical assessment in the surgical management of disc protrusion. Neurol Neurosurg 1998l51:169-173 (N=100)

www.medicaleducator.co.uk SLR: Marker Pain occurring when the angle is between 30 and 60 degrees is a provocative sign of nerve root irritation popliteal compression test Bending the knee while maintaining hip flexion should relieve the pain, and pressure in the popliteal region should worsen it Lasègue's sign If placing the knee back in full extension during straight leg raising and dorsiflexing the ankle also increase the pain nerve root and sciatic nerve irritation is likely. Crossed SLR / cervical flexion

www.medicaleducator.co.uk SLR/ Crossed SLR Sensitivity? Specificity?

www.medicaleducator.co.uk SLR Evidence Radiculopathy: Meta analysis Deville et al Spine 2000;25:1140-1147

www.medicaleducator.co.uk Miss X Neurological Examination Whilst Lying on the bed Grade 3+/5 power in her left leg (hip flexion) other power normal Reflexes normal No objective sensory deficit Noted that the patient walked into the room normally

www.medicaleducator.co.uk What is the standard for nerve root lesions, dermatomal distributions and levels for reflexes? FOR Example ankle dorsiflexion sensation posterior thigh

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www.medicaleducator.co.uk Should I do an X-ray or MRI Evidence? Even if it just makes the patient feel better?

www.medicaleducator.co.uk Kendrick D 2001 West Midlands 421 patients with low back pain presenting to the GP at 73 practices in Midlands, UK. had pain for more than 6 weeks and on the day of randomisation. No "red-flag" symptoms and aged 20-55. Randomised to either immediate radiography or later imaging at the discretion of the GP Participants were assessed using the Roland score (the primary outcome measure), VAS, EuroQol, patient satisfaction, duration of pain, duration of sick leave, use of other services and sick leave. Assessments made at 3 and 9 months.

www.medicaleducator.co.uk Outcomes No Difference Interestingly only 14% of the patients in the “no xray” arm went on to have imaging No significant pathology picked up on X-ray

www.medicaleducator.co.uk What About an MRI scan? Lets look at asymptomatic individuals….

www.medicaleducator.co.uk MRI in the Asymptomatic 98 patients 36% normal disks at all levels. 52% percent of the subjects had a bulge at at least one level 27% percent had a protrusion, 1% extrusion. 38 %abnormality of more than one intervertebral disk. The prevalence of bulges, but not of protrusions, increased with age. 1 in 5 had Schmorl's nodes (herniation of the disk into the vertebral-body end plate), 14 % annular defects (disruption of the outer fibrous ring of the disk), facet arthropathy in 8 percent. Jensen et al Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain. NEJM 1994: 331:69-73

www.medicaleducator.co.uk So in asymptomatic adults on MRI: 1 in 5 will have a herniated disc 50% will have degenerative disc disease Up to 10% will have spinal stenosis

www.medicaleducator.co.uk Applying the The Latest Guidelines to The Patient R. Chou, A. Qaseem, V. Snow, D. Casey, J. T. Cross Jr, P. Shekelle, D. K. Owens, and for the Clinical Efficacy Assessment Subcommittee Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Ann Intern Med, October 2, 2007; 147(7): 478 - 491

Summary of the 7 recommendations Recommendation 1: Focus Hx and examination into a of 3 categories: NSLBP Radiculopathy &stenosis Other Recommendation 2: No routine imaging Recommendation 3: Image where LBP has neurological signs or with suspecion of underlying serious illness. Recommendation 4: MRI only if fit for an intervention Recommendation 5: Evidence based counselling Recommendation 6: Use NSAID & approppriate analgesia Recommendation 7: Consider other options (e.g. CBT/ massage/ accupuncture)

www.medicaleducator.co.uk Summary Red flags Importance of clinical examination and history Judicious use of imaging Discussed guidelines Available Here or at http://www.acponline.org/clinical_information/guidelines/current/#acg