Low Back Pain Evaluation and Management
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Bill McCarberg
Founder
Chronic Pain Management Program
Kaiser Permanente
San Diego, California
Adjunct Assistant Clinical Professor
University of California
School of Medicine
San Diego, California
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Discuss the differential diagnosis
for low back pain (LBP) and the
importance of clinical red and yellow
flags in evaluation of LBP
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In 2007, the American College of
Physicians (ACP) and American Pain
Society (APS) issued comprehensive
joint clinical practice guidelines for
diagnosis and treatment of LBP
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Clinicians should conduct a focused history
and physical examination to help place
patients with LBP into 1 of 3 broad categories
Nonspecific LBP
Back pain potentially associated with radiculopathy
or spinal stenosis
Back pain potentially associated with another
specific spinal cause
The history should include assessment of
psychosocial risk factors, which predict risk
for chronic disabling back pain
Strong recommendation
Moderate-quality evidence
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Determine presence and level of
neurological involvement
1,2
Classify patients into 3 broad categories
Nonspecific LBP potentially associated with radiculopathy
Spinal stenosis
Back pain potentially associated with another specific
spinal cause
Patients with serious or progressive neurologic deficits
or underlying conditions requiring prompt evaluation
Tumor
Infection
Cauda equina syndrome
Patients with other conditions that may respond to
specific treatments
Ankylosing spondylitis
Vertebral compression fracture
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Site
Length of illness
Spread
Quality
Intensity
Frequency
Duration
Time of onset
Mode of onset
Precipitating factors
Aggravating factors
Relieving factors
Associated features
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90% of American adults experience an
episode of back pain during their lifetime
Of patients who have acute back pain
90% to 95% have a non–life-threatening condition
Although up to 85% cannot be given an exact diagnosis,
nearly all recover within 4 to 6 weeks
For 5% to 10% of patients, acute back pain
is a manifestation of more serious pathology
Vascular catastrophes, malignancy, spinal
cord compressive syndromes, and infectious
disease processes
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In minority of patients presenting for initial evaluation
in primary care setting, LBP is caused by
1
Cancer (approximately 0.7% of cases)
Compression fracture (4%)
Spinal infection (0.01%)
Estimates for prevalence of ankylosing spondylitis
in primary care patients range from 0.3%1 to 5%
2
Spinal stenosis and symptomatic herniated disc are
present in about 3% and 4% of patients, respectively
Cauda equina syndrome most commonly associated
with massive midline disc herniation, but rare
Estimated prevalence of 0.04%
3
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LBP is one of top 10 reasons patients seek care from
family physicians
1
Prevalence of LBP has varied from 7.6% to 37%
Peak prevalence between 45 and 60 years of age
2
Also reported by adolescents and by adults of all ages
80% of adults seek care at some time for acute LBP
3
One-third of US disability costs are due to low
back disorders
3
Direct costs of diagnosing and treating LBP in United
States estimated in 1991 to be $25
*
billion annually
4
Indirect costs, including lost earnings, are even higher
4
Proper diagnosis and appropriate treatment of LBP
saves healthcare resources, relieves suffering
*
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Nonspecific LBP
Back pain potentially associated
with radiculopathy or spinal stenosis
Back pain potentially associated
with another specific spinal cause
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Muscles of the back
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Interspinous ligaments
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Intervertebral discs
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Mechanical
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or chemical irritation
of dura mater
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Possible sources of back pain have
been demonstrated; causes have been
more elusive
Refuted: conditions traditionally considered
to be possible causes are actually not causes
Eg, spondylolysis, spondylolisthesis, degenerative
changes (spondylosis)
Accepted: tumors and infections
Untested: muscle sprain, ligament sprain,
segmental dysfunction, and trigger points
Known source, unknown cause: sacroiliac joints,
zygapophyseal joints, internal disc disruption
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Inquire about
Location of pain
Frequency of symptoms
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History of previous symptoms, treatment,
and response to treatment
Consider possibility of LBP due to problems
outside the back
Pancreatitis
Nephrolithiasis
Aortic aneurysm
Systemic illnesses (eg, endocarditis or
viral syndromes)
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2
Clinicians should not routinely obtain
imaging or other diagnostic tests
in patients with nonspecific LBP
Strong recommendation
Moderate-quality evidence
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There is no evidence that routine plain radiography in
patients with nonspecific LBP is associated with a greater
improvement in patient outcomes than selective imaging
1-3
Exposure to unnecessary ionizing radiation should be
avoided, particularly in young women (amount of gonadal
radiation from obtaining a single plain radiograph [2 views]
of the lumbar spine is equivalent to daily chest radiograph
for more than 1 year)
4
Routine advanced imaging (computed tomography [CT]
or magnetic resonance imaging [MRI]) is not associated
with improved patient outcomes,
5
identifies radiographic
abnormalities poorly correlated with symptoms,
6
and could
lead to additional, possibly unnecessary interventions
7,8
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.
3
.
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.
2
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2
;
5
2
(
4
7
9
)
:
4
6
9
-
4
7
4
.
4
.
J
a
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v
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k
J
G
.
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u
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l
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m
.
2
0
0
3
;
1
3
(
2
)
:
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9
3
-
3
0
5
.
5
.
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i
l
b
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J
,
e
t
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.
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a
d
i
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o
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y
.
2
0
0
4
;
2
3
1
(
2
)
:
3
4
3
-
3
5
1
.
6
.
J
a
r
v
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k
J
G
,
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t
a
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.
A
n
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d
.
2
0
0
2
;
1
3
7
(
7
)
:
5
8
6
-
5
9
7
.
7
.
J
a
r
v
i
k
J
G
,
e
t
a
l
.
J
A
M
A
.
2
0
0
3
;
2
8
9
(
2
1
)
:
2
8
1
0
-
2
8
1
8
.
8
.
L
u
r
i
e
J
D
,
e
t
a
l
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
2
0
0
3
;
2
8
(
6
)
:
6
1
6
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6
2
0
.
P
l
a
i
n
X
-
R
a
y
s
f
o
r
L
o
w
B
a
c
k
P
a
i
n
(
c
o
n
t
.
)
Plain radiography is recommended for initial
evaluation of possible vertebral compression fracture
in select high-risk patients, such as those with a
history of osteoporosis or steroid use
1
Evidence to guide optimal imaging strategies is
not available for LBP that persists for more than
1 to 2 months if there are no symptoms suggesting
radiculopathy or spinal stenosis, although plain
radiography may be a reasonable initial option
(see recommendation 4 for imaging recommendations
in patients with symptoms suggesting radiculopathy
or spinal stenosis)
2
Thermography and electrophysiologic testing are
not recommended for evaluation of nonspecific LBP
1.
J
a
r
v
i
k
J
G
,
e
t
a
l
.
A
n
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I
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t
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d
.
2
0
0
2
;
1
3
7
(
7
)
:
5
8
6
-
5
9
7
.
2.
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
G
u
i
d
e
l
i
n
e
#
3
Clinicians should perform diagnostic
imaging and testing for patients with
LBP when severe or progressive
neurologic deficits are present or
when serious underlying conditions
are suspected on the basis of history
and physical examination
Strong recommendation
Moderate-quality evidence
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
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d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
C
T
o
r
M
R
I
D
i
a
g
n
o
s
t
i
c
I
m
a
g
i
n
g
Prompt work-up with MRI or CT is
recommended if severe or progressive
neurologic deficits or suspected serious
underlying condition; delayed diagnosis
and treatment associated with
poorer outcomes
1-3
MRI is generally preferred over CT if
available; does not use ionizing radiation,
provides better visualization of soft tissue,
vertebral marrow, and the spinal canal
4
1
.
L
o
b
l
a
w
D
A
,
e
t
a
l
.
J
C
l
i
n
O
n
c
o
l
.
2
0
0
5
;
2
3
(
9
)
:
2
0
2
8
-
2
0
3
7
.
2
.
T
o
d
d
N
V
.
B
r
J
N
e
u
r
o
s
u
r
g
.
2
0
0
5
;
1
9
(
4
)
:
3
0
1
-
3
0
6
.
3
.
T
s
i
o
d
r
a
s
S
,
e
t
a
l
.
C
l
i
n
O
r
t
h
o
p
R
e
l
a
t
R
e
s
.
2
0
0
6
;
4
4
4
:
3
8
-
5
0
.
4
.
J
a
r
v
i
k
J
G
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
2
;
1
3
7
(
7
)
:
5
8
6
-
5
9
7
.
C
T
o
r
M
R
I
D
i
a
g
n
o
s
t
i
c
I
m
a
g
i
n
g
(
c
o
n
t
.
)
There is insufficient evidence to guide diagnostic
strategies in patients who have risk factors for cancer
but no signs of spinal cord compression
Proposed strategies generally recommend plain
radiography or measurement of erythrocyte
sedimentation rate
3
, with MRI reserved for patients
with abnormalities on initial testing
1,2
Alternative strategy is to directly perform MRI
in patients with a history of cancer, the strongest
predictor of vertebral cancer;
2
for patients older than
50 without other risk factors for cancer, delaying imaging
while offering standard treatments and reevaluating
within 1 month may also be a reasonable option
4
1
.
J
a
r
v
i
k
J
G
,
e
t
a
l
.
A
n
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I
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.
2
0
0
2
;
1
3
7
(
7
)
:
5
8
6
-
5
9
7
.
2
.
J
o
i
n
e
s
J
D
,
e
t
a
l
.
J
G
e
n
I
n
t
e
r
n
M
e
d
.
2
0
0
1
;
1
6
(
1
)
:
1
4
-
2
3
.
3
.
v
a
n
d
e
n
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o
o
g
e
n
H
M
,
e
t
a
l
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
1
9
9
5
;
2
0
(
3
)
:
3
1
8
-
3
2
7
.
4
.
S
u
a
r
e
z
-
A
l
m
a
z
o
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E
,
e
t
a
l
.
J
A
M
A
.
1
9
9
7
;
2
7
7
(
2
2
)
:
1
7
8
2
-
1
7
8
6
.
G
u
i
d
e
l
i
n
e
#
4
Clinicians should evaluate patients
with persistent LBP and signs or
symptoms or radiculopathy or spinal
stenosis with MRI (preferred) or CT
only if they are potential candidates
for surgery or epidural steroid injection
(for suspected radiculopathy)
Strong recommendation
Moderate-quality evidence
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
I
m
a
g
i
n
g
f
o
r
L
o
w
B
a
c
k
P
a
i
n
The natural history of lumbar disc herniation with
radiculopathy in most patients is for improvement within
the first 4 weeks with noninvasive management
1,2
There is no compelling evidence that routine imaging
effects treatment decisions or improves outcomes
3
For prolapsed lumbar disc with persistent radicular
symptoms despite noninvasive therapy, discectomy
or epidural steroids are potential treatment options
4-8
Surgery is also a treatment option for persistent
symptoms associated with spinal stenosis
9-12
1
.
V
r
o
o
m
e
n
P
C
,
e
t
a
l
.
B
r
J
G
e
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P
r
a
c
t
.
2
0
0
2
;
5
2
(
4
7
5
)
:
1
1
9
-
1
2
3
.
2
.
W
e
b
e
r
H
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
1
9
8
3
;
8
(
2
)
:
1
3
1
-
1
4
0
.
3
.
M
o
d
i
c
M
T
,
e
t
a
l
.
R
a
d
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o
l
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g
y
.
2
0
0
5
;
2
3
7
(
2
)
:
5
9
7
-
6
0
4
.
4
.
G
i
b
s
o
n
J
N
,
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t
a
l
.
C
o
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.
2
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(
3
)
:
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0
0
1
3
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0
.
5
.
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i
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o
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t
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.
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2
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:
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0
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1
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2
.
6
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e
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m
a
n
s
P
J
,
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t
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l
.
S
p
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(
P
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i
l
a
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6
)
.
2
0
0
1
;
2
6
(
5
)
:
5
0
1
-
5
1
5
.
7
.
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e
u
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W
C
,
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t
a
l
.
N
E
n
g
l
J
M
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d
.
2
0
0
7
;
3
5
6
(
2
2
)
:
2
2
4
5
-
2
2
5
6
.
8
.
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e
i
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t
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i
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t
a
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.
J
A
M
A
.
2
0
0
6
;
2
9
6
(
2
0
)
:
2
4
5
1
-
2
4
5
9
.
9
.
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d
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T
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t
a
l
.
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p
i
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e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
2
0
0
0
;
2
5
(
1
1
)
:
1
4
2
4
-
1
4
3
5
.
1
0
.
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t
l
a
s
S
J
,
e
t
a
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.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
2
0
0
5
;
3
0
(
8
)
:
9
3
6
-
9
4
3
.
1
1
.
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e
i
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s
t
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i
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J
N
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t
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l
.
N
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n
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l
J
M
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d
.
2
0
0
7
;
3
5
6
(
2
2
)
:
2
2
5
7
-
2
2
7
0
.
1
2
.
M
a
l
m
i
v
a
a
r
a
A
,
e
t
a
l
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
2
0
0
7
;
3
2
(
1
)
:
1
-
8
.
M
R
I
f
o
r
L
o
w
B
a
c
k
P
a
i
n
MRI (preferred if available) or CT is recommended for
evaluating patients with persistent back and leg pain
who are potential candidates for invasive interventions
Plain radiography cannot visualize discs or accurately evaluate
the degree of spinal stenosis
1
However, clinicians should be aware that findings on
MRI or CT (such as bulging disc without nerve root
impingement) are often nonspecific
Recommendations for specific invasive interventions,
interpretation of radiographic findings, and additional
work-up beyond scope of guideline, but decisions
should be based on clinical correlation between
symptoms and radiographic findings, severity of
symptoms, patient preferences, surgical risks,
and costs and will generally require specialist input
2
1
.
J
a
r
v
i
k
J
G
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
2
;
1
3
7
(
7
)
:
5
8
6
-
5
9
7
.
2
.
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
C
r
i
t
i
c
a
l
C
l
i
n
i
c
a
l
I
n
d
i
c
a
t
o
r
s
o
f
P
a
t
h
o
l
o
g
y
In patients with back and leg pain, a typical
history for sciatica (back and leg pain in
a typical lumbar nerve root distribution)
has a fairly high sensitivity, but uncertain
specificity for herniated disc
1,2
>90% of symptomatic lumbar disc
herniations (back and leg pain due to a
prolapsed lumbar disc compressing a nerve
root) occur at L4/L5 and L5/S1 levels
3
1
.
v
a
n
d
e
n
H
o
o
g
e
n
H
M
,
e
t
a
l
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
1
9
9
5
;
2
0
(
3
)
:
3
1
8
-
3
2
7
.
2
.
V
r
o
o
m
e
n
P
C
,
e
t
a
l
.
J
N
e
u
r
o
l
.
1
9
9
9
;
2
4
6
(
1
0
)
:
8
9
9
-
9
0
6
.
3
.
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
C
r
i
t
i
c
a
l
C
l
i
n
i
c
a
l
I
n
d
i
c
a
t
o
r
s
o
f
P
a
t
h
o
l
o
g
y
(
c
o
n
t
.
)
A focused examination that includes
straight-leg-raise testing and a
neurologic examination that includes
evaluation of knee strength and reflexes
(L4 nerve root), great toe and foot
dorsiflexion strength (L5 nerve root),
foot plantarflexion and ankle reflexes
(S1 nerve root), and distribution of
sensory symptoms should be done to
assess the presence and severity of
nerve root dysfunction
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
C
r
i
t
i
c
a
l
C
l
i
n
i
c
a
l
I
n
d
i
c
a
t
o
r
s
o
f
P
a
t
h
o
l
o
g
y
(
c
o
n
t
.
)
A positive result on straight-leg-raise test
(defined as reproduction of the patient’s
sciatica between 30 and 70 degrees
of leg elevation) has a relatively high
sensitivity (91%
[95% CI, 82% to 94%])
, but
modest specificity (26%
[CI, 16% to 38%])
for diagnosing herniated disc
Crossed straight-leg-raise test is more
specific (88%
[CI, 86% to 90%])
, but
less sensitive (29%
[CI, 24% to 34%])
D
e
v
i
l
l
e
W
L
,
e
t
a
l
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
2
0
0
0
;
2
5
(
9
)
:
1
1
4
0
-
1
1
4
7
.
C
r
i
t
i
c
a
l
C
l
i
n
i
c
a
l
I
n
d
i
c
a
t
o
r
s
o
f
P
a
t
h
o
l
o
g
y
(
c
o
n
t
.
)
All patients should be evaluated for
Presence of rapidly progressive
or severe neurologic deficits
Motor deficits at more than 1 level, fecal
incontinence, and bladder dysfunction
Most frequent finding in cauda
equina syndrome is urinary retention
(90% sensitivity)
Without urinary retention, probability
is approximately 1 in 10,000
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
D
e
y
o
R
A
,
e
t
a
l
.
J
A
M
A
.
1
9
9
2
;
2
6
8
(
6
)
:
7
6
0
-
7
6
5
.
Y
e
l
l
o
w
F
l
a
g
s
Identify psychosocial problems in
acute phase
Slow progress to recovery may be
due to undetected, or unrevealed
psychosocial factors
Pertain to patient's beliefs and behaviors
concerning physical activity and domestic,
social, and vocational responsibilities
Example: patient believes physical activity might harm
back, make pain worse, so avoids activities
Most destructive is aversion to work
Belief that work caused pain, work aggravates pain,
work is too heavy, and work should not be done
M
c
G
u
i
r
k
B
E
,
e
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a
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Stronger predictors of LBP outcomes than either physical
findings or severity/duration of pain
1-3
Assessment of psychosocial factors identifies patients who
may have delayed recovery and could help target interventions
1 trial in referral setting found intensive multidisciplinary rehabilitation more
effective than usual care in patients with acute or subacute LBP identified
as having risk factors for chronic back pain disability
4
Direct evidence on effective primary care interventions for
identifying and treating such factors in patients with acute LBP
is lacking
5,6
Evidence is currently insufficient to recommend optimal methods
for assessing psychosocial factors and emotional distress
7
However, psychosocial factors that may predict poorer LBP
outcomes include presence of depression, passive coping
strategies, job dissatisfaction, higher disability levels, disputed
compensation claims, or somatization
8-10
1
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History
Gradual onset of back pain
Age <20 years or >50 years
Thoracic back pain
Pain lasting longer than 6 weeks
History of trauma
Fever/chills/night sweats
Unintentional weight loss
Pain worse with recumbency
Pain worse at night
Unrelenting pain despite
supratherapeutic doses of analgesics
History of malignancy
History of immunosuppression
Recent procedure causing bacteremia
History of intravenous drug use
Physical Examination
Fever
Hypotension
Extreme hypertension
Pale, ashen appearance
Pulsatile abdominal mass
Pulse amplitude differentials
Spinous process tenderness
Focal neurologic signs
Acute urinary retention
W
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y
Vertebral infection
Intravenous drug use, recent infection
Vertebral compression fracture
Older age, history of osteoporosis,
and steroid use
Musculoskeletal
Inactivity
In general
Emotional distress
C
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r
s
Large, prospective study from a primary
care setting
History of cancer (positive likelihood ratio, 14.7)
Unexplained weight loss (positive likelihood ratio, 2.7)
Failure to improve after 1 month (positive likelihood
ratio, 3.0)
Age >50 years (positive likelihood ratio, 2.7)
Posttest probability of cancer increases from
approximately 0.7% to 9% in patients with a history
of cancer (not including nonmelanoma skin cancer)
In patients with any 1 of the other 3 risk factors,
the likelihood of cancer only increases to
approximately 1.2%
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Features predicting vertebral infection not well studied,
but may include fever, intravenous drug use, or
recent infection
1
Consider risk factors for vertebral compression fracture,
such as older age, history of osteoporosis, and steroid
use; and for ankylosing spondylitis, such as younger
age, morning stiffness, improvement with exercise,
alternating buttock pain, and awakening due to back
pain during the second part of the night only
2
Clinicians should be aware that criteria for diagnosing
early ankylosing spondylitis (before the development
of radiographic abnormalities) are evolving
3
1
.
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To communicate effectively with all patients
Always use simple words, not medical jargon
Determine what the patient/caregiver already
knows or believes about his/her health situation
Encourage questions by asking, “What
questions do you have?” (allows for an open-
ended response), instead of “Do you have any
questions?” (allows for a “no” response, ending
the conversation)
Use the “teach-back” method to confirm the
level of understanding: Ask patients/family
members to restate what was just
communicated in the appointment or meeting
Z
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Ensure that patients/consumers receive effective,
understandable, and respectful care that is
provided in a manner compatible with their
cultural health beliefs and practices and
preferred language
Implement strategies to recruit, retain, and
promote at all levels of the organization a diverse
staff and leadership that are representative of the
demographic characteristics of the service area
Ensure that staff, at all levels and across all
disciplines, receives ongoing education and
training in CLAS delivery
U
S
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,
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Make pain assessment mandatory
Give a nonopioid analgesic at triage
Track reasons for unscheduled returns
Audit for ethnic bias
Consider which pain scales should
be used
Use multilingual laminated cards
T
o
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d
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H
.
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r
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r
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i
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e
Categorize patients into 1 of 3 broad groups:
nonspecific low back pain, back pain
potentially associated with radiculopathy
or spinal stenosis, or back pain potentially
associated with another specific spinal cause
Evaluate psychosocial risk factors to predict
the risk for chronic, disabling low back pain
Provide patients with evidence-based
information on expected course of low back
pain, effective self-care options, and
recommend that they be physically active
C
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.
?
?
Q
Q
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?
?
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p
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s
Roger Chou, MD, FACP
Associate Professor of Medicine,
Department of Medicine
Department of Medical Informatics
and Clinical Epidemiology
Oregon Health & Science University
D
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Dr. Chou has disclosed that he
has no actual or potential conflict
of interest in regard to this activity
His presentation will include off-label
discussion of anticonvulsants,
benzodiazepines, and tricyclic
antidepressants for the treatment
of low back pain (LBP)
L
e
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r
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i
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g
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b
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c
t
i
v
e
Integrate evidence-based pharmacologic
and nonpharmacologic therapies into
a comprehensive treatment plan for
chronic LBP
L
o
w
B
a
c
k
P
a
i
n
B
u
r
d
e
n
LBP is the fifth most common reason
for US office visits, and the second
most common symptomatic reason
1-2
$90.7 billion dollars in total healthcare
expenditures in 1998
3
LBP is the most common cause for
activity limitations in persons under
the age of 45
4
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a
l
e
n
c
e
r
a
t
e
r
a
t
i
o
.
*
T
h
e
P
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s
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n
d
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w
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t
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v
i
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t
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;
9
7
.
5
%
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s
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.
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*
U
n
a
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e
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t
i
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o
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i
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l
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o
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n
t
(
n
<
5
)
.
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r
e
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u
r
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e
r
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K
,
e
t
a
l
.
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r
c
h
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n
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e
d
.
2
0
0
9
;
1
6
9
(
3
)
:
2
5
1
-
2
5
8
.
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r
e
v
a
l
e
n
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f
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h
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a
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r
t
h
C
a
r
o
l
i
n
a
,
1
9
9
2
a
n
d
2
0
0
6
%
P
r
e
v
a
l
e
n
c
e
(
9
5
%
C
I
)
1
9
9
2
:
3
.
9
%
2
0
0
6
:
1
0
.
2
%
P
r
a
c
t
i
c
e
P
a
t
t
e
r
n
s
Spine surgery rates in the US are the
highest in the world
Rates in the US 5 times higher than in the UK
20-fold variation in fusion: 4.6 per 1000 in
Idaho Falls to 0.2 per 1000 in Bangor, Maine
Interventional therapies are also
widely used
Intradiscal electrothermal therapy estimated
at 7000-10,000 annually
20-fold variation in epidural steroid injections:
104 per 1000 in Palm Springs to 5.6 per 1000
in Honolulu
D
e
y
o
R
A
,
e
t
a
l
.
C
l
i
n
O
r
t
h
o
p
R
e
l
a
t
R
e
s
.
2
0
0
6
;
4
4
3
:
1
3
9
-
1
4
6
.
W
e
i
n
s
t
e
i
n
J
N
,
e
t
a
l
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
2
0
0
6
;
3
1
(
2
3
)
:
2
7
0
7
-
2
7
1
4
.
“
7
B
a
c
k
P
a
i
n
B
r
e
a
k
t
h
r
o
u
g
h
s
:
A
r
e
y
o
u
h
u
r
t
i
n
g
?
H
e
r
e
’
s
h
e
l
p
.
”
Reader’s Digest
July 2007
End Back
Pain Agony
(Michael J. Weiss)
W
e
i
s
s
M
J
.
R
e
a
d
e
r
'
s
D
i
g
e
s
t
.
J
u
l
y
,
2
0
0
7
.
R
e
a
d
e
r
’
s
D
i
g
e
s
t
“
C
u
r
e
s
”
f
o
r
L
o
w
B
a
c
k
P
a
i
n
“Cures” based on anecdotal evidence, not
yet approved, and/or only in animal studies
Infrared belt: $2335
“Magic Spinal Wand”
Percutaneous automatic discectomy
Flexible fusion
Stem cells
Site-directed bone growth
New bed
Based on an unpublished observational study funded
by a sleep products trade group
W
e
i
s
s
M
J
.
R
e
a
d
e
r
'
s
D
i
g
e
s
t
.
J
u
l
y
,
2
0
0
7
.
L
o
w
B
a
c
k
P
a
i
n
G
u
i
d
e
l
i
n
e
s
P
r
o
j
e
c
t
O
v
e
r
v
i
e
w
a
n
d
T
i
m
e
l
i
n
e
Began 2004; primary care guidelines published
October 2007
Address both acute and chronic LBP, and nonspecific
LBP and LBP with radiculopathy or spinal stenosis
Guideline for interventional therapies/surgery
published May 2009
Partnership between the American Pain Society
and the American College of Physicians (ACP)
Funded by the American Pain Society
Multidisciplinary panel with 25 members;
over 15 specialties/organizations represented
Series of 3 face-to-face meetings to
develop guidelines
Consensus achieved for all recommendations
R
e
c
o
m
m
e
n
d
a
t
i
o
n
G
r
i
d
A
C
P
M
e
t
h
o
d
s
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
S
t
r
e
n
g
t
h
o
f
R
e
c
o
m
m
e
n
d
a
t
i
o
n
B
a
s
i
c
P
r
i
n
c
i
p
l
e
s
o
f
S
e
l
e
c
t
i
n
g
T
h
e
r
a
p
y
f
o
r
L
o
w
B
a
c
k
P
a
i
n
For most LBP, labeling with a specific etiology
doesn’t help inform therapy choices
Most patients with acute LBP will improve
regardless of which therapy is chosen
For chronic LBP, therapies are moderately
effective at best
Use interventions with proven efficacy
Noninvasive approaches to most LBP
Consider psychosocial factors
R
e
c
o
m
m
e
n
d
a
t
i
o
n
T
r
e
a
t
m
e
n
t
o
f
L
o
w
B
a
c
k
P
a
i
n
Provide patients with evidence-based
information about their expected
course, advise patients to remain
active, and provide information
about effective self-care options
Strong recommendation
Moderate-quality evidence
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
A
d
v
i
c
e
a
n
d
S
e
l
f
-
C
a
r
e
f
o
r
L
o
w
B
a
c
k
P
a
i
n
Inform patients of generally favorable
prognosis of acute LBP with or without sciatica
Discuss need for re-evaluation if not improved
Advise to remain active
Consider self-care education books
Superficial heat moderately effective for
acute LBP
No evidence to support use of lumbar supports
Firm mattresses inferior to medium-firm
mattresses (1 RCT)
R
C
T
=
r
a
n
d
o
m
i
z
e
d
c
o
n
t
r
o
l
l
e
d
t
r
i
a
l
.
R
e
c
o
m
m
e
n
d
a
t
i
o
n
T
r
e
a
t
m
e
n
t
o
f
L
o
w
B
a
c
k
P
a
i
n
Consider the use of medications with
proven benefits in conjunction with
back care information and self-care …
for most patients, first-line medication
options are acetaminophen or NSAIDs
Strong recommendation
Moderate-quality evidence
N
S
A
I
D
s
=
n
o
n
s
t
e
r
o
i
d
a
l
a
n
t
i
-
i
n
f
l
a
m
m
a
t
o
r
y
d
r
u
g
s
.
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
P
h
a
r
m
a
c
o
l
o
g
i
c
I
n
t
e
r
v
e
n
t
i
o
n
s
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
5
0
5
-
5
1
4
.
T
h
i
s
i
n
f
o
r
m
a
t
i
o
n
i
n
c
l
u
d
e
s
a
u
s
e
t
h
a
t
h
a
s
n
o
t
b
e
e
n
a
p
p
r
o
v
e
d
b
y
t
h
e
U
S
F
D
A
.
P
h
a
r
m
a
c
o
l
o
g
i
c
I
n
t
e
r
v
e
n
t
i
o
n
s
(
c
o
n
t
.
)
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
5
0
5
-
5
1
4
.
T
h
i
s
i
n
f
o
r
m
a
t
i
o
n
i
n
c
l
u
d
e
s
a
u
s
e
t
h
a
t
h
a
s
n
o
t
b
e
e
n
a
p
p
r
o
v
e
d
b
y
t
h
e
U
S
F
D
A
.
R
e
c
o
m
m
e
n
d
a
t
i
o
n
T
r
e
a
t
m
e
n
t
o
f
L
o
w
B
a
c
k
P
a
i
n
For patients who do not improve with
self-care options, consider the addition of
nonpharmacologic therapy with proven benefits
For chronic or subacute LBP, options include
Intensive interdisciplinary
rehabilitation
Exercise therapy
Acupuncture
Massage therapy
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
7
8
-
4
9
1
.
Spinal manipulation
Yoga
Cognitive-behavioral
therapy
Progressive relaxation
Weak recommendation
Moderate-quality evidence
N
o
n
i
n
v
a
s
i
v
e
I
n
t
e
r
v
e
n
t
i
o
n
s
f
o
r
C
h
r
o
n
i
c
o
r
S
u
b
a
c
u
t
e
L
B
P
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
9
2
-
5
0
4
.
N
o
n
i
n
v
a
s
i
v
e
I
n
t
e
r
v
e
n
t
i
o
n
s
f
o
r
C
h
r
o
n
i
c
o
r
S
u
b
a
c
u
t
e
L
B
P
(
c
o
n
t
.
)
T
E
N
S
=
t
r
a
n
s
c
u
t
a
n
e
o
u
s
e
l
e
c
t
r
i
c
a
l
n
e
r
v
e
s
t
i
m
u
l
a
t
i
o
n
.
C
h
o
u
R
,
e
t
a
l
.
A
n
n
I
n
t
e
r
n
M
e
d
.
2
0
0
7
;
1
4
7
(
7
)
:
4
9
2
-
5
0
4
.
R
e
c
o
m
m
e
n
d
a
t
i
o
n
I
n
t
e
r
v
e
n
t
i
o
n
a
l
T
h
e
r
a
p
i
e
s
f
o
r
N
o
n
r
a
d
i
c
u
l
a
r
L
o
w
B
a
c
k
P
a
i
n
In patients with persistent nonradicular LBP,
facet joint corticosteroid injection,
prolotherapy, and intradiscal corticosteroid
injection are not recommended
Strong recommendation
Moderate-quality evidence
There is insufficient evidence to adequately
evaluate benefits of other interventional
therapies for nonradicular LBP
C
h
o
u
R
,
e
t
a
l
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
2
0
0
9
;
3
4
(
1
0
)
:
1
0
6
6
-
1
0
7
7
.
I
n
t
e
r
v
e
n
t
i
o
n
a
l
T
h
e
r
a
p
i
e
s
f
o
r
N
o
n
r
a
d
i
c
u
l
a
r
L
o
w
B
a
c
k
P
a
i
n
Interventional therapies not proven to be effective
in placebo-controlled, randomized trials
No trials (SI joint injection), trials showing no benefit
(facet joint injection), inconsistent results (IDET, RFDN),
or poor-quality evidence (trigger point injections)
Promising results from nonrandomized studies
not replicated in randomized trials
IDET
Facet joint steroid injection
Not clear if interventions are ineffective,
or if patients were not accurately selected
I
D
E
T
=
i
n
t
r
a
d
i
s
c
a
l
e
l
e
c
t
r
o
t
h
e
r
m
a
l
t
h
e
r
a
p
y
.
R
F
D
N
=
r
a
d
i
o
f
r
e
q
u
e
n
c
y
d
e
n
e
r
v
a
t
i
o
n
.
C
h
o
u
R
,
e
t
a
l
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
2
0
0
9
;
3
4
(
1
0
)
:
1
0
6
6
-
1
0
7
7
.
P
l
a
c
e
b
o
-
C
o
n
t
r
o
l
l
e
d
T
r
i
a
l
s
o
f
R
F
D
N
f
o
r
P
r
e
s
u
m
e
d
F
a
c
e
t
J
o
i
n
t
P
a
i
n
N
S
=
n
o
t
s
i
g
n
i
f
i
c
a
n
t
.
P
l
a
c
e
b
o
-
C
o
n
t
r
o
l
l
e
d
T
r
i
a
l
s
o
f
R
F
D
N
f
o
r
P
r
e
s
u
m
e
d
F
a
c
e
t
J
o
i
n
t
P
a
i
n
P
l
a
c
e
b
o
-
C
o
n
t
r
o
l
l
e
d
T
r
i
a
l
s
o
f
R
F
D
N
f
o
r
P
r
e
s
u
m
e
d
F
a
c
e
t
J
o
i
n
t
P
a
i
n
(
c
o
n
t
.
)
R
e
c
o
m
m
e
n
d
a
t
i
o
n
S
u
r
g
e
r
y
f
o
r
N
o
n
r
a
d
i
c
u
l
a
r
L
o
w
B
a
c
k
P
a
i
n
In patients with nonradicular LBP,
common degenerative spinal
changes, and persistent and disabling
symptoms … discuss risks and
benefits of surgery as an option
Weak recommendation
High-quality evidence
C
h
o
u
R
,
e
t
a
l
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
2
0
0
9
;
3
4
(
1
0
)
:
1
0
6
6
-
1
0
7
7
.
S
u
r
g
e
r
y
f
o
r
N
o
n
r
a
d
i
c
u
l
a
r
L
o
w
B
a
c
k
P
a
i
n
W
i
t
h
D
e
g
e
n
e
r
a
t
i
v
e
C
h
a
n
g
e
s
Benefits vary depending on comparator
Benefits of fusion vs standard nonsurgical therapy
less than 15 points on a 100-point pain or function
scale (1 RCT)
No difference vs intensive interdisciplinary
rehabilitation (3 RCTs)
All enrollees failed >1 year of nonsurgical management
and are not at higher risk for poor surgical outcomes
Fewer than half experience optimal outcomes
(relief of pain, return to work, decreased analgesic use)
No evidence that instrumentation improves outcomes
Shared decision-making approach recommended
C
h
o
u
R
,
e
t
a
l
.
S
p
i
n
e
(
P
h
i
l
a
P
a
1
9
7
6
)
.
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In patients with persistent radiculopathy
due to herniated lumbar disc … discuss
risks and benefits of epidural steroid
injection as an option
Weak recommendation
Moderate-quality evidence
C
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t
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.
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/
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p
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c
Epidural steroid injection
Short-term benefits in some higher-quality
trials, but data are inconsistent (could be
related to comparator used in trials)
No long-term benefits
No route clearly superior
Limited evidence of no benefit for
spinal stenosis
Shared decision-making
approach recommended
C
h
o
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,
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t
a
l
.
S
p
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(
P
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(
1
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7
7
.
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P
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p
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t
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n
o
s
i
s
In patients with persistent radiculopathy
due to herniated lumbar disc or
persistent and disabling leg pain due
to spinal stenosis … discuss risks
and benefits of surgery as an option
Strong recommendation
High-quality evidence
C
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t
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l
.
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y
Discectomy associated with more
rapid improvement in symptoms than
nonsurgical therapy
Patients improved either with or without surgery
No progressive neurologic deficits without
immediate surgery
Long-term (after 1-2 years) outcomes similar
in some trials
Most trials evaluated standard open discectomy
or microdiscectomy
Shared decision-making approach recommended
C
h
o
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R
,
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t
a
l
.
S
p
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(
P
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1
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6
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1
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7
7
.
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(
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2
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0
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;
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1
0
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0
9
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1
1
0
9
.
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f
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s
i
s
Decompressive laminectomy associated with
superior outcomes vs nonsurgical therapy
Mild improvement with nonsurgical therapy
No severe neurologic deficits without
immediate surgery
Benefits may diminish with long-term
(>2 years) follow-up
Shared decision-making approach recommended
C
h
o
u
R
,
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t
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l
.
S
p
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(
P
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.
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0
0
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;
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4
(
1
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:
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6
-
1
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7
7
.
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.
2
0
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;
3
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(
1
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1
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4
-
1
1
0
9
.
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l
u
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i
o
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s
The quality of evidence for different LBP
therapies varies
A number of therapies appear similarly
and moderately effective for LBP
Guidelines can provide clinicians with a
useful framework for choosing therapies
Factors that influence choices from
recommended therapies include patient
preferences, availability, and costs
Shared decision-making can help make
decisions consistent with patient values
and preferences
P
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.
?
?
Q
Q
u
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?
?
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a
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Bill McCarberg, MD
Founder, Chronic Pain Management Program
Kaiser Permanente San Diego
Adjunct Assistant Clinical Professor,
University of California, San Diego
D
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:
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D
Dr. McCarberg’s presentation will not include
discussion of off-label, experimental, and/or
investigational uses of drugs or devices
L
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b
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Evaluate early interventions for acute
back pain in patients considered at
high risk for transition to chronic low
back pain (CLBP)
D
i
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y
f
r
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m
B
a
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k
P
a
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n
The minority of cases which involve disability
account for a disproportionate percentage
of overall healthcare costs
The most cost-effective approach is to more
aggressively pursue
secondary prevention
efforts on
subacute patients
before chronic
disability is fully established
1
Acute: <3 weeks
Subacute: >3 weeks but <3 months
Chronic: >3 months, or more than 6 episodes
in 12 months
1
.
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s
Yellow flags are psychosocial
indicators suggesting increased risk
of progression to long-term distress,
disability, and pain
Can be applied more broadly to assess
likelihood of development of persistent
problems from acute pain presentation
Yellow flags can relate to the patient’s
attitudes and beliefs, emotions,
behaviors, family, and workplace
K
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.
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Belief that pain and activity are harmful
“Sickness behavior” such as extended rest
Bodily preoccupation and catastrophic thinking
Low or negative mood, anxiety, social withdrawal
Personal problems (eg, marital, financial, etc)
History of substance abuse
Problems/dissatisfaction with work (“blue flags”)
Overprotective family/lack of support
History of disability and other claims
Inappropriate expectations of treatment
Low expectation of active participation
The presence of yellow flags highlights the need to address
specific psychosocial factors as part of a multimodal
management approach
A
d
d
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h
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n
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c
i
t
y
Previous history of low back pain
Age
Nerve root involvement
Poor physical fitness
Self-rated health poor
Heavy manual labor, inability for light duty
upon return to work (“black flags”)
Ongoing medico-legal actions
Obesity
*
Smoking
*
*
N
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y
Additionally, regardless of the comparator intervention, there is
no convincing evidence that epidural steroids are associated with
long-term benefits or reduced rates of subsequent surgery
C
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a
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i
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r
s
Pain Catastrophizing Scale (PCS)
1
13 items
Fear of Pain Questionnaire (FPQ)
2
30 items
Fear-Avoidance Beliefs Questionnaire (FABQ)
3
16 items
Coping Strategies Questionnaire (CSQ)
4
42 items
1
.
S
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1
9
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5
;
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(
4
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:
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2
4
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3
2
.
2
.
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1
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.
3
.
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1
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9
3
;
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2
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.
4
.
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1
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4
.
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g
Numerous interventions appear effective
Cognitive-behavioral therapies
1-4
Physiotherapy and other activity-
based interventions
5
Intensive patient education and
exposure interventions
6,
7
Limited understanding of the mechanisms
by which changes in catastrophizing occur
1
.
L
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.
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High-risk patients identified with SCID
Intensive interdisciplinary team intervention
4 major components: psychology, physical therapy,
occupational therapy, and case management
Physical therapy sessions: both individual and group
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Interventions spaced over a 3-week period
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Behavioral medicine intervention (n=34)
Four 1-hour individual treatment sessions included
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to quota with feedback
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Self-management and problem-solving training to cope
with pain
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nonreinforcement of pain behaviors
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Tell patients your plan and
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of therapeutic options
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patient outcomes
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interventions appear promising; aggressive/
intensive intervention seems most important
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This informative resource delves into the evaluation, management, and prognosis of low back pain. It covers evidence-based evaluation, differential diagnosis, and the importance of clinical red and yellow flags in assessing low back pain. Guidelines from the American College of Physicians and the American Pain Society are highlighted, emphasizing the importance of conducting a focused history and physical examination to categorize patients with low back pain. The content also discusses the significance of assessing psychosocial risk factors and provides insights into conducting a thorough neurological examination and classifying patients based on specific criteria.
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Presentation Transcript
Welcome to Low Back Pain: Evaluation, Management, and Prognosis
Welcome and Overview Bill McCarberg Founder Chronic Pain Management Program Kaiser Permanente San Diego, California Adjunct Assistant Clinical Professor University of California School of Medicine San Diego, California
Evidence-Based Evaluation of Patients With Low Back Pain
Learning Objective Discuss the differential diagnosis for low back pain (LBP) and the importance of clinical red and yellow flags in evaluation of LBP
Low Back Pain Guidelines In 2007, the American College of Physicians (ACP) and American Pain Society (APS) issued comprehensive joint clinical practice guidelines for diagnosis and treatment of LBP Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Guideline #1 Clinicians should conduct a focused history and physical examination to help place patients with LBP into 1 of 3 broad categories Nonspecific LBP Back pain potentially associated with radiculopathy or spinal stenosis Back pain potentially associated with another specific spinal cause The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain Strong recommendation Moderate-quality evidence Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Focused History and Physical Examination Determine presence and level of neurological involvement1,2 Classify patients into 3 broad categories Nonspecific LBP potentially associated with radiculopathy Spinal stenosis Back pain potentially associated with another specific spinal cause Patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation Tumor Infection Cauda equina syndrome Patients with other conditions that may respond to specific treatments Ankylosing spondylitis Vertebral compression fracture 1. Deyo RA, et al. JAMA. 1992;268(6):760-765. 2. Bigos SJ, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, No. 14; 1994.
Evaluation of Back Pain Site Duration Length of illness Time of onset Spread Mode of onset Quality Precipitating factors Intensity Aggravating factors Frequency Relieving factors Associated features McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1094-1105.
Epidemiology of Low Back Pain 90% of American adults experience an episode of back pain during their lifetime Of patients who have acute back pain 90% to 95% have a non life-threatening condition Although up to 85% cannot be given an exact diagnosis, nearly all recover within 4 to 6 weeks For 5% to 10% of patients, acute back pain is a manifestation of more serious pathology Vascular catastrophes, malignancy, spinal cord compressive syndromes, and infectious disease processes Winters ME, et al. Med Clin North Am. 2006;90(3):505-523.
What Is Seen in Primary Care Practice? In minority of patients presenting for initial evaluation in primary care setting, LBP is caused by1 Cancer (approximately 0.7% of cases) Compression fracture (4%) Spinal infection (0.01%) Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3%1 to 5%2 Spinal stenosis and symptomatic herniated disc are present in about 3% and 4% of patients, respectively Cauda equina syndrome most commonly associated with massive midline disc herniation, but rare Estimated prevalence of 0.04%3 1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 2. Underwood MR, et al. Br J Rheumatol. 1995;34(11):1074-1077. 3. Deyo RA, et al. JAMA. 1992;268(6):760-765.
Cost of Low Back Pain LBP is one of top 10 reasons patients seek care from family physicians1 Prevalence of LBP has varied from 7.6% to 37% Peak prevalence between 45 and 60 years of age2 Also reported by adolescents and by adults of all ages 80% of adults seek care at some time for acute LBP3 One-third of US disability costs are due to low back disorders3 Direct costs of diagnosing and treating LBP in United States estimated in 1991 to be $25* billion annually4 Indirect costs, including lost earnings, are even higher4 Proper diagnosis and appropriate treatment of LBP saves healthcare resources, relieves suffering *40 billon in 2008 using Consumer Price Index to compute the relative value of money. 1. AAFP. Facts About Family Practice; 1996. 2. Borenstein DG. Curr Opin Rheumatol. 1997;9(2):144-150. 3. Kuritzky L, et al. Prim Care Rep 1995;1:29-38. 4. Frymoyer JW, et al. Orthop Clin North Am. 1991;22(2):263-271.
Etiology of Low Back Pain Nonspecific LBP Back pain potentially associated with radiculopathy or spinal stenosis Back pain potentially associated with another specific spinal cause Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Structural Sources of Low Back Pain Muscles of the back1,2 Interspinous ligaments2-4 Zygapophyseal joints5-7 Sacroiliac joint(s)8 Intervertebral discs9-12 Mechanical12 or chemical irritation of dura mater13 1. Kellgren JH. Clin Sci. 1938;3:175-190. 2. Bogduk N. Med J Aust. 1980;2(10):537-541. 3. Kellgren JH. Clin Sci. 1939;4:35-46. 4. Feinstein B, et al. J Bone Joint Surg Am. 1954;36-A(5):981-997. 5. Mooney V, et al. Clin Orthop Relat Res. 1976(115):149-156. 6. McCall IW, et al. Spine (Phila Pa 1976). 1979;4(5):441-446. 7. Fukui S, et al. Clin J Pain. 1997;13(4):303-307. 8. Fortin JD, et al. Spine (Phila Pa 1976). 1994;19(13):1475-1482. 9. Wilberg G. Acta Orthop Scand. 1947;19:211-221. 10. Falconer MA, et al. J Neurol Neurosurg Psychiatry. 1948;11(1):13-26. 11. Kuslich SD, et al. Orthop Clin North Am. 1991;22(2):181-187. 12. O'Neill CW, et al. Spine (Phila Pa 1976). 2002;27(24):2776-2781. 13. El-Mahdi MA, et al. Neurochirurgia (Stuttg). 1981;24(4):137-141.
Causes of Low Back Pain Possible sources of back pain have been demonstrated; causes have been more elusive Refuted: conditions traditionally considered to be possible causes are actually not causes Eg, spondylolysis, spondylolisthesis, degenerative changes (spondylosis) Accepted: tumors and infections Untested: muscle sprain, ligament sprain, segmental dysfunction, and trigger points Known source, unknown cause: sacroiliac joints, zygapophyseal joints, internal disc disruption McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1105-1122.
Diagnostic Triage Guides Subsequent Decision-Making Inquire about Location of pain Frequency of symptoms Duration of pain History of previous symptoms, treatment, and response to treatment Consider possibility of LBP due to problems outside the back Pancreatitis Nephrolithiasis Aortic aneurysm Systemic illnesses (eg, endocarditis or viral syndromes)
Differential Diagnosis for Acute Low Back Pain Patient Age (Years) Disease or Condition Location of Pain Low back, buttock, posterior thigh Aggravating or Relieving Factors Quality of Pain Signs Increased with activity or bending Local tenderness, limited spinal motion Back strain 20-40 Ache, spasm Sharp, shooting, or burning pain; paresthesia in leg Decreased with standing; increased with bending or sitting Increased with walking, especially up an incline; decreased with sitting Positive straight leg raise test, weakness, asymmetric reflexes Mild decrease in extension of spine; may have weakness or asymmetric reflexes Exaggeration of the lumbar curve, palpable step off (defect between spinous processes), tight hamstrings Decreased back motion, tenderness over sacroiliac joints Fever, percussive tenderness; may have neurologic abnormalities or decreased motion May have localized tenderness, neurologic signs, or fever Acute disc herniation Low back to lower leg 30-50 Low back to lower leg; often bilateral Ache, shooting pain, pins and needles sensation Osteoarthritis or spinal stenosis 30-50 Back, Increased with activity or bending Spondylolisthesis Any age Ache posterior thigh Sacroiliac joints, lumbar spine Ankylosing spondylitis 15-40 Ache Morning stiffness Lumbar spine, sacrum Infection Any age Sharp pain, ache Varies Dull ache, throbbing pain; slowly progressive Affected bone(s) Increased with recumbency or cough Malignancy >50 Adapted from: Patel AT, et al. Am Fam Physician. 2000;61(6):1779-1786.
Guideline #2 Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific LBP Strong recommendation Moderate-quality evidence Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Plain X-Rays for Low Back Pain There is no evidence that routine plain radiography in patients with nonspecific LBP is associated with a greater improvement in patient outcomes than selective imaging1-3 Exposure to unnecessary ionizing radiation should be avoided, particularly in young women (amount of gonadal radiation from obtaining a single plain radiograph [2 views] of the lumbar spine is equivalent to daily chest radiograph for more than 1 year)4 Routine advanced imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) is not associated with improved patient outcomes,5 identifies radiographic abnormalities poorly correlated with symptoms,6 and could lead to additional, possibly unnecessary interventions7,8 1. Deyo RA, et al. Arch Intern Med. 1987;147(1):141-145. 2. Kendrick D, et al. BMJ. 2001;322(7283):400-405. 3. Kerry S, et al. Br J Gen Pract. 2002;52(479):469-474. 4. Jarvik JG. Neuroimaging Clin N Am. 2003;13(2):293-305. 5. Gilbert FJ, et al. Radiology. 2004;231(2):343-351. 6. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 7. Jarvik JG, et al. JAMA. 2003;289(21):2810-2818. 8. Lurie JD, et al. Spine (Phila Pa 1976). 2003;28(6):616-620.
Plain X-Rays for Low Back Pain (cont.) Plain radiography is recommended for initial evaluation of possible vertebral compression fracture in select high-risk patients, such as those with a history of osteoporosis or steroid use1 Evidence to guide optimal imaging strategies is not available for LBP that persists for more than 1 to 2 months if there are no symptoms suggesting radiculopathy or spinal stenosis, although plain radiography may be a reasonable initial option (see recommendation 4 for imaging recommendations in patients with symptoms suggesting radiculopathy or spinal stenosis)2 Thermography and electrophysiologic testing are not recommended for evaluation of nonspecific LBP 1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 2. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Guideline #3 Clinicians should perform diagnostic imaging and testing for patients with LBP when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination Strong recommendation Moderate-quality evidence Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
CT or MRI Diagnostic Imaging Prompt work-up with MRI or CT is recommended if severe or progressive neurologic deficits or suspected serious underlying condition; delayed diagnosis and treatment associated with poorer outcomes1-3 MRI is generally preferred over CT if available; does not use ionizing radiation, provides better visualization of soft tissue, vertebral marrow, and the spinal canal4 1. Loblaw DA, et al. J Clin Oncol. 2005;23(9):2028-2037. 2. Todd NV. Br J Neurosurg. 2005;19(4):301-306. 3. Tsiodras S, et al. Clin Orthop Relat Res. 2006;444:38-50. 4. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597.
CT or MRI Diagnostic Imaging (cont.) There is insufficient evidence to guide diagnostic strategies in patients who have risk factors for cancer but no signs of spinal cord compression Proposed strategies generally recommend plain radiography or measurement of erythrocyte sedimentation rate3, with MRI reserved for patients with abnormalities on initial testing1,2 Alternative strategy is to directly perform MRI in patients with a history of cancer, the strongest predictor of vertebral cancer;2 for patients older than 50 without other risk factors for cancer, delaying imaging while offering standard treatments and reevaluating within 1 month may also be a reasonable option4 1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 2. Joines JD, et al. J Gen Intern Med. 2001;16(1):14-23. 3. van den Hoogen HM, et al. Spine (Phila Pa 1976). 1995;20(3):318-327. 4. Suarez-Almazor ME, et al. JAMA. 1997;277(22):1782-1786.
Guideline #4 Clinicians should evaluate patients with persistent LBP and signs or symptoms or radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) Strong recommendation Moderate-quality evidence Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Imaging for Low Back Pain The natural history of lumbar disc herniation with radiculopathy in most patients is for improvement within the first 4 weeks with noninvasive management1,2 There is no compelling evidence that routine imaging effects treatment decisions or improves outcomes3 For prolapsed lumbar disc with persistent radicular symptoms despite noninvasive therapy, discectomy or epidural steroids are potential treatment options4-8 Surgery is also a treatment option for persistent symptoms associated with spinal stenosis9-12 1. Vroomen PC, et al. Br J Gen Pract. 2002;52(475):119-123. 2. Weber H. Spine (Phila Pa 1976). 1983;8(2):131-140. 3. Modic MT, et al. Radiology. 2005;237(2):597-604. 4. Gibson JN, et al. Cochrane Database Syst Rev. 2000(3):CD001350. 5. Gibson JN, et al. Cochrane Database Syst Rev. 2005(4):CD001352. 6. Nelemans PJ, et al. Spine (Phila Pa 1976). 2001;26(5):501-515. 7. Peul WC, et al. N Engl J Med. 2007;356(22):2245-2256. 8. Weinstein JN, et al. JAMA. 2006;296(20):2451-2459. 9. Amundsen T, et al. Spine (Phila Pa 1976). 2000;25(11):1424-1435. 10. Atlas SJ, et al. Spine (Phila Pa 1976). 2005;30(8):936-943. 11. Weinstein JN, et al. N Engl J Med. 2007;356(22):2257-2270. 12. Malmivaara A, et al. Spine (Phila Pa 1976). 2007;32(1):1-8.
MRI for Low Back Pain MRI (preferred if available) or CT is recommended for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventions Plain radiography cannot visualize discs or accurately evaluate the degree of spinal stenosis1 However, clinicians should be aware that findings on MRI or CT (such as bulging disc without nerve root impingement) are often nonspecific Recommendations for specific invasive interventions, interpretation of radiographic findings, and additional work-up beyond scope of guideline, but decisions should be based on clinical correlation between symptoms and radiographic findings, severity of symptoms, patient preferences, surgical risks, and costs and will generally require specialist input2 1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 2. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Critical Clinical Indicators of Pathology In patients with back and leg pain, a typical history for sciatica (back and leg pain in a typical lumbar nerve root distribution) has a fairly high sensitivity, but uncertain specificity for herniated disc1,2 >90% of symptomatic lumbar disc herniations (back and leg pain due to a prolapsed lumbar disc compressing a nerve root) occur at L4/L5 and L5/S1 levels3 1. van den Hoogen HM, et al. Spine (Phila Pa 1976). 1995;20(3):318-327. 2. Vroomen PC, et al. J Neurol. 1999;246(10):899-906. 3. Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Critical Clinical Indicators of Pathology (cont.) A focused examination that includes straight-leg-raise testing and a neurologic examination that includes evaluation of knee strength and reflexes (L4 nerve root), great toe and foot dorsiflexion strength (L5 nerve root), foot plantarflexion and ankle reflexes (S1 nerve root), and distribution of sensory symptoms should be done to assess the presence and severity of nerve root dysfunction Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Critical Clinical Indicators of Pathology (cont.) A positive result on straight-leg-raise test (defined as reproduction of the patient s sciatica between 30 and 70 degrees of leg elevation) has a relatively high sensitivity (91% [95% CI, 82% to 94%]), but modest specificity (26% [CI, 16% to 38%]) for diagnosing herniated disc Crossed straight-leg-raise test is more specific (88% [CI, 86% to 90%]), but less sensitive (29% [CI, 24% to 34%]) Deville WL, et al. Spine (Phila Pa 1976). 2000;25(9):1140-1147.
Critical Clinical Indicators of Pathology (cont.) All patients should be evaluated for Presence of rapidly progressive or severe neurologic deficits Motor deficits at more than 1 level, fecal incontinence, and bladder dysfunction Most frequent finding in cauda equina syndrome is urinary retention (90% sensitivity) Without urinary retention, probability is approximately 1 in 10,000 Chou R, et al. Ann Intern Med. 2007;147(7):478-491. Deyo RA, et al. JAMA. 1992;268(6):760-765.
Yellow Flags Identify psychosocial problems in acute phase Slow progress to recovery may be due to undetected, or unrevealed psychosocial factors Pertain to patient's beliefs and behaviors concerning physical activity and domestic, social, and vocational responsibilities Example: patient believes physical activity might harm back, make pain worse, so avoids activities Most destructive is aversion to work Belief that work caused pain, work aggravates pain, work is too heavy, and work should not be done McGuirk BE, et al. In: Ballantyne J, Fishman S and Bonica JJ, eds. Bonica's Management of Pain. 2010:1094-1105.
Psychosocial Factors of Low Back Pain Stronger predictors of LBP outcomes than either physical findings or severity/duration of pain1-3 Assessment of psychosocial factors identifies patients who may have delayed recovery and could help target interventions 1 trial in referral setting found intensive multidisciplinary rehabilitation more effective than usual care in patients with acute or subacute LBP identified as having risk factors for chronic back pain disability4 Direct evidence on effective primary care interventions for identifying and treating such factors in patients with acute LBP is lacking5,6 Evidence is currently insufficient to recommend optimal methods for assessing psychosocial factors and emotional distress7 However, psychosocial factors that may predict poorer LBP outcomes include presence of depression, passive coping strategies, job dissatisfaction, higher disability levels, disputed compensation claims, or somatization8-10 1. Pengel LH, et al. BMJ. 2003;327(7410):323. 2. Fayad F, et al. Ann Readapt Med Phys. 2004;47(4):179-189. 3. Pincus T, et al. Spine (Phila Pa 1976). 2002;27(5):E109-120. 4. Gatchel RJ, et al. J Occup Rehabil. 2003;13(1):1-9. 5. Hay EM, et al. Lancet. 2005;365(9476):2024-2030. 6. Jellema P, et al. BMJ. 2005;331(7508):84. 7. Chou R, et al. Ann Intern Med. 2007;147(7):478-491. 8. Steenstra IA, et al. Occup Environ Med. 2005;62(12):851-860. 9. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23):2724-2727. 10. Carey TS, et al. Spine (Phila Pa 1976). 1996;21(3):339-344.
Red Flags of Lower Back Pain History Gradual onset of back pain Age <20 years or >50 years Thoracic back pain Pain lasting longer than 6 weeks History of trauma Fever/chills/night sweats Unintentional weight loss Pain worse with recumbency Pain worse at night Unrelenting pain despite supratherapeutic doses of analgesics History of malignancy History of immunosuppression Recent procedure causing bacteremia History of intravenous drug use Physical Examination Fever Hypotension Extreme hypertension Pale, ashen appearance Pulsatile abdominal mass Pulse amplitude differentials Spinous process tenderness Focal neurologic signs Acute urinary retention Winters ME, et al. Med Clin North Am. 2006;90(3):505-523.
Risk for Chronicity Vertebral infection Intravenous drug use, recent infection Vertebral compression fracture Older age, history of osteoporosis, and steroid use Musculoskeletal Inactivity In general Emotional distress
Cancer-Related Risk Factors Large, prospective study from a primary care setting History of cancer (positive likelihood ratio, 14.7) Unexplained weight loss (positive likelihood ratio, 2.7) Failure to improve after 1 month (positive likelihood ratio, 3.0) Age >50 years (positive likelihood ratio, 2.7) Posttest probability of cancer increases from approximately 0.7% to 9% in patients with a history of cancer (not including nonmelanoma skin cancer) In patients with any 1 of the other 3 risk factors, the likelihood of cancer only increases to approximately 1.2% Deyo RA, et al. J Gen Intern Med. 1988;3(3):230-238.
Non-Cancer-Related Risk Factors Features predicting vertebral infection not well studied, but may include fever, intravenous drug use, or recent infection1 Consider risk factors for vertebral compression fracture, such as older age, history of osteoporosis, and steroid use; and for ankylosing spondylitis, such as younger age, morning stiffness, improvement with exercise, alternating buttock pain, and awakening due to back pain during the second part of the night only2 Clinicians should be aware that criteria for diagnosing early ankylosing spondylitis (before the development of radiographic abnormalities) are evolving3 1. Jarvik JG, et al. Ann Intern Med. 2002;137(7):586-597. 2. Rudwaleit M, et al. Arthritis Rheum. 2006;54(2):569-578. 3. Rudwaleit M, et al. Arthritis Rheum. 2005;52(4):1000-1008.
Racial/Cultural Aspects of Assessment To communicate effectively with all patients Always use simple words, not medical jargon Determine what the patient/caregiver already knows or believes about his/her health situation Encourage questions by asking, What questions do you have? (allows for an open- ended response), instead of Do you have any questions? (allows for a no response, ending the conversation) Use the teach-back method to confirm the level of understanding: Ask patients/family members to restate what was just communicated in the appointment or meeting Zacharoff KL. Cross-Cultural Pain Management: Effective Treatment of Pain in the Hispanic Population; 2009.
Culturally Competent Care Ensure that patients/consumers receive effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language Implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area Ensure that staff, at all levels and across all disciplines, receives ongoing education and training in CLAS delivery USDHHS OMH. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care; 2001.
Avoiding Racial and Cultural Bias per Knox H. Todd, MD, MPH Make pain assessment mandatory Give a nonopioid analgesic at triage Track reasons for unscheduled returns Audit for ethnic bias Consider which pain scales should be used Use multilingual laminated cards Todd KH. Medical Ethics Advisor. 1999.
Pearls for Practice Categorize patients into 1 of 3 broad groups: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause Evaluate psychosocial risk factors to predict the risk for chronic, disabling low back pain Provide patients with evidence-based information on expected course of low back pain, effective self-care options, and recommend that they be physically active Chou R, et al. Ann Intern Med. 2007;147(7):478-491.
Questions? Please pass your question card to a staff member.
Treatment of Low Back Pain: Pharmacologic and Nonpharmacologic Options Roger Chou, MD, FACP Associate Professor of Medicine, Department of Medicine Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University
Disclosure: Roger Chou, MD, FACP Dr. Chou has disclosed that he has no actual or potential conflict of interest in regard to this activity His presentation will include off-label discussion of anticonvulsants, benzodiazepines, and tricyclic antidepressants for the treatment of low back pain (LBP)
Learning Objective Integrate evidence-based pharmacologic and nonpharmacologic therapies into a comprehensive treatment plan for chronic LBP
Low Back Pain Burden LBP is the fifth most common reason for US office visits, and the second most common symptomatic reason1-2 $90.7 billion dollars in total healthcare expenditures in 19983 LBP is the most common cause for activity limitations in persons under the age of 454 1. Hart LG, et al. Spine (Phila Pa 1976). 1995;20(1):11-19. 2. Deyo RA, et al. Spine (Phila Pa 1976). 2006;31(23):2724-2727. 3. Luo X, et al. Spine (Phila Pa 1976). 2004;29(1):79-86. 4. Von Korff M, et al. Spine (Phila Pa 1976). 1996;21(24):2833-2837.
Increasing Rates of Back Surgery Trends in Rates of Discectomy/Laminectomy and Fusion in 1992-2003 US Average Rate of Discharges per 1000 Medicare Enrollees Weinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
Increasing Rates of Back Injections Lumbosacral Injection Rates by Year: Age- and Sex-Adjusted per 100,000 2055.2 553.4 263.9 212.3 79.7 SI=sacroiliac. Friedly J, et al. Spine (Phila Pa 1976). 2007;32(16):1754-1760.
Increasing Costs Mean ($) Year Martin BI, et al. JAMA. 2008;299(6):656-664.
Rising Prevalence of Chronic LBP Prevalence of Chronic Low Back Pain in North Carolina, 1992 and 2006 % Prevalence (95% CI) 1992: 3.9% 2006: 10.2% 1992 (n=8067) 3.9 (3.4-4.4) 2006 (n=9924) 10.2 (9.3-11.0) PRR Characteristic Total Sex Male Female Age (Years) 21-34 35-44 45-54 55-64 65 Race/Ethnicity Non-Hispanic White Non-Hispanic Black Hispanic Other % Increase 162 (2.5-97.5% CI)* 2.62 (2.21-3.13) 2.9 (2.2-3.6) 4.8 (4.0-5.6) 8.0 (6.8-9.2) 12.2 (10.9-13.5) 176 154 2.76 (2.11-3.75) 2.54 (2.13-3.08) 1.4 (0.8-2.0) 4.8 (3.3-6.3) 4.2 (3.0-5.5) 6.3 (4.2-8.3) 5.9 (4.5-7.3) 4.3 (3.0-5.6) 9.2 (7.2-11.2) 13.5 (11.4-15.7) 15.4 (12.8-17.9) 12.3 (10.2-14.4) 201 92 219 146 109 3.01 (1.95-5.17) 1.92 (1.35-2.86) 3.19 (2.29-4.59) 2.46 (1.73-3.50) 2.09 (1.62-2.84) 4.1 (3.5-4.7) 3.0 (2.0-4.0) ** 4.1 (1.4-6.8) 10.5 (9.4-11.5) 9.8 (8.2-11.4) 6.3 (3.8-8.9) 9.1 (6.0-12.0) 155 226 2.55 (2.13-3.05) 3.26 (2.32-4.96) 120 2.20 (1.16-6.99) CI=confidence interval. PRR=prevalence rate ratio. *The PRRs and CI were estimated via bootstrapping; 97.5% CIs were reported rather than to assume normality. **Unable to estimate owing to scall cell count (n<5). Freburger JK, et al. Arch Intern Med. 2009;169(3):251-258.
Practice Patterns Spine surgery rates in the US are the highest in the world Rates in the US 5 times higher than in the UK 20-fold variation in fusion: 4.6 per 1000 in Idaho Falls to 0.2 per 1000 in Bangor, Maine Interventional therapies are also widely used Intradiscal electrothermal therapy estimated at 7000-10,000 annually 20-fold variation in epidural steroid injections: 104 per 1000 in Palm Springs to 5.6 per 1000 in Honolulu Deyo RA, et al. Clin Orthop Relat Res. 2006;443:139-146. Weinstein JN, et al. Spine (Phila Pa 1976). 2006;31(23):2707-2714.
7 Back Pain Breakthroughs: Are you hurting? Here s help. Reader s Digest July 2007 End Back Pain Agony (Michael J. Weiss) Weiss MJ. Reader's Digest. July, 2007.
