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8/12/2019 BackNeckBW

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Acute Low Back and Neck Pain

Introduction to Clinical Neurology

Daniel Lowenstein, MD

Andy Josephson, MDWade Smith, MD, PhD


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John Engstrom, M.D.Potential Conflicts ofInterest

NoneProfessor of Neurology

Adult Neurology ResidencyProgram Director

Betty Anker Fife EndowedProfessor of Neurology

Department of Neurology,UCSF School of Medicine


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Learning Objectives


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Learning Objectives-Epidemiologyo Be able to explain the impact of back and neck pain on

public health

o Be able to list the risk factors by history and examinationfor serious causes of back and neck pain

o Be able to explain how the function of anterior spinediffers from the posterior spine

o Be able to describe the course of lumbar nerve rootsfrom the lower spinal cord to the exit of the spine


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Learning Object ives-Pat ient Evaluat ion

o Explain how the history and examination of a patient isused in clinical management

o Be able to describe the significance of:o Straight-leg raising and reverse straight leg raising signso Focal palpation tenderness over the bony spineo Pain with passive internal or external rotation of the leg at

the hip

oDescribe the utility of plain x-rays, CT scans, and MRIimaging of the spine


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Learning Object ives-Neuro Evaluat ion

o Describe the distribution of reflex, motor, and sensoryfindings for injury to the L4, L5, and S1 nerve roots

o Describe the distribution of reflex, motor, and sensoryfindings for injury to the C6, C7, and C8 nerve roots

o Describe initial non-pharmacologic and pharmacologictreatment of non-specific acute low back pain

o Describe the indications for surgical treatment of aherniated lumbar disk


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Epidemiology and Risk Factors


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Background: ImportanceoBack and neck pain are the second most

common reason for neurologic consultation

o1% of US adults are chronically disableddue to back or neck pain

o70% of adults will experience back or neckpain during their lives


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Scope Impact of Back/Neck PainoAnnual cost in USA > $100 billion/yearo Direct medical costso Indirect costs (e.g.-loss of work hours)o Back pain is the most common reason for

long term opioid use

o Need for an organized, rational approach toinitial assessment and management


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Risk Factors by Clinical History-I

oPrior history of canceroPain worse at rest or at nightoHistory of chronic infection-skin, lungs,

urinary tract, poor dentition

oHistory of spine trauma


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Risk Factors by Clinical History-II

oChronic corticosteroid useo Intravenous drug useoRapidly progressive neurologic deficitoAge > 70 years


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Acute Low Back Pain-Natural History

o85-90% of patients return to functionalbaseline in 12-16 weeks

oTreat symptomso Reassurance!


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Anatomy


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Basic Spine AnatomyoThe spine is divided into 4 regions:

cervical, thoracic, lumbar, and sacral

oEach region has a normal curvatureoEach vertebra of the spine is separated

from its neighboring vertebra by a disk

oSacral vertebra are fused as the sacrum


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Segmental Spine AnatomyoEach vertebra protects a central spinal

canal though which the spinal cord passes

from the neck to the lower backoThe anterior spine (blue arrows)-absorbs

the force of vertical body movements Disks act as shock absorbers Vertebra provide stability in the vertical plane


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Special Clinical Lumbar Anatomyo Spinal cord normally ends (conus medullaris)

at L1-2 level

oA cluster of lumbar nerve roots follow a longcourse within the lumbar spinal canal

oA lumbar puncture for spinal fluid examination(LP) is performed in the low lumbar region-there is no danger of spinal cord injury


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Pathophysiology


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Pain From Injury to the SpineoMost benign causes of acute back pain

resolve on their own

oPain sensitive spine structures-periosteum,facet joints, outer disk, vessels, ligaments,dura (sac in the spinal canal that containsthe spinal fluid)

oNerve roots (radiculopathy)


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Spine Pain: Serious Causes-Tumor

oUsually due to metastatic spread of tumorfrom the body to the vertebral body

oHistory-prior history of cancer, weight loss,fever, pain worse at rest or at night,pathologic spine fracture, age >70 years

oFocal spine tendernessoFocal neurologic deficits by examination


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Spine Pain: Serious Causes-Infect iono Usually due to blood-borne spread of bacteria from

a body source to the vertebral body

o Chronic infection sources-skin, urine, lungso History-weight loss, fever, pain worse at rest or at

night, pathologic spine fracture, age >70 years,chronic corticosteroid use, intravenous drug use

o Focal spine tendernesso Focal neurologic deficits by clinical examination


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Spine Pain: Serious Causes-Fracture

oObvious trauma-MVAs, fallsoPathologic fractures with minor trauma but

structurally weakened vertebra-infection,tumor, osteoporosis, chronic steroid use

oAssociated focal neurologic deficitsassociated with findings of spinal cord

injury, nerve root injury, or both


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Back Pain-Focal Neurologic Def ici ts

oFocal neurologic deficits (FND) mayindicate nerve root or central nervous

system (e.g.-spinal cord or brain) injuryoFND from an unrelated peripheral nervous

system injury (e.g.-peroneal neuropathy)

oDiagnosis is determined by associatedhistory and examination, and some testing


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Non-Spinal Causes of Back PainoNot all back pain arises from the spine

Cuts, trauma, burns, inflammation of theoverlying skin or soft tissues can cause pain

Referred pain from viscera of the abdomen orpelvis, or bones/joints of the pelvis

Pain associated with paraspinal muscle,tendon, or ligament injury


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Non-Spinal Low Back Pain: AAAoAbdominal aortic aneurysm (AAA)o Classic: Back pain, abdominal pain, shocko Presents as back pain only in 20%o Misdiagnoses non-specific back pain,

diverticulitis, renal colic, myocardial infarction

o Pulsatile abdominal mass on exam in 50-75%o High risk: Older smokers with atherosclerosis


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Back and Leg Pain-Signif icanceo Nerve root injury-pain in a dermatomal

distribution of a nerve root with or withoutfocal neurologic deficits by examination

o Referred pain-pain often circumferential in thelimb or crossing multiple dermatomes, butthere are no focal neurologic deficits

oCombination of referred and nerve root injurypain can be difficult to assess


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Clinical Presentation


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Acute Back/Neck Pain: Assessment

o Risk factor assessment determines how toproceed in the patient evaluation

oIf no risk factors, then treat symptoms withprimary goal of return to normal function

o History-prior cancer, trauma, fever, weightloss, pain at rest or night, focal neurologic

deficit, chronic infections, IV drugs, chronicsteroid use, age > 70 years


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Acute Back Pain Risk Factors: Exam

oUnexplained, documented feveroUnexplained, documented weight lossoAbdominal, rectal, or pelvic massoRapidly progressive focal neurologic deficitoGeneral examination findingsoNeurologic examination findings


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Acute Back Pain Risk Factors: Exam

oPalpation tenderness over spineoStraight-leg raise (SLR) or reverse straight

leg raise (RSLR) examination signsoHip pain elicited by passive internal or

external rotation of the leg at the hip


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Exam Signs : Focal Spine Tenderness

oPalpation over spinous process transmitsforce through the posterior bony spine to

the vertebral body anteriorly Pain-sensitive structures that are not normal

may be affected to produce pain

Control stimuli over parasp muscles or otherspine levels shows if pain is genuinely focal


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Exam Signs: Nerve Tissue Stretcho Straight-leg raising-Places traction on the L5

or S1 roots, or sciatic nerve by passive flexionof the entire leg at the hip (sciatic nerve androots posterior to the hip)

o Reverse straight-leg raising-Places tractionon the L2, L3, or L4 roots or femoral nerve bypassive extension of the entire leg at the hip(femoral nerve and roots anterior to the hip)


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Nerve/Root Stretch Signs: In terpretat ion

o If the maneuver reproduces the typicalback or leg pain, then the sign is present

o If the maneuver elicits back or leg pain ofdifferent quality or location, sign is absent

o If the maneuver elicits stretching of thehamstring or other muscles, sign is absent


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Passive Leg Rotation at the HipoPassive rotation of the leg at the hip can

be performed in supine or seated positions

o If passive internal or external rotationreproduces the patients back or leg pain,then hip pathology must be considered


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Demonstration of Root Findings

oCommon Cervical Roots (C6, C7, and C8)oCommon Lumbar Roots (L4, L5, and S1)


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Lumbosacral Root- Neuro Exam Findings

Root Motor Reflex Sensory Pain Distribution

L4 Quadriceps Knee Medial calf Medial calf(knee extension)

L5 Peronei None Lateral calf, Posterolat thigh;(foot eversion) dorsal foot Lat calf, dorsal foot S1 Abductor hallucis Ankle Sole foot Posterior thigh/calf

(toe flexors) Sole foot


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Cervical Root: Neuro Exam FindingsRoot Motor Reflex Sensory Pain Distribution

C6 Biceps brachii Biceps Lateral hand, Lateral hand,(arm flexion) forearm forearm, arm

C7 Triceps Triceps Dorsal forearm, Posterior arm,(arm extension) dorsal hand, dorsal forearm,Finger extensors Third finger dorsal hand

C8 Abductor pollicis brevis Finger Medial hand, Medial arm,(thumb abduction) flexors medial forearm medial forearm,

medial hand


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Nerve Root Injury Caveatso Disk herniations are frequently asymptomatico The localization of nerve root injury only begins the

process of finding a cause

Disk herniation is one common cause Bony compression at the foramen is another Tumor, infection or fracture are others


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Diagnosis


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Init ial Approach to Acute LBP

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Role of Spine Imagingo Plain x-rays show bony integrity only, no soft tissue

detail-good for fractures

o CT scans show bony anatomy in multiple planes-good forfracture, tumor, infection

o MRI shows soft tissue detail-excellent for tumor, infection;good for fracture

o CT or MRI can often distinguish between infectious,neoplastic, fracture, and other etiologies


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Role of Electromyography Studieso Stimulate nerves along their course and record over

same nerve or muscles

o Assess electrical activity patterns in muscle to determineif muscle and nerve supply to the muscle are normal

o Semi quantitative measure of motor and sensory functiono Localize nerve tissue injury to root or nerveo Assess severity of nerve tissue injury


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Treatment


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Acute Back Pain-Init ial Drug Rxo Patients should consult their health care provider regarding the need

for an office visit and to discuss medication choices, especially ifother illnesses are present or other medications are being taken

o There is no evidence that narcotics are better than acetaminophen ornon-steroidal drugs for the initial treatment of acute low back pain

o The approach I outline is based upon clinical evidence, mindful ofcost, and based upon my experience

o Learn to tailor your approach to individual patient circumstances(e.g.-need for prompt return to work, tailoring dose to symptoms)


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Acute Back Pain-Nonpharmacologic Rx

o Limited bed rest not more than two days, thenprogressive ambulation

oAvoid heavy exertion or activities that clearlyexacerbate symptoms

o Cold packs acutely x 15-20 minutes Temporary relief-useful at night to promote sleep Supine on cold pack with wet cloth between skin and pack Store 2-3 packs in a freezer and rotate Substitute frozen peas or plastic bag of ice


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Acute Back Pain-Init ial Drug Rxo Nocturnal skeletal muscle relaxants may relieve paraspinal muscle

spasm and promote sleep

Drowsiness limits daytime use Cyclobenzaprine 5-10mg by mouth at night only

o Consider ibuprofen 400mg by mouth 3 times/day for 4 days Acute back pain is often inflammatory and justifies using non-steroidal

medications as first-line agents

If effective follow published guidelines for further dosing If ineffective proceed to acetaminophen


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Acute Back Pain-Init ial Drug Rxo Consider acetaminophen 650mg by mouth 3 times/day

for 4 days If effective follow published guidelines for further dosing If ineffective begin acetaminophen + ibuprofen for 4 days

o Opioid analgesics are best used for patients who do nottolerate acetaminophen or non-steroidals

o Steroids or neuropathic pain medications that treat nervepain are not initial treatments for low back pain


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Acute Back Pain-Patient Educat iono Provide reassurance about the usual favorable outcome!o Anticipate 85% return to functional baseline at 12 weekso 2/3 seen in primary care first are better by 7 weeks!o Avoid unnecessary diagnostic testing for patients without

risk factors

o Establish a mechanism for follow-up if symptoms worseno The evolution of new symptoms or focal neurologic

symptoms should prompt a follow-up physician visit


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Disk Herniat ion: Surgical Indicat ions

o Spinal cord compressiono Progressive motor weakness by examo Cauda equina (the many roots that fill the lumbar spinal

canal) or conus medullaris (distal spinal cord) syndromes

o Intractable Pain Most common and controversialreason


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Summary


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Acute Low Back/Neck Pain: Summaryo Back and neck pain are costly public health issues and

common problems for patients

o Use your understanding of spine anatomy and function toconsider the many possible etiologies for back pain

o Use your knowledge of historical and exam risk factorsfor serious causes of back pain to decide who needsfurther assessment or symptomatic management


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Acute Low Back/Neck Pain: Summaryo Consider tumor, infection, or fracture as possible

etiologies for patients with risk factors for a serious cause

o Not all disk herniations require surgeryo Have a simple and cost-effective initial approach to

symptomatic management for patients lacking risk factors

o Educate these patients and reinforce the overall excellentprognosis in the absence of unnecessary testing

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