The Non Surgical Treatment of Spine Pain

Overview

• Important statistics

• History and Physical back pain patient

• “ Red Flags” for further work-up and imaging

Overview

• Diagnostic workup-

• Electromyography and nerve conduction velocity studies(EMG/NCV)

• When to order what?

Overview

Treatment recommendations• Physical therapy• When to Order Injections• Putting It Together For the Patient

Why do we care?

• Back pain accounts for 2-3% of all physician visits in the United States (Cielo, 1994)

• Two National Surveys- 26.4% reported an entire day of low back pain in the last 3 months

• 13.8 of the 26.4% also had and entire day of neck pain in the last 3 months

• (Cielo, 1994)

• (Cielo, 1994)

The History

• ITS AS EASY AS THE ABC’s

The History

• Start With The Basics• It’s as easy as ABC• Or Rather • P-Q-R-S-T

Don’t Ask Don’t Tell

• Yes, it has been overturned !

• This was about Low Back Pain . Right?• Do Ask the right questions and they will Tell you the Answer• Now Back to our alphabet • P-Q-R-S-T• Also- Hint- I Spy A Red Flag- look for these throughout the

History, PMHX, ROS, and PE

• Do Ask the right questions and they will Tell you the Answer

• Now Back to our alphabet • P-Q-R-S-T• Also- Hint- I Spy A Red Flag- look for these

throughout the History, PMHX, ROS, and PE

The History

• P- Pain• Q-Quality• R-Radiation• S-Severity or Situation• T-Timing

History-

• Pain- Where is the pain? How did the pain occur? Insidiously, *injury, acutely -did it start like a thunderbolt- Point with one finger

• Significant trauma-red flag• What makes it better? What makes it worse? • What would you rather do for 15 min?• Sit , stand in place, lie down, walk• Soft Rule- sitting makes disc pain worse

A Good History

Soft Rules

• From the Quality History• Sitting is worse bending is worse, driving ,

shaving brushing my teeth, first thing in the morning-think disc

• Standing in one place, getting in and out of the car, lying down, rolling over in bed, twisting- think facet

• Neurogenic vs. Vascular Claudication

Quality

• Quality-• Description words- • throbbing, sharp, burning,constant,

intermittent, pins and needles, • It moves around or changes• “You are going to think I am crazy” It is usually nerve!

History-Q for Quality

• Throbbing- often a word to describe swelling,• Burning, pins and needles, or it is difficult to

pin point or explain,or it changes with the situation, like a toothache – nerve pain

• When the patient says –”you are going to think I am crazy” my experience- it is nerve pain until proven otherwise

• Associated weakness *progressive (red flag)

From Here to Eternity?

• Radiation-does the pain travel,• From Where to Where?• Cervical travels to the neck, arms , chest,

upper back –scapulae-think C6• Thoracic around the chest and flank• Lumbar to the back, buttocks, legs• The cervical can cause leg weakness but not

the other way around

How Bad Is It Really?

• Severity- very few things bring patients to their knees like nerve pain

• Positive Valsalva?• Is it worse with bearing down to have a bowel

movement or cough?• Yes- think disc herniation

Review of Systems reveals Red Flags

• Constitutional-• *Fever and Chills, Unexplained weight loss• think contrast MRI, • GI-*fecal incontinence• GU- *urinary retention, overflow

incontinence, saddle anesthesia

• Use the scale 0 to 10 , 0 is no pain and 10 is worst pain of your life

• It helps let you know if you are getting anywhere later in your treatment

• Are they happy as a clam sitting there but reporting a 10. Clarify before assuming

Severity

• Use the scale 0 to 10 , 0 is no pain and 10 is worst pain of your life

• It helps let you know if you are getting anywhere later in your treatment

• Are they happy as a clam sitting there but reporting a 10. Clarify before assuming

• Timing• If the person is describing right sided neck

pain that last only 20 to 30 minutes and only with activity-that is not neck pain

• When does the pain occur- on first awakening• as the day progresses, intermittent , constant

When do we worry?• When something becomes so common, and frankly not so fun, for doctor or

patient-• We can become complacent • We can order too many tests, the wrong tests• Write too many prescriptions • Fail to follow up • Fail to think it is something to worry about• Pain- Where is the pain? How did the pain occur? Insidiously, *injury, acutely -

did it start like a thunderbolt- Point with one finger• Significant trauma-red flag- imaging work-up• What makes it better? What makes it worse? • What would you rather do for 15 min?• Sit , stand in place, lie down, walk• Soft Rule- sitting makes disc pain worse

Review -Red Flag for Work-UP and Imaging

• AGE- under 20 or over 50• Less common in under age 20• More common in over age 50 but so is

malignancy ( timing hx-night pain)• Unexplained Weight Loss- people will say they

have had pain and didn’t feel like eating• Weight loss is always a Worry

Red Flags for Further Work Up

• The Obvious is Always Obvious• Information isn’t always offered • Remote history of cancer-• Common metastatic disease to the spine includes-

Lymphoma, Lung, Breast, and Prostate• ( my personal one- smokers with poor medical

follow up)

More Things to Work Up

• Progressive Weakness of the lower extremities• History of significant Trauma• CT – (think bones) for fractures • MRI – (think soft tissue) with contrast when

thinking infection or metastatic disease, herniation

• When do we think vascular workup? Go back to your history- what relieves the pain

Fun Physical

• General- are they sitting, standing, pacing• Posture- Do they have a shift, flattened lordosis, • cervical-head tilt and rotation• Measure from tragus of the ear to anterior

border of upper trap• Iliac crests – is a knee bent- may need to

measure leg lengths• Scapulae high or low- kyphosis, scoliosis-true?

Musculoskeletal- palpation

• Palpation- where does it hurt to press• Upper trapezius, levator scapulae, rhomboids• Spinous processes, facets, quadratus, SI,

sacrum, gluteus medius, greater trochanter, • Sacrotuberous ligamnets, ischial bursae• Coccyx• Sternum, tibia- pain (think vitamin D

deficiency)

Physical-Musculoskeletal

• Cervical and Lumbar Range of Motion• Flexion-hurts with herniated discs• Extention with rotation hurts the opposite

lumbar facets, cervical tilt hurts the same side• Atrophy of muscles notes-look at the EDB,

First DI of the hand, Abductor and Opponins

Neurologic Exam

• Alert and Oriented • Cranial Nerves• Remember CN XII- Trapezius• Straight Leg Raise vs Tight Hamstrings• Muscle Stretch Reflexes- upper and lower• Spurlings for Cervical • Sensation- remember the DRG is distal to the

nerve root– back problems do not give you neuropathy-intact with nerve root lesion

More Work Up Options- Don’t forget Your EMG/NCV

• Electromyography and Nerve Conduction Velocity Studies

• Provides information on the function of the anatomy at the level of the nerve and motor unit

• MRI’s and CT’s give you information on anatomy only

When to do The EMG/NCV

• Sometimes the body doesn’t read the book• MRI shows a right HNP and the left is

symptomatic, Normal radiographs, or level not consistent with exam normal

• Sensory findings• pinpoint acuity, location,i.e.multilievel disease,

severity • Sometimes the body doesn’t read the book• Rule out Double Crush -

Nerves Conduction Velocity

• NCV- this gives you information on all nerves those that may be affected by the pathology and those that shouldn’t be affected by that pathology

• Eg. Peripheral Neuropathy-only way to diagnose other than biopsy of the nerve

• Radiculopathy- shows up as drop in amplitude but must be followed up by a complete EMG

NCV

• Sensory involvement is not consistent with spinal stenosis or radiculopathy

• Peripheral neuropathy is not caused by stenosis

• Sensory finding are reflect problems distal to the dorsal root ganglion

• Beware of the double crush injury

Electromyography

• Tells the story of the nerve root• Tells the severity of nerve pathology noted on

nerve conduction study• Cannot assess severity without an EMG• Radiculopathy or radiculitis can only be

assessed by EMG- also can assess timing • Acute vs. subacute vs, chronic• EMG- looks easy to do but hard to interpret

Musculoskeletal -Strength

• Atrophy of muscles notes-look at the EDB, First DI of the hand, Abductor and Opponens

• Do They Make The Grade? Things that make you go Hmm

• 2/5-fullROM without gravity• 3/5 full ROM against gravity• Toe walk and heel walk the best way to test L5

and S1 muscles

Red Flag Review

• Prolonged Steroid Use• Immunosuppressed patients or those with

known infection• IV Drug Abuse• Back Pain not improved with rest- I think this

one is vague• Acute urinary symptoms and/or fecal

incontinence, Saddle anesthesia

Treatment

• Aside from the red flags- lots of studies• In the first four weeks – conservative tx.• Stay active• Some evidence for spinal manipulation in the

first four weeks ( Chou 2007)• Belief that 80-90% will get better regardless of

the treatment

Protocols of treatment

• This can get very detailed and the majority is for pain that is not intractable and for pain lasting for greater than four weeks

• Multimodal approach• Physical therapy is a key factor• Antiinflammatories• Changing the simple things- workplace

Physical Therapy

• Is Your Prescription Evaluate and Treat?• Always give some parameters• Don’t order Williams Flexion Exercises for • disc problem- think MCKenzie• Qualifications of the therapist• Day one –are they being put on a treadmill for

45 minutes?

Physical Therapy

• Beware of Modalities• USG is contraindicated in an acute disc

herniation• Know your therapist• Are they placing the patient in traction and

walking away? Traction is to reduce a disc but it can also cause a herniation, very scary without experience

Physical Therapy

• Are they getting heat and ice for 60 minutes and nothing else?

• Do they know what to do at home? This should be discussed from day one.

• Exercises- however simple should be given on day one

• The patient should have a complete program to do at home by completion

Goals

• The Doctor and Therapist and patient need to have a plan and this plan needs to be understood by the patient

• Therapy doesn’t end when the insurance runs out. It ends when goals are met.

• Therapist should give recommendations and so should the doctor after follow-up.

Treatment

• When to do injections?• Sometimes although rarely –the injection is

the entire answer.• When the patient is seen, a plan is mapped

out and injections can be part of the plan?• Let us look at an example to clarify .

Sample Case

• 34 yo female has new onset LBP that began insidiously and has been getting progressively worse over the past two months. She was taking OTC motrin and aleve which helped but did not resolve the pain. Without the medication the pain would be 6/10. No weakness, no valsalva

• Worse with sitting and lifting her child

Plan

• Physical therapy – was then prescribed and a once a day NSAID

• After 3 weeks in PT she calls office and says she cannot continue to deal with this pain.

• PT helps for that day but doesn’t last • She went to her chiropracter as well as after a

daily manipulation she is still not better

What do you do?• A. Tell the nurse to tell the patient you are on a

cruise and not reachable by cell.• B. Make your Partner call the patient• C. Quickly realize you do not have a partner and

therefore cannot do B.• D. Hide under your desk and turn out the light

hoping your staff thinks you have left for the day even though they are standing in front of you.

• E. See the patient and then order a Lumbar MRI

The plan

Lumbar MRI is ordered and shows disc protrusion at L4-5 and degenerative disc disease at L5-S1.

Now what?Because you and your patient discussedYour plan at the time she was evaluated You know that you will refer the patient for A multipmodal approach

Injections

• This is a talk for another.• There are more than just epidurals and • The story doesn’t end because the patient

“failed the epidurals”

To Review The treatment Plan

• You tell the patient.• Sally you have been having pain for two

months and it isn’t getting better.• We have a couple of options.• If you are able to care for your child and

work, we can try:

More on Sally

• Our other option is to refer you to a physician who works more closely with low back pain patients. This doctor may offer you injections to treat your pain, as part of her treatment plan.

• Sally responds that she will try PT and the NSAID and the rest is history.

• She is ready and expecting the referral when she does not get better.

More on Sally

• Directed physical therapy for four weeks. If you begin to plateau in four weeks, let me know and we can go forward with a Lumbar MRI. ( explanation of MRI given)

• We can also add some moderate pain med like tramadol or use a stronger longer lasting antiinflammatory like meloxicam .

Treatment

• This 90 % theory is being questioned because most patients will go on to experience multiple episodes of back –

• Stanton most conservative study –found reoccurrence of ranging 24-33% ( still higher than 10%)

• Multimodal approach is Recommended

• Combination of medication, physical therapy • when necessary spinal injections

summary

• Important statistics

• History and Physical back pain patient• “ Red Flags”

• Diagnostic workup-When to order what?

• Electromyography

Summary

• Treatment recommendations• Physical therapy• When to Order Injections• Putting It All Together

Thank you!