89 Lower Back Pain — Conservative Management

Case 89 Lower Back Pain — Conservative Management

Hashem Al Hashemi, Remi Nader, and Abdulrahman J. Sabbagh

Clinical Presentation

A 45-year-old man presented to your clinic complaining of lower back pain for the past 3 months.

The patient’s work activities do involve heavy lifting.

Magnetic resonance imaging (MRI) of his lumbar spine was done prior to his visit; the image is shown in Fig. 89.1.

Fig. 89.1 T2-weighted sagittal magnetic resonance image of the lumbar spine demonstrating degenerative disk disease at the L5–S1 level.

Fig. 89.2 Plain radiographs taken while performing the following interventional procedures: (A,B) L3 medial branch neurotomy and L3 and (C) L4 medial branch blocks, (D) caudal epidural steroid injection, (E) L5 transforaminal epidural steroid injection, and (F) S1 transforaminal epidural steroid injection.

Questions

What are some common causes of lower back pain?
Provide a broad differential diagnosis for lower back pain.
What are some red flags or critical conditions that can present with lower back pain (on both history and physical examination)?
What imaging studies would you like to obtain?
What other investigations may be warranted?
Describe nonoperative measures of management of lower back pain.
What interventional procedures may be used to differentiate the types of spinal-related lower back pain?
Discuss interventional options for management of spinal pain.

Answers

What are some common causes of lower back pain?

Common causes include ¹

Poor posture

Poor sitting or standing posture

Sleeping position and/or pillow positioning

Bending forward too long

“Hiking” your shoulder to hold the phone receiver to your ear

Excess weight

Pregnancy

Obesity

Sudden or strenuous physical effort

Improper lifting

Accident, sports injury, or fall

Carrying a heavy purse, briefcase, or backpack

Stress and muscle tension

Lack of muscle tone

Deconditioning
Provide a broad differential diagnosis for lower back pain.
- Differential diagnosis includes¹
- Congenital
  - Scoliosis, kyphosis
  - Isthmic spondylolisthesis
  - Spina bifida
  - Short pedicle syndrome
- Infectious
  - Diskitis, osteomyelitis, tuberculosis
  - Pyelonephritis, urinary tract infections, psoas abscess
  - Endometritis
- Traumatic
  - Lumbosacral fracture or dislocation
  - Spondylolisthesis,
  - Muscle strain or sprain
- Tumor
  - Metastatic disease to the spine
  - Primary bone tumors of the spine
  - Abdominopelvic retroperitoneal tumors
- Environmental
  - Repetitive heavy lifting at work
  - Poor posture, obesity
  - Prolonged riding in car or truck
- Neurogenic
  - Herniated disk, spinal stenosis
  - Hypertrophied ligaments
  - Neuropathic pain, failed back syndrome
- Drugs
  - Antivirals, antibiotics
  - Chemotherapeutics
  - Coumadin
- Inflammatory
  - Ostearthritis, rheumatoid arthritis
  - Ankylosing spondylitis
  - Systemic lupus erythematosus
- Vascular
  - Abdominal aortic aneurysm
  - Arteriovenous malformation of the spine
  - Hemangioma, hematoma
- Gynecologic
  - Menstruating
  - Endometriosis
  - Pregnancy
  - Tumors
- Acquired and other
What are some red flags or critical conditions that can present with lower back pain (on both history and physical examination)?
- Clinical symptoms on history^2–4
  - Age older than 50 years
  - Cancer: history of cancer, unexplained weight loss, pain at multiple sites
  - Pain worsening at night and not mechanical in character
  - Immunosuppression: human immunodeficiency virus (HIV), steroid use, transplant patient
  - Infection: fever, night sweats, back tenderness, limited range of motion
  - Trauma: history of significant trauma or minor trauma in osteoporotic patients
  - Intractability
  - Cauda equina syndrome: bladder or bowel dysfunction, saddle anesthesia, leg weakness or pain
  - Other neurologic symptoms
- Clinical signs on physical examination2–4
  - Saddle anesthesia
  - Incontinence
  - Fever (>38°C)
  - Urinary retention
  - Muscular weakness
  - Bony tenderness (vertebral)
  - Very limited range of spinal motion
What imaging studies would you like to obtain?
- Basic imaging studies include plain x-rays of the lumbar and possibly of the thoracic spine.⁵
- MRI of the lumbar spine^2,5
  - Is not indicated for nonspecific low back pain.
  - Many people without symptoms show abnormalities on radiographs and MRI. The chances of finding coincidental disk prolapse increases with age.
  - MRI should be reserved for patients with red flag conditions and those with neurologic symptoms and/or signs severe enough to consider surgery.
  - In the presence of bowel and bladder incontinence, diffuse weakness suggestive of multiple roots involvement or upper motor signs, an urgent whole spine MRI is recommended.
- Flexion and extension radiographs of the lumbar spine: recommended in cases of spondylolysis or spondylolisthesis (as there is potential spine instability)
- Computed tomography (CT) scan of the lumbar spine recommended in trauma cases to evaluate for fracture and alignment or in certain degenerative conditions to assess pars integrity, osteophytes, etc.⁵
- Other studies depend on the suspected pathologies.
  - Bone scan: recommended in suspected cases of malignancy (history of malignancy, history of weight loss, or night pain)
  - Abdominal x-ray and renal ultrasound (US): if kidney stones are suspected
  - Vascular studies (ankle brachial index, magnetic resonance angiography [MRA] or angiography): if the patient gives a history of vascular claudication (smokers, diabetics, history of stenting or vascular bypass).
What other investigations may be warranted?
- Investigative measures strongly depend on the detailed history and examination obtained from the patient. Certain important tests are mentioned below. This list is, however, by no means exhaustive.
- With history suggestive of osteoporosis (steroid use, previous osteoporotic fractures, family history of osteoporosis, or osteopenia on radiograph), a bone densimetry is recommended.
- If the clinical picture is suggestive of connective tissue disease (multiple joints or skin manifestations), a screening should be done with some laboratory tests: erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), and antinuclear antibodies (ANA).
- If you suspect multiple myeloma, a skeletal survey, total proteins, and protein electrophoresis should be completed.
- If the patient is diabetic, control of blood glucose should be checked with hemoglobin A1–C.
Describe nonoperative measures of management of lower back pain.
- Activity modification: This may involve taking 2–3 days off work, avoiding activities that provoke pain, doing a different task at work with less stress on the spine; may result in changing jobs.^6,7
- Pain control: This is important initially with the activity modification to allow the patient to mobilize more and do some strengthening exercises. This could be done with the help of passive therapeutic modalities while in physical therapy sessions, such as heat, cold, ultrasound, and transcutaneous electrical nerve stimulation (TENS) machines.
- Physical therapy programs include^8,9
  - During the first month of symptoms: low impact aerobic exercise can minimize debility due to inactivity, such as walking, bicycling, or swimming.
  - Also, conditioning exercises for trunk muscles may be done such as exercises to strengthen back extensors and abdominal muscles (the McKenzie techniques comprise a well-known set of such exercises).
  - During the first 2 weeks, these exercises may aggravate symptoms. Therefore, the recommended exercise quotas are gradually escalated, resulting in better outcomes than having patients simply stop when pain occurs.
- Educating the patient is also important in improving and hastening recovery.
  - Explanation of the condition to the patient in understandable terms.
  - Positive reassurance that the condition will almost certainly subside.
  - Teach the patient about proper posture, sleeping positions, lifting techniques, and weight loss techniques if overweight.
- If there is no improvement with such conservative techniques, then resorting to medications initially and later interventional procedures may be considered.
- Maintenance/recurrence prevention programs should also be set up.
  - After some control of the pain is achieved using the activity modification and medications (±) interventions, a core strengthening program should be initiated.
  - This involves lumbar stabilization exercise: strengthening and training muscles that surround the spine can help support and protect the spine.
  - A simple way to start is with walking and performing general aerobic exercises.
  - Exercise has a good general effect on the human body that includes increasing the pain threshold and building resistance to pain.
  - The patient also has to modify unhealthy lifestyle habits and poor body mechanics that may have initiated the pain.
- Medical management includes5,10
  - Nonsteroidal antiinflammatory drugs (NSAIDS)
  - Acetaminophen
  - Other antiinflammatories or nonnarcotic pain medications such as tramadol and combination of the above.
  - For radicular pain that affects sleep, amitriptyline or other antidepressant-type pain medications may be used.
  - Alternatively, gabapentin or pregabalin can be employed. Both have no significant interactions with other medications, but need to be avoided in patients with significant renal dysfunction.
  - Strong narcotics may be used in the short term in cases of intractable pain. These include morphine derivatives – MS Contin, OxyContin (both Purdue Pharma, Stamford, CT), hydromorphone, etc. Fentanyl patches are contraindicated for narcotics naive patients.
What interventional procedures may be used to differentiate the types of spinal-related lower back pain?
- For mechanical back pain, the following measures may apply.
  - Medial branch blocks may help diagnose facet-related pain in cases of whiplash injuries and degenerative disc disease.
  - Sacroiliac (SI) joint injections may help diagnose and treat SI joint pain in cases of leg length discrepancy, multiple-level fusion, or spondyloarthropathy (ankylosing spondylitis or inflammatory bowel disease).
  - Discography may be used to diagnose diskogenic pain and to narrow the level of most severe involvement if surgical fusion is contemplated.
  - Trigger point injections may aid the diagnosis and treat of muscular back pain.
Discuss interventional options for management of spinal pain.
- Options for interventional pain management include the following (Fig. 89.2 for illustrative intraprocedural x-rays)^11–13:
- Transforaminal, caudal, or interlaminal epidural injections, for radicular back pain.^14,15
  - Transforaminal and caudal epidural carries less risk for “wet” tap with spinal fluid leakage, spinal headache, and epidural hematomas.
  - Complications during epidural injections for back pain happen due to the following mistakes¹⁶:
    - Performing a blind epidural injection with no radiographic guidance
    - Not using contrast
    - Using particulate steroids such as methylprednisolone (Depo-Medrol; Pfizer Pharmaceuticals, New York, NY)
    - Other faulty techniques
  - There is no definite evidence that these procedures are effective in treating acute radiculopathy or lower back pain alone.
  - Epidural injections may be an option for short-term relief of radicular pain when control on oral medications is inadequate or for patients who are not surgical candidates.
- Radiofrequency denervation (neurotomy), for facet-related mechanical spinal pain that is proved by two positive medial branch blocks, using two different local agents of different duration.¹⁷
- Spinal cord stimulators for treatment for chronic back pain¹⁸
- Sacroiliac joint injection, to diagnose and treat mechanical back pain that is related to sacroiliac joint disease
- Vertebroplasy or kyphoplasty for management of osteoporotic compression spine fractures¹⁹
- In general, interventional procedures are delayed for 4–12 weeks, depending on the case. It is essential to determine if the patient responds to more conservative measures first.
- In proven one-level diskogenic pain, after failure of conservative measures, consideration could be made to anterior lumbar interbody fusion (ALIF) versus disk arthroplasty; the latter could only be considered in the absence of facet arthropathy.