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  • Dr. Stiles: Hello. My name is Dr. Melissa

  • Stiles. I'm with the UW Department of Family

  • Medicine, and I'm joined today by Dr. Jeff Patterson,

  • Professor of Family Medicine, and today we're going to

  • be talking about low back pain and focusing on

  • evaluation. Welcome, Jeff.

  • Dr. Patterson: Thank you. It's great to be

  • here.

  • Dr. Stiles: One of the most common

  • complaints to the primary care office is low back

  • pain, how do you approach this issue?

  • Dr. Patterson: Well, you're right, it is,

  • and of course, there are two areas. One is acute low

  • back pain, which is not so bad when you see it on your

  • schedule and the other is chronic low back pain which

  • gives you a pain in the back when you see it on your

  • schedule. And so we can talk about both of those

  • issues. The second one probably is the more difficult

  • to deal with, actually. The first thing is, seeing an

  • acute low back pain, I think one needs to be careful

  • to rule out any bad things that might be there, and

  • that's done pretty quickly with your history and

  • physical. And I would say that the history and

  • physical in both acute and chronic low back pain are

  • probably the most important features of diagnosing and

  • treating a low back problem. With the acute low back

  • pain, I think the things that we want to make sure are

  • not there are any neurological problems that might

  • indicate a herniated disc, might indicate cauda equina

  • syndrome or advanced cancer or something like that,

  • and again, that can be done fairly quickly in your

  • examination. And once you've done that, infection

  • probably would be the other issue that, again, history

  • would give you an indication about. Once you've done

  • that, then you really have time and can you buy time

  • in terms of your treatment and working with the

  • patient to get them through this acute episode of

  • their low back pain. The chronic low back pain is

  • another story, and generally, those people have been

  • through all kinds of treatment and diagnostic things,

  • and so that becomes a bigger dilemma.

  • Dr. Stiles: What do you need to

  • consideration in the differential diagnosis which is

  • very broad?

  • Dr. Patterson: Sure. So I think the most

  • common things coming from the most common, just strain

  • and sprain, and again what those mean is an

  • interesting question. The person leans over or

  • they've done some activity and their back tightens up

  • and they can't straighten up, can't move, and so

  • that's probably again the most common thing that

  • happens. If we look beyond that, obviously we need to

  • worry about herniated discs and the nerve compromise

  • that might occur with that. We need to worry about

  • cancer, metastatic cancer, and certainly if there is a

  • history of cancer, one needs to have a heightened

  • awareness of that. Infection would be another thing

  • that is really pretty rare in the spine area unless

  • there's been some intervention that's been done maybe

  • somewhere else in the body but certainly can occur

  • that way. Then arthritis and typically osteoarthritis

  • is probably the most common, degenerative arthritis,

  • which is similar to that, and things like

  • spondylolisthesis and spondylolysis, but now we move

  • into the area in what really causes the pain, the back

  • pain. And again, with acute problems, the most common

  • thing is just going to be, quote, lumbar strain and

  • sprain.

  • Dr. Stiles: You touched on some of what I

  • term, the red flags, things that you need to really

  • ask in the history, can you expand on that?

  • Dr. Patterson: Sure. So I think in your

  • history finding out how this started and what

  • happened. If you have a history of a lifting injury,

  • trauma, mild trauma of some sort, then I think you can

  • be fairly reassured that you may not need an urgent

  • MRI or X rays. If there has been more acute trauma

  • than that then certainly we want to think about

  • getting X rays, think being a fracture, compression

  • fracture, or other type of injury like that.

  • Obviously, signs of infection, talking about fever,

  • chills, and probably recent infection elsewhere in the

  • body because certainly I've seen infections spread

  • into the spinal column where the abscesses that form

  • there secondary to infections elsewhere, but that's

  • not real common. And then in the history asking about

  • neurological symptoms, do you have weakness, numbness,

  • tingling, but realizing that weakness, numbness and

  • tingling can all occur just from the sprain and

  • strain, and the weakness most frequently is what I

  • call just pain weakness. It hurts and so I can't do

  • these things, and it's hard for patients to

  • differentiate is this true weakness versus is this

  • pain weakness. But I think those, and then any

  • history of cancer, of course, would heighten my

  • suspicion that I might need to get a scan sooner

  • rather than later here, thinking of metastatic

  • disease. But most of the time, with the history, and

  • sort of the nature of the pain, you can get a pretty

  • good idea of how quickly you need to move with those

  • things.

  • Dr. Stiles: What do you focus on in the

  • physical exam?

  • Dr. Patterson: The physical exam, I think,

  • always should be careful, it should be methodical, and

  • it should be on a bare back. And I think without

  • looking at people's backs, how the back moves, how it

  • feels with palpation, you really don't know much about

  • what's going on. So I think the focus should be on

  • examination, just eye balling the patient's back, and

  • I do that, I have them put a gown on, then I look at

  • their spine, is the spine straight, look for any

  • asymmetry and muscles, I look for asymmetry in pelvic

  • heights, do they have a short leg either because of

  • spasm or because of a true short leg, and do other

  • tests to confirm that. And then range of motion of

  • the back is very important. And not just how far can

  • you bend, because you can have a totally normal range

  • of motion, but very abnormal mechanics in the spine,

  • so get used to looking at that spine with forward

  • bending, with side bending, and rotation to see how it

  • moves. People can't fake that. And you'll see

  • remarkable restrictions in motion in people with back

  • pain. And that's an objective finding in terms of

  • back pain. You'll see, for example, I think side

  • bending is probably the most accurate one. You'll see

  • the spine in the lumbar area not bend at all to the

  • side and people compensate with shoulder motion,

  • perhaps hip motion, they may bend a leg, and then to

  • the other side the spine has a normal curve. And

  • again, that's an objective finding, people can't fake

  • that, and you can document it from one visit to

  • another. The next thing is ruling out a neurological

  • deficits, and this is fairly quick. I just have

  • people rise up on their tip toes, rise up on their

  • heels, and when they rise up on their heels, I watch

  • the dorsal flexion of the big toe, extensor hallucis

  • longus, dorsal flexion of the foot, anterior tibialis

  • and then we rule out one nerve root right then, and

  • then check the reflexes, patellar and achilles

  • reflexes, sometimes that can be difficult to get. I

  • don't worry too much about subtle differences in

  • those, but are they there or not is the thing. And

  • then I often recheck the dorsal flexion of the foot

  • and dorsal flexion of the toe thinking about the nerve

  • roots the patellar, L3, 4, the achilles, L5, S1, and

  • sometimes students have difficulty remembering the

  • levels, and I always say, what does the achilles

  • tendon look like and put my finger up which is like a

  • 1. Okay. And the achilles tendon looks like a 1, and

  • that's an easy way to remember that's L5, S1, and

  • dorsal flexion of the foot, and of big toe, two

  • separate motions, which is L4, 5. Then the rest of

  • the exam, can you do straight leg raising, you can do

  • hip flexion and see what that looks like. Straight

  • leg raising, I think, is probably one of the most

  • overrated tests, and I don't routinely do it, quite

  • frankly. I do hip motion to see if that might be a

  • restricting factor. I also check knees and ankles

  • because there could be other joints that are involved

  • in this. Then palpating the back, turning the patient

  • on their stomach, having them tell you where the pain

  • is, and then careful palpation of the muscles, of the

  • bones, of the ligaments in the area. And I've really

  • come to believe that much of both acute and chronic

  • back pain has ligamentous involved in it, and so

  • careful palpation of the ligaments that are involved

  • gives you probably one of the most beneficial clues to

  • what's going on.

  • Dr. Stiles: When do you consider imaging?

  • Dr. Patterson: So imaging is an interesting

  • question, and frankly, with both acute and chronic

  • pain, in acute pain if there were a neurological

  • deficit, if somebody were having quite severe pain

  • down one leg, then I probably would think about acute

  • imaging that would be X rays to begin with, but

  • probably an MRI is going to be the definitive test

  • here if you're think being a diss, a herniated disc or

  • cancer cause. In chronic pain, most people have had

  • imaging and so I'll try to get those and look at

  • those, and I'll not really anxious in most chronic

  • pain to repeat those things. Many people have had

  • more than one MRI or CAT scan, and frankly, it's just

  • not necessary. Imaging is, probably in the treatment

  • of back pain, one of the most overrated diagnostic

  • things simply because it leads us down the path of

  • what I call reductionist or partialist medicine. And

  • that is, we see a bulging disc or even a herniated

  • disc on the X ray or on the MRI, and it really isn't

  • the cause of the pain and that's quite frequently the

  • case. It leads, I think, to excessive surgery because

  • we see that thing on the X ray, and boy, that's the

  • cause of your pain, and I know we've all seen cases in

  • our practices where after surgery the patient has the

  • same pain or worse pain, and so I think careful

  • palpatory observational diagnosis is probably the most

  • important feature.

  • Dr. Stiles: And where can people go for

  • additional resources on back pain?

  • Dr. Patterson: You know, I think the Academy

  • of Family Medicine has information in terms of the

  • ligamentous causes of pain. I would look to

  • literature on prolotherapy and looking at anatomy and

  • courses that might be involved with that. And I

  • think, again, for chronic back pain, ligamentous

  • involvement probably is the most common cause of

  • chronic low back pain.

  • Dr. Stiles: Great. Thank you very much.

  • Dr. Patterson: Thank you.

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