Low back pain –

Pitfalls in its management

Prof (Dr) Rajibul Alam MBBS, FCPS, MD, MACP

Professor of Medicine

SSMC and Mitford Hospital

Who will treat? NSAID

Rest

Exercise

DMARD

Education

How to overcome?

Physical

therapy

Anti

depressant

Drugs for

systemic

disease

General surgeon +

Neurosurgeon +

Rheumatologist +

Physician +

Psychiatrist +

Physical

therapist

+

Ortho surgeon +

Gynaecologist +

Outcome? (Mortality, Morbidity, Cost)

Initial decision, nature and severity of disease

depends on

90% Mechanical,

short lasting; and

resolved within 6 wks

To Exclude “Red flag signs”

• Neurological Deficit

• Systemic pathology (wt loss, fever)

Acute back pain with/without sciatica

Rest

Acupuncture

Exercise

Traction

Mattress

Patient education

NSAID

Which one? Which combination?

SHOULD BE INDIVIDUALIZED

Muscle relaxant

Rx Options

Rest

Randomized trials

183 patients with sciatica

Bed rest

87% improved at 12 wks in both group

“Watchful waiting”

for 2 wks

Ref: Hagen, KB, Hilde, G, Jamtvedt, G, Winnem, M. Bed rest for acute low-back pain

and sciatica. Cochrane Database Syst Rev 2004; :CD001254

Return to work is recommended - INDIVIDUALIZED

Exercise

Ref: Hayden, JA, van Tulder, MW,

Malmivaara, A, Koes, BW. Exercise

therapy for treatment of non-specific

low back pain. Cochrane Database

Syst Rev 2005; :CD000335

• No value in acute LBP

• Prevent recurrent

attack in chronic LBP

Study Population (n=186), employees of

city of Helsinki, Finaland

• Bed rest 2 days, (n=67)

• Back mobilizing exercise (n=52)

• Ordinary activity (n=67)

Low back pain patient

Ordinary activity within the limit permitted by pain

Rapid recovery than either bed rest / back

mobilization exercise

Ref: Antti Malmivaara, Unto Hakkinen, Timo Aro et. al. The treatment of acute low back pain –

Bed rest, exercises, or ordinary activity? New England Journal of Medicine 1995:332:351-5

Traction

24 randomized

control trials (5 high

quality)

Traction provides NO significant benefit in short- or

long-term outcome for LBP with or without sciatica

Ref: Van Tulder, MW, Jellema, P, van Poppel, MN, et al. Lumbar supports for prevention

and treatment of low back pain. Cochrane Database Syst Rev 2000; :CD001823

Acupuncture

• Short term benefit in chronic back pain

• Better than no treatment

• Equivalent to NSAID

Ref: Furlan, AD, van Tulder, MW,

Cherkin, DC, et al. Acupuncture and dry-

needling for low back pain. Cochrane

Database Syst Rev 2005; :CD001351

NSAID + Muscle relaxant → not superior

to NSAID alone (randomized trial)

Ref: Childers, MK, Borenstein, D, Brown, RL, et al. Low-dose cyclobenzaprine

versus combination therapy with ibuprofen for acute neck or back pain with

muscle spasm: A randomized trial. Curr Med Res Opin 2005; 21:1485

Mattress

European randomized trial (n=313)

Ref: Kovacs, FM, Abraira, V, Pena, A, et al. Effect of firmness of mattress on chronic

non-specific low-back pain: randomised, double-blind, controlled, multicentre trial.

Lancet 2003; 362:1599

Medium firm mattress superior to firm mattress

Sciatica

• Conservative Rx and / or surgery

• Rx on the basis of X-ray and MRI (?)

MRI done on 98 normal person

Normal 36%

Disc bulged 52%

Disc prolapse 27%

Radiology dependent management sometimes

MISLEADING

Abnormal

findings }

Study Reports

Abnormal findings from 100

normal population

CT 34%

MRI 64%

Myelogram 25%

Ref: Akerman SJ, S Jeinberg EP, Bryan RN,et al. Trends in diagnostic imaging

for low back pain - Has MR imaging been a substitute or add on? Radiology

1997: 203: 533-8

Patient Education

• Cause of LBP

• Favorable

prognosis

• Minimal value of

lab test

• Activity and work

recommendation

• Rest

• NSAID

• Physical therapy

• Patient education

• Recurrence

• Maximum

investigation

required

• Minimum

investigation

Treatment

64 articles published between 1966-2000

Stronger association of low education with higher

duration and / or higher recurrence of back pain

Ref: J Epidemiol Community Health 2000: 55: 455-468

Acute Low Back Pain

• Appropriate specialist and regime

• Rx options having scientific basis

• Looking for “Red Flag Signs”

RECAPITULATION

Spondyloarthropathy

• Spinal (spondylo) arthritis

• Sacroilitis

• Asymmetrical large (lower limb) joint involvement

• Enthesitis

• Mucocutaneous inflammation

• Iritis

• Association with HLA B27

• Rheumatoid factor negative

• Ankylosing spondilitis

• Psoriatic arthritis

• Reiter’s syndrome & reactive arthritis

• Enteropathic arthritis

Type Presentation

Spdyloarthropathy

Patients of spondyloarthropathy suffer

badly because of -

• Historical lack of coordination and cooperation

for making

– Diagnostic criteria

– Outcome measurement

• Limited scope of drug treatment particularly for

axial disease

Spondyloarthropathy

Uncertain

destination

• Long term trial of

DMARD – few

• Selection of

standard drug

Case History

Mrs S., 25 years, married

Bilateral hip arthritis (inflammatory back pain) for 5 years

Moves with wheel chair

Synovial biopsy → Non-specific (Calcutta)

Rx anti TB → No response

Methotrexate + Sulphasalazine @ Maximum dose

After 2 years treatment,

patient could walk without support

SP

A

SPA : investigation dependent

2004 Dhaka

Case History: Mr Z.

• 45 years

• Inflammatory back pain

• Recurrent asymmetric oligo arthritis (wrist, knee, ankle) - 17 years

• X-ray SI joint normal (NSAID, steroids, traction

no response

• Improved with maximum dose of Methotrexate + Sulphasalazine

Undifferentiated SPA may not have SI joint involvement

SPA : investigation dependent

2002 SSMC

Rx given usually X-ray SI joint normal + OA (incidental)

Physical

steroid

NSAID

X 60% develops sacroilitis in 10 years

Inflammatory back pain + HLA B27 positive 59% probability

So diagnosis by inflammatory back pain, peripheral arthritis,

enthesitis, buttock pain, uveitis, family history

Inflammatory

chronic back pain

SPA : investigation dependent

Spondyloarthropathy

• Inflammatory arthritis and / or

back pain more than 3 months

• SPA

Rx

• Sulphasalazine 1 tab (500

mg) BD for 3 months (?)

HOW TREATED?

X-ray SI joint abnormal

Spondyloarthropathy

• Underdiagnosis

• Overdiagnosis

• Appropriate Rx schedule ?

• Patient education ?

Acute back pain

• Short history: 1 months duration

• SI joint X-ray normal

• Treated as mechanical

Spondyloarthropathy

Acute pain Long history of

Inflammatory back pain

missed during history

taking (chronic)

X

Missing long history of back pain

1 month

Case History

• Young female 19 years

• Hematemesis & malena (NSAID induced)

• LBP (inflammatory) - 1 year

• Could not appear in SSC exam

• Both SI joints very tender and hip joints stiff

• X-ray SI joint sclerosed

Missing long history of back pain

* Spondyloarthropathy improved with Sulphasalazine

2007 SSMC

Clark and his colleagues reported that depression (2%) leading to back pain not vise versa

Ref: Psychiatric news, April 18, 2003

Back pain & Psychiatry

Back pain cases

Case History

• A beautiful lady, 25 years;

husband, 50 years

• Back pain for 6 months

• On anti-depressant

• Back pain was inflammatory

• Both SI joint tender

• X-ray SI joint normal

• SPA: Sulphaasalazine full

dose → dramatic

improvement after 2 months

Back pain & Psychiatry

2008 Dhaka

Case History

• 13 years girl, back pain for few months

• No specific tender points

• On antidepressant (HCR)

• No improvement

What to do?

• Planter response extensor

• MRI meningioma of spinal cord

• Surgical treatment → improved

Back pain & Psychiatry

Neurological examination is a must in a case of backache

1994 Khulna

Underdiagnosis

Overdiagnosis

Sometimes overdiagnosis dangerous

Back pain & Rheumatic Fever

Case History

• Mr. Su 17 yrs

• Back pain with knee pain for 4 yrs

• Bed redden for 3 months

• D/H: Penicillin

• Arthritis, rt hip and lt knee

• * JIA

• Improved with DMARD (Sulphasalazine)

Back pain & Rheumatic Fever

2007 SSMC

Case History

• Mr X : passport officer 40 yrs

• Admitted in a hospital with stretcher with severe back pain

• Rec. oligoarthritis (knee, ankle) since childhood

• Rx: NSAID, Penicillin as RF

• O/E both SI joint were very tender

• SI joints sclerosed and fused

• * : SPA improved with Methotrexate

Back pain & Rheumatic Fever

2004 Dhaka

Case History

• Mr X 38 yrs

• Back pain and peripheral arthritis 11 years

• Echocardiography → AR (operated in Calcutta)

• Penicillin for rheumatic carditis

• Ankylosing spondylitis é A/R

• Back pain improved with Sulphasalazine + Methotrexate

Back pain & Rheumatic Fever

2002 Dhaka

Back pain &

Spondyloarthropathy

• Diagnosis – mostly clinical

• Female SPA

• Diagnosis of RF, depression – to be

careful

RECAPITULATION

Elderly, Post

Menopausal, Senile

Back pain & Osteoporosis

Story of an osteoporotic lady

• Mrs. N, 65 years

• Menopause – 25 years

• Back pain – 15 years

Vertebral Fracture, 1990 (1st), 1996 (2nd)

(NSAID and traction)

Severe back pain - 3 months Multiple vertebral fractures (X-ray Spine)

Osteoporosis (T score -4.5 LS -3.8 hip)

Improved with Risedronate, Vit D, Calcium

Back pain & Osteoporosis

2002, SSMC

If medical

treatment is

not given

Operated for right hip fracture in the past,

recently developed left hip and vertebral fracture

Back pain & Osteoporosis 2005 SSMC

Elderly, post menopausal → # Hip / Vertebra

Hip operation

Another fracture

Another operation

Hip operation

BMD

Rx of Osteoporosis

X

Back pain & Osteoporosis

Osteoporosis

in male

Frequently missed

as it is thought to be

present in post

menopausal lady

Back pain & Osteoporosis

Back pain, osteoporosis

frequently not diagnosed

below 40 years

Mrs. K, 22 years – back pain (Osteoporosis)

Back pain & Osteoporosis

Patient on steroid for asthma

Back pain elderly patient

Treated as osteoarthritis

without doing BMD

Frequently

osteoporosis is

missed from

diagnosis

Back pain & Osteoporosis

Back pain & Osteoporosis

It is effective only for pain due to

osteoporotic vertebral fracture

Rx:

Inj calcitonin for pain

of osteoarthritis

Back pain and Osteoporosis

• Female post menopausal

• Male, early age

• Pathological # BMD }

RECAPITULATION

Case History

• Male 35 years

• Back pain 1 year

• Not responding to therapy

• MRI: soft tissue shadow in the lumber spine

• Operation: Laparotomy → soft tissue in and around spinal cord

• Histopathological examination: NHL

• Subsequent Rx and F/U in Narayangonj, Bangladesh in 1998

Back pain and systemic disease In

BD

In

KS

A

Case History • Male 60, H/O acute pancreatitis 3 months back

• Admitted in SSMC (2005) with sever abdominal pain

for 3 days

• P/A soft, no tenderness

• Tender lumber spine

Back pain and systemic disease

* Multiple myeloma: Spine pathology presented as

abdominal pain

• Acute pancreatitis (past history) due to hypercalcemia

Case History

• Elderly male 55 yrs

• Back pain for 2 months

• Husband & wife were separated due to some

familial problem

• O/E: no specific tenderness and no neurological

findings in leg

• On antidepressant

• Patient died after 1 week → What happened?

Back pain and systemic disease

• Before death he was examined thoroughly → pulses in dorsalis pedis & ant. post tibial absent

• Arotic aneurysm (presented as back pain), finally ruptured, caused sudden death

Pulse examination in lower limb is a must in a case of back pain

Back pain and systemic disease

Case History • Back pain, wt loss – 1 year

• D/H: NSAID

Back pain and systemic disease

Royal disease should not be missed

2008, SSMC

Gibbus

Pott’s disease

Back examination in back pain

Back pain and systemic

diseases

• Wide range of systemic / serious disease

• Critical clinical evaluation

RECAPITULATION

Cost of Rx,

morbidity,

mortality

Correct assessment

(clinical +++, Lab +) • ALBP vs. CLBP

• Mechanical vs.

inflammatory

• Red flag signs (?)

↑

Appropriate package

of Management

Source of information

• Journals

• Personal diary (real stories and reports)

• Pictures – original, sketch

• Names – not real to protect identity

Thank you