Ayder Comprehensive Specialized Hospital/Mekelle University Low Back Pain Protocol

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Low Back Pain Protocol Tony Magana MD Professor in Neurosurgery Neurosurgical Unit, Department of Surgery, College of Health Sciences Chief Medical Specialist for Ethiopia in Neurosurgery Ayder Comprehensive Specialized Hospital July 2016 Introduction: Worldwide back pain remains one of the leading complaints leading patients to see doctors. Although the vast majority of adult sufferers of low back pain harbor a benign problem that will not require surgery or lead to significant disability there are some which are much more serious. Additionally, some patients who claim a work injury or accident where there is litigation present a challenge to the physician in assessment.

This guideline deals with adult patients who present with low back pain not involved with immediate trauma.

It is intended for use by general practioners, interns, primary care residents, outlying clinics and Mekelle University clinics, and referring hospitals to help guide appropriate management of this large patient population. It can be used as a teaching tool for medical students, nursing students, health officers, physical therapy students, and others. More than 95% of patients with low back pain should be able to be managed by primary care physicians so that few actually need surgical consultation. The main intent of this protocol is to help prepare primary care providers for this role and understand when further investigation and referral is necessary.

This protocol was reviewed by senior faculty of the College of Health Sciences at Mekelle University including general surgeons, orthopedic surgeons, internal medicine, and radiology. Special thanks to Dr. Senay Aregawi, neurologist at Mekelle, and Dr. David Clifford, neurologist at Washington University Medical School in the United States, for their comments and suggestions.

Initial Evaluation

Low Back Pain Protocol, Mekelle College of Health Sciences, Professor Tony Magana

2 Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories:  nonspecific low back pain  back pain potentially associated with radiculopathy or spinal stenosis 1. Pain radiating from the back to the extremity is not always representative of nerve root or spinal compression. Radiculopathy is defined as dysfunction of a nerve root associated with pain, sensory impairment, weakness, or diminished deep tendon reflexes in a nerve root distribution. Sciatica is pain radiating down the leg below the knee in the distribution of the sciatic nerve, suggesting nerve root compromise due to mechanical pressure or inflammation. Most radiculopathies will have sciatica but most sciatica is not necessarily suggestive of significant radiculopathy.

2. Pseudoradiculopathy is pain that mimics radiculopathy but is not associated with neurological findings or a straight leg raising sign.  Back pain potentially associated with another specific spinal cause The duration of pain should be discerned into the categories of  acute (6 weeks or less)  subacute (7 to 12 weeks)  chronic (greater than 12 weeks).

Taking the history should include:  Location of pain, frequency of symptoms, duration, what exacerbates or reliefs the pain, previous history of similar pain and treatment. Note that pain history and location cannot always localize well between thoracic and lumbar source.  Occupation and job duties (example heavy lifting)  Screening for organ disorders or systemic disease outside the spine which can mimic spine pain or secondarily affect the spine including risk factors of cancer, tuberculosis, osteoporosis, recent infection  Symptoms of neurologic disorder: weakness, numbness, bladder, bowel, or sexual dysfunction  Assessment of psychosocial risk factors, which predict risk for chronic disabling back pain. psychosocial factors that may predict poorer low back pain outcomes include presence of depression, passive coping strategies, job dissatisfaction, higher disability levels, disputed compensation claims, or somatization Physical examination should include:  General examination for fever, weight loss, or signs of cancer or systemic disease  Evaluate the spine for range of motion, deformity, tenderness. Tenderness to palpation is not a reliable indicator by itself of the presence of a significant lesion in the spine.  Assess the extremities for range of motion, circulation, and atrophy.  Neurological examination including reflexes, motor power, and sensation of the upper and lower extremities. Changes in reflex or motor function are more significant findings than isolated subjective changes in sensation generally.  Presence or absence of straight leg raising sign(SLR). A positive SLR is very sensitive Low Back Pain Protocol, Mekelle College of Health Sciences, Professor Tony Magana

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( approaching 90% in some studies when properly done but is much less specific (32%) in diagnosing a herniated lumbar disc. The straight leg raise is a passive test. Each leg is tested individually with the normal leg being tested first. When performing the SLR test, the patient is positioned in supine without a pillow under his/her head, the hip medially rotated and adducted, and the knee extended. The clinician lifts the patient's leg by the posterior ankle while keeping the knee in a fully extended position. The clinician continues to lift the patient's leg by flexing at the hip until the patient complains of pain or tightness in the back of the leg. Pain at less than 30 degrees of elevation or increasing pain beyond 60 degrees of elevation are not typical of disc herniation and may be significant for nonorganic findings.

Observing consistency of the patient's complaints in how he/she walks in and out of the room, sits, stands or bends when not being formally examined.

Management Nonspecific Low Back Pain Pain occurring primarily in the back with no signs of a serious underlying condition (such as cancer, infection, or cauda equina syndrome), spinal stenosis or radiculopathy, or another specific spinal cause (such as vertebral compression fracture or ankylosing spondylitis). Degenerative changes on lumbar imaging are usually considered nonspecific, as they correlatepoorly with symptoms.The vast majority (85%) of these patients have no clearly identifiable cause of their pain.

What is the pathophysiology of low back pain?

Traditionally it was once believed that low back pain especially if it was severe was due to pressure on the cauda equina or the spinal cord. However studies over the past twenty years have shown there are pain receptors in the facet joint and it's capsule, disc, muscles and even bone which can cause back pain. Somatically these are poorly locatized to primitive pain centers in the brain which localize to the back, hip or leg in a poorly defined area similar to radiculopathy. Aging changes to the facet joints, chronic inflammation, infection, tumor, or trauma can lead to this pseudoradiculopathy.

Characteristically it is not associated with neurological deficit or straight leg raising sign.

These receptors are stimulated or altered by biochemical factors including cytokines such as matrix metalloproteinases, phospholipase A2, nitric oxide, and tumor necrosis factor-alpha are thought to contribute to the development of low back pain. Inflammatory responses and sensitivity changes to these substances can occur with repetitive motion. Cox-2 inhibitors such as nonsteroidal antiinflammatory drugs have been shown to be more effective than acetopminophen in helping to relieve pain. Additionally neurophysiological mechanisms exist in the midst of stress and/or depression, for example, which can mediate or amplify pain responses.

Nerve root inflammation with and without direct mechanical irritation of the spinal nerve roots in the lumbar spine is thought to occur from the release of substances leaking from the intervertebral disk including phospholipases, leukotrienes, and thromboxane. Chronic bony stenosis causes an reduction in the blood flow to nerves causing inflammatory responses and neural element ischemia. Theoretically corticosteroids can inhibit this inflammatory response, reduce pathological capillary permeability, and decreasce nociceptive input from C-fibers. This has led to widespread use of epidural steroid use for Low Back Pain Protocol, Mekelle College of Health Sciences, Professor Tony Magana

4 radicular pain in the United States but studies have been mixed as to the results. Poor technique and patient selection was found to contribute to poor outcomes. Although some report this treatment may temporarily aleviate pain allowing the patient to avoid surgery the evidence of long term benefit is lacking. This type of treatment is not available at Mekelle University and not really well established anywhere in Ethiopia. Recent studies have found that oral administration of gabapentin gave similar results as epidural steroids for nerve root pain or claudication type of pain seen with spinal stenosis.

However gabapentin is not available in Ethiopia generally.

Since the development of MRI and CT Scan, however, it has been clearly recognized that although most the population will have disc degeneration and facet changes beginning in their thirties and progressing through aging this changes do not always correlate with pain. Thus the medical practioner has to be careful about ascribing pain to these changes of aging and patients should avoid fixating on these findings.

6 weeks or less duration. 

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Although developed country guidelines recommend against plain x-ray screening the endemic occurrence of tuberculosis in Ethiopia suggests that screening lateral and AP x-ray of the lumbar and thoracic spine along with erythrocyte sedimentation rate can identify tuberculosis with a high specificity and sensitivity approaching 90%. MRI or CT Scan is unnecessary at this point.

If there are no medical contraindications a month's course of nonsteroidal antiflammatory medication is appropriate. Narcotics, muscle relaxants, steroids, antidepressants, and anticonvulsants have no proven role for most patients.

Counsel patients that most back pain episodes are benign in nature and self-limited.

Improvement will occur for most within 6 weeks although some will take up to a year. Explain that aging changes occur in most people beginnin by age 30 that gradually limit abilities as one gets older. They should avoid heavy lifting, be instructed in stretching, exercise, and proper mechanics by a physical therapist. Changing position every 30 minutes to one hour may be helpful.

Advise patients to return to clinic in 4 to 6 weeks if not better. If radicular pain, weakness, numbness, bladder, bowel, or sex dysfunction occurs they should seek timely follow-up sooner.

7 to 12 weeks duration  Although most of these patients will have degenerative changes of the spine at this point it is reasonable to obtain an MRI of lumbar spine. If the location of the pain is not clear then the thoracic spine should also be included.  If only degenerative changes are seen such as disc degeneration, Schmorl's node, facet hypertrophy, disc protrusion or herniation without neurologic symptoms or signs, or mild sublulxation or curvature then the patient should be counseled to continue conservative measures as there is still a good chance for improvement. Patients should be counseled that degenerative changes like bulging disc, small disc herniation, dehydration of the disc, straightening of lumbar lordosis, and facet hypertrophy occur with greater frequency as one Low Back Pain Protocol, Mekelle College of Health Sciences, Professor Tony Magana

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ages over the age of the thirty and can be considered somewhat consistent with the aging process. Their contribution to back pain is unclear because many people have these findings without significant back pain.

Once the patient has learned to do exercises and stretching then selfcare is appropriate such that prolonged physical therapy is not necessary. The focus is on function rather than pain. Outcome studies have shown that patient confidence and satisfaction improve with physical training even if they continue to have pain complaints.

Follow-up in three months should be scheduled.

The physician should be cautious in answering requests for job change or allowing for long leaves from work. Patients who are independent in their activies of daily living (walking, dressing, bathing, traveling) should very rarely be taken off work totally.

12 weeks duration  Patients who have persisent complaints of significant nonspecific low back pain in the absence of significant findings other than degenerative changes on the MRI should undergo a medical evaluation by internal medicine to rule out other causes. Additionally a review of psychosocial factors such as job dissatifaction, pending litigation, or mental illness may indicate a need for mental illness treatment referral. However it is important to not be confrontational with the patient.  Patients with spondylolisthesis should undergo neurosurgical consultation  Some patients with degenerative changes may need to make some permanent lifestyle changes and adjust to their situation if there is no improvement over a year's time.  These patients can be followed once yearly unless there is a change in symptoms.

Back pain associated specifically with lumbar radiculopathy or spinal stenosis Patients who present with low back pain and lumbar radiculopathy (dysfunction of a nerve root associated with pain, sensory impairment, weakness, or diminished deep tendon reflexes in a nerve root distribution) or spinal stenosis (narrowing of the spinal canal that may result in bony constriction of the cauda equina and the emerging nerve roots). They may have sciatic pain (pain radiating down the leg below the knee in the distribution of the sciatic nerve, suggesting nerve root compromise due to mechanical pressure or inflammation.) Sciatica is the most common symptom of lumbar radiculopathy. Patients with spinal stenosis may also present with symptoms of leg pain (and occasionally weakness) on walking or standing, relieved by sitting or spinal flexion.

6 weeks or less duration.  Most patients who have low back pain with lumbar radiculopathy or an initial presentation of spinal stenosis improve with conservative treatment. Only about 5% ever need surgical intervention. Typically with supportive therapy most patients will improve with 4 to 6 weeks.

Studies have shown that most patients with herniated disc treated conservatively are significantly better by one year's time.  Patients who have mild neurological findings of mild weakness or sensory loss and a positive straight leg raising sign can be counseled that they have some nerve irritation that will likely improve with time.

1. They can be conservatively treated with nonsteroidal antiflammatory drugs, Low Back Pain Protocol, Mekelle College of Health Sciences, Professor Tony Magana

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restriction of activities (avoid heavy lifting, frequent change of position) 2. There is no need for MRI scanning initially as a trial of conservative treatment should be done first. If they fail to improve after 6 weeks or if they have progression of radicular pain or neurological finds then an MRI should be ordered.

3. For patients with more severe pain the addition of Tramadol for pain control is an option.

4. Patients should be counseled to avoid strict bedrest as it increases the chance for deep venous thrombosis and weakens the core muscles supporting the spine 5. Physical therapy focusing on improving range of motion, core muscle strengthening, and proper body mechanics can be started .

Patients who have significant neurological findings of motor loss (grade 3/5 or less) or cauda equina syndrome (Compression on nerve roots from the lower cord segments, usually due to a massive, centrally herniated disc, which can result in urinary retention or incontinence from loss of sphincter function, bilateral motor weakness of the lowerextremities, and saddle anesthesia.)

1. Should undergo an MRI of the lumbar spine to look for significant compression of the cauda equina. Note that if the patient has clonus or Babinski sign then the compression is likely to be in the thoracic region.

2. These patients should be evaluated and treated in a timely fashion. Cauda equina syndrome and/or severe weakness should be evaluated and treated urgently.

3. If MRI findings suggest compression of the spinal canal with cauda equina syndrome (incontinence, saddle anesthesia, multiple motor deficits, urinary retention) then urgent neurosurgical consultation is indicated.

4. If MRI finding suggest lateral nerve root involvement and there is moderate weakness but no cauda equina syndrome then neurosurgical consultation should be soon but not urgent.

5. Progressive neurological deficit and/or cauda equina syndrome are strong indications that timely surgical intervention may be necessary

Back pain potentially associated with another specific spinal cause  Patients who have a “red flag” in their history or physical findings should be considered for undergoing further evaluation before assuming the cause is degenerative in nature.

These include: 1. history of cancer 2. unexplained weight loss 3. failure to improve after one month 4. fever 5. recent infection 6. intravenous drug use 7. pain worse at night 8. prolonged steroid therapy 9. elderly Low Back Pain Protocol, Mekelle College of Health Sciences, Professor Tony Magana

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10. osteoporosis Imaging and Diagnositic Studies  MRI is superior to CT Scan in showing the spinal canal and nerve roots, bone marrow, and soft tissue. There is no know side effect of the magnetic field while growing concerns about the cumulative effect of ionizing radiation from CT Scans are being documented.CT Scan is useful only for initial trauma assessment where a determination of the presence of a spinal fracture is necessary and can be done at the same time as a CT Scan of the head. Thus CT Scan should only be done in cases of acute trauma. CT Scan can be substituted for MRI if MRI will be unavailable for some time but later an MRI may still need to be done to clarify findings.  EMG/NCS studies may be useful in determining if patients are suffering neurological symptoms from peripheral neuropathy versus spinal disease such as in diabetics with low back pain. They can show objective evidence the presence or absence of compressive radiculopathy in cases where patients history and physical findings are inconsistent.  Plain x-ray combined with erthrocyte sedimentation rate can often detect tuberculosis involvement of the lumbar spine so that treatment can be started but is not useful in management apart from screening for tuberculosis.

Medications  The standard medication for most low back pain should be nonsteroidal antiinflammatory drugs. Prescribing anticonvulsants, anti-depressants, muscle relaxants, and opiods on a routine basis should be avoided as there is no proof to their benefit. For select patients who are identified to have comorbities such as depression or other contributory mental disorder than other medications may be of benefit. Cox-2 inhibitors have been shown to be effective while acetopminophen has not.  Although widely used in developed countries the evidence for steroid use, either via epidural injection or oral ingestion is very weak. Clinical experience does support short courses of steroids where there is documented evidence of nerve root compression for symptomatic temporary relief but no clear benefit to long term outcome.

Physical Therapy  Early referral to a physical therapist has been to shown to increase patient confidence and optimism for recovery thus reducing subsequent costs. The focus is more on improving function. Patients were less likely to seek more aggressive treatments like injections, narcotics, and even surgery.  Components should include strengthening, neuromuscular re-education, proper body mechanics and avoidance of reinjury with the patient ultimately continuing their stretching and exercises daily at home after completion of treatment.

Low Back Pain Protocol, Mekelle College of Health Sciences, Professor Tony Magana

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11. Systematic review of therapeutic lumbar transforaminal epidural steroid injections.Buenaventura RM, Datta S, Abdi S, Smith HS. Pain Physician. 2009 Jan-Feb. 12(1):233-51.

12. Epidural Steroid Injections Compared with Gabapentin for Lumbarsacral Radicular Pain. A multicenter randomized double blind comparative study. Cohen S.P. et al. BMJ. April 2015: 350(h1748).

13. Implications of early and guideline adherent physical therapy for low back pain on utilization and costs. Childs J.D. et al.BMC Health Services Research 2015 15:15

Low Back Pain Protocol, Mekelle College of Health Sciences, Professor Tony Magana