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.