#59 Back pain and Sciatica: Straighten out your practice

September 25, 2017 | By Matthew Watto, MD

Solidify your approach to back pain with Dr. Chris Miles, Assistant Professor, Family & Community Medicine and Associate Director, Sports Medicine program, Wake Forest Baptist Medical Center. He schools us on red/yellow flags, physical exam maneuvers, when to order imaging, and practical tools and tips for evidence-based management! Correspondent Dr. Shreya Trivedi cohosts!

Full show notes available at http://thecurbsiders.com/podcast

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Case from Kashlak Memorial: 53 yo M construction worker with a BMI of 29 and PMhx of DM2, HTN, depression presenting with right low back pain. He can’t remember any trauma or injury. Denies radiation, no bowel or bladder dysfunction, saddle anesthesia, weakness

Case from Kashlak Memorial: 48 yo F nurse who has had intermittent back pain for years presented with acute flare after helping lift a patient. The pain similar to previous episodes but more severe and also radiates to her left foot. She has tried naproxen and exercises/mindful stress reduction for months without improvement. It is unbearable for her to work.

Clinical Pearls:

1. Yellow Flag signs are psychosocial factors shown to be indicative of long term chronicity and disability. Address them early on!
   1. Fear and avoidance of activity
   2. Tendency to low mood and social withdrawal
   3. Belief that passive treatment rather than active participation will help.
   4. Belief that back pain is harmful or potentially severely disabling
2. Differential diagnosis: When evaluating back pain, it is important to keep in mind that back pain can be from visceral organs, such as intraabdominal or extraperotenial ones.
3. Straight Leg Test: Passive lifting of affected leg to an angle less than 60 degrees reproduces pain radiating DISTAL to knee.
   1. Pooled Sensitivity of 85% and Specificity: 52% (Vroomen J Neurology 1999)
4. Crossed Straight Leg Test: Passive lifting of the unaffected leg reproduces pain in affected (opposite) leg
   1. Pooled Sensitivity 30% and Specificity 84% (Vroomen J Neurology 1999)
5. Slump Test: Have patient slump forward at thoracic and lumbar spine and neck flexed by placing chin to chest. Then have the patient extend their knee and ankle as much as possible. If the patient has pain, then have the patient look upward at the ceiling. If their pain is relieved, that is considered a positive sign for nerve root impingement.
6. Trendelenburg Test: looks for weakness in gluteus musculature. Stand behind patient and have patient stand on one leg. If there is dipping of the hip, it indicates weakness of gluteus musculature of the leg patient is standing on.
7. Patient Counseling: 90% of acute back pain will get better within 6 weeks. Encourage as much activity as tolerated. Movement is medicine.
8. Imaging: If back pain present for more than 6 weeks, a few weeks after intervention or with neurological abnormality on exam, consider imaging. However, keep in mind, radiographic findings correlate poorly with low back symptoms.
9. Initial management of low back pain: New ACP guidelines recommends initial focus non-pharmacological therapies rather than medications.
10. Non-pharmacological treatment for acute LBP: Superficial heat (moderate quality evidence), massage, acupuncture or spinal manipulation (low-quality evidence). (ACP guidelines Feb 2017)
11. Non-pharmacological treatment for chronic LBP: Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, cognitive behavior therapy or spinal manipulation (low quality evidence) (ACP guidelines Feb 2017)
12. Acetaminophen and LBP: There is a lack of benefit of acetaminophen in acute low back pain.
13. Muscle Relaxants: Consider advising patients to take muscle relaxants at night due to sedating properties. Most muscle relaxants poorly tolerated by older adults, because of anticholinergic side effects, sedation, increased risk of fractures (AGS Beer’s List Pocket Card 2016)
14. Tizanidine: Specifically listed as being highly anticholinergic in 2012, but not 2015 Beers Criteria. Be cautious if using any skeletal muscle relaxants in the elderly, frail.
15. Severe pain and avoidance of opioids: Try high dose NSAIDS, such as diclofenac instead of opioids. Studies have shown high dose NSAIDS to be more efficacious in controlling pain than morphine in post-op as well as other illness associated with significant pain.
16. Sciatica and Radiculopathy: They are not the same thing! You can have radicular symptoms that may NOT have the distribution of the sciatic nerve e.g. cervical radiculopathy.
17. Sciatica medications: Despite anecdotal stories, a small double-blind RCT questions effectiveness of pregabalin in sciatica (Mathieson NEJM 2017).
18. Gabapentin in low back pain: Similar to pregabalin and despite anecdotal stories, a recent systematic review gabapentin was associated with a small reduction in pain compared to placebo with associated increased risk of dizziness (NNH 7) and fatigue (NNH 8) (Shanthanna PLOS 2017)
19. Surgery: Most people do not need surgery even if they have herniated discs. There are questionable benefits of surgery.

Goal: Listeners will be able to learn high-value, cost-conscious decision-making in the work-up and management of back pain while also reviewing updated ACP guidelines to back pain

Learning objectives:
After listening to this episode listeners will…

1. Identify key factors in the history to back pain (acute, subacute, chronic, age, red flag signs, etc) and its implications
2. Recognize the importance of screening for yellow flag signs and how they are strong predictors for back pain outcomes
3. Differentiate various common causes of back pain
4. Be able to counsel patients on expected course for their back pain
5. Select effective non-pharmacological therapy based on acute/subacute, and chronic back pain
6. Choose effective pharmacological treatments for back pain
7. Guide patients with more invasive treatment options such as epidural steroid injections or surgery

Disclosures: Dr. Miles reports no relevant financial disclosures.

Time Stamps
00:00 Intro
02:14 Listener feedback
03:44 Announcements
05:14 Picks of the week
08:20 Millenial learners
10:40 Topic intro and guest bio
12:06 Getting to know our guest
17:30 Clinical case of back pain
20:18 How to hand sensory deficits
21:51 Red and yellow flag symptoms
25:44 How to approach patient with yellow flag symptoms
28:00 Physical exam for back pain
30:00 Special testing: Trendelenburg, Slump test, and Straight leg raise
35:48 Classifying types of back pain and a quick recap of teaching points so far
39:28 How to manage patient expectations
40:42 Treatment of non-radicular back pain
46:33 Home exercises and YouTube training
49:31 When to follow up after initial treatment trial
51:35 The patient with severe acute pain
53:33 Some pearls on muscle relaxants
55:22 Clinical case and how to treat radicular pain
59:40 Invasive treatment of back pain
65:04 Back pain treatments that don’t work
66:06 Take home points
67:34 Outro

Links from the show:

1. MSKCC Database on Supplements and Herbs
2. Side Hustle Nation (podcast)
3. Pro Circle Speed Jump Rope
4. Death from Above (album)
5. Simon Sinek “Nobody Wins” on YouTube
6. A Grief Observed (book) by C.S. Lewis
7. Chou R. In the Clinic: Low Back Pain. Ann Intern Med. 2014
8. Vroomen, P. C. A. J., De Krom, M. C. T. F. M., & Knottnerus, J. A. (1999). Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. Journal of neurology, 246(10), 899-906.
9. Slump Test: https://www.youtube.com/watch?v=Y0gZg5bSJuQ
10. Crossed Straight leg test: https://www.youtube.com/watch?v=Yp7es4deo0Q
11. Qaseem, Amir, et al. “Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of PhysiciansNoninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain.” Annals of internal medicine 166.7 (2017): 514-530.
12. AGS Beer’s List Pocket Card. 2016 http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf
13. Holdgate, Anna, and Tamara Pollock. “Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic.” Bmj 328.7453 (2004): 1401.
14. McEvoy, Andrew, Jeremy I. Livingstone, and C. Joseph Cahill. “Comparison of diclofenac sodium and morphine sulphate for postoperative analgesia after day case inguinal hernia surgery.” Annals of the Royal College of Surgeons of England 78.4 (1996): 363.
15. Mathieson, Stephanie, et al. “Trial of pregabalin for acute and chronic sciatica.” New England Journal of Medicine 376.12 (2017): 1111-1120.
16. Shanthanna, Harsha, et al. “Benefits and safety of gabapentinoids in chronic low back pain: A systematic review and meta-analysis of randomized controlled trials.” PLoS medicine 14.8 (2017): e1002369.