Panelists: Professor Fathie, and Drs.Andrew, Darrow, Kuritzky, Serrato, Wilske
Introduction
More than 25 million patients worldwide suffer from some form of back pain. Back pain is a complex symptomatology that results in patients presenting to one or all of the following specialists: primary care physicians, neurosurgeons, ortho- paedic surgeons, rheumatologists, physical and rehabilitation professionals, and emergency medicine physicians. Therefore, a panel consisting of members from each of these specialties was brought together to discuss an interdisciplinary approach to the treatment of back pain. The panel consisted of Drs. Kazem Fathie, Associate Professor of Neurosurgery at the University of Reno School of Medi- cine in Nevada; Louise B. Andrew, Principal Consultant at the Center for Professional Well-Being in Maryland and Emergency Physician at North Arundel Hospital in Maryland; Marc Darrow, President of the Joint Rehabilitation & Sports Medical Center in Los Angeles, California; Louis Kuritzky, Clinical Associate Professor of Community Health and Family Medicine at the University of Florida in Gainesville; J.C. Serrato Jr., Surgeon-in-Chief at the Serrato Spinal Center and Director of the Columbus Orthopedic and Rehabilitation Center in Columbus, Georgia; and Kenneth R. Wilske, Head of the Section of Rheumatology and Clinical Immunology at the Virginia Mason Clinic in Seattle, Washington. The panel focused on such areas as diagnosis, differential diagnosis, types of back pain, and various treatment options. The approach to patients with back pain begins with a thorough history. The history provides a tremendous amount of information regarding the patients’ complaints, duration, location, intensity, and type of pain. It also provides an opportunity to determine whether the pain is real or fabricated, i.e., related to psychological factors or financial gain. When determining the cause of baek pain, it is important to rule out secondary pathology such as kidney stones, abdominal aneurysms, metastatic lesions, or psychological factors. Treatment of patients with acute back pa in may vary according to specialty; however, the members of the panel agreed that the pain should be modulated to allow patients the best mobility and rehabilitation. Once the pain is controlled via oral analgesics and nonsedating muscle relaxants, patients are encouraged to remain active, whether by walking, swimming, exercising, or undergoing physiotherapy. The roundtable discussion was sponsored through an unrestricted educational grant by Elan Pharmaceuticals. Through such academic interaction, much can be learned about the treatment of patients with acute back pain.
TREATMENT OF ACUTE BACK PAIN: An Interdisciplinary Approach
Each year, millions of Americans present with some form of back pain. The pain may be acute, typically defined as pain in the back region of recent onset that limits activity and lasts for 3 weeks or less, or chronic, persisting beyond 6 to 12 weeks. Back pain may result in time lost from work and the development of psychological problems, such as depression. Back pain is further classified as primary (also known as mechanical), which is most commonly of indeterminate musculoskeletal origin, and secondary, caused by a discernible secondary disorder such as an aortic aneurysm, hyperparathyroidism, ankylosing spondylitis, infection, or a space-occupying lesion (including carcinoma). Mechanical back pain arises from transient derangement of an anatomic structure in the back. Degeneration of intervertebral disks and desiccation with age are responsible for most cases of mechanical back pain. It is seen most often in middle-aged and older patients and usually is benign. inflammatory back pain often results from a seronegative spondyloarthropathy affecting the axial skeleton and sacroiliac joints. It is most common in younger men and usually is a chronic condition. Infectious back pain is less common; however, it is important to diagnose this type of pain early because it may result in paralysis or neurologic impairment. Red flags that suggest a secondary cause of acute back pain include fever or intravenous drug use, which may herald an infection in the disk space; localized bony tenderness; history of cancer, fever, or weight loss, which may indicate a carcinomatous process (either primary or metastatic); ankylosing spondylitis, seen most commonly in patients with a family history; and pain beginning during adolescence. Back pain is the presenting complaint for many focal as well as systemic diseases, with the possibility of serious morbidity or even death. Therefore, it is important to ascertain the correct diagnosis and rule out serious secondary pathology. Patients with back pain may present to a variety of specialists, including primary care physicians, orthopaedic surgeons, neuro- surgeons, rheumatologists, physical and rehabilitation professionals, and emergency physicians. Therefore, a multidisciplinary approach to the diagnosis and treatment of patients with acute back pain is essential. Diagnosis and Differential Diagnosis A thorough history, physical examination, and neurologic examination
“Mechanical or primary back pain has been a useful umbrella under which we place the poorly differentiated or poorly defined syndrome of patients who have no demonstrable pathology in the back nor any secondary gain that would cause them to magnify their symptoms.”
Louis Kuritzky, M.D.
Table 1
Medical Management of Patients with Acute Back Pain
Pharmacologic
Oral Analgesics
Oral Muscle Relaxants
Opioid Analgesics (rarely and only short term)
Nonpharmacologic
Exercise
Massage
Application of Heat or Ice
Use of TENS Unit
Use of Back Support or Corset Patient Education are the basis on which an accurate diagnosis of acute back pain is made. The diagnosis must take into account several nonmedical factors as well, such as psychological, financial, and emotional. Unfortunately, some patients complain of back pain because they hope to obtain a financial settlement in a lawsuit or they have psychological problems. Therefore, the history should include questions that will help to rule out the nonphysiologic cases of back pain.
HISTORY
The history should include questions regarding the presence of fever in association with the back pain, weight loss, prior malignancy, chronic steroid therapy, chronic hypertension or peripheral vascular disease, kidney stones, pathologic fractures, or prior aneurysms. It is important to ascertain whether there has been recent trauma to the spine resulting in pain. Any pain history should also assess the severity, location, quality, duration and course, tim- ing, exacerbating and relieving factors, and associated symptoms (with emphasis on psychological state and vegetative symptoms). The age of the patient is important because this parameter allows patients to be classified according to risk factors for secondary pathology. For example, patients younger than 20 and those older than 50 are at higher risk of having a secondary source of their back pain than patients who are not in these age groups. Most patients with acute back pain of a mechanical nature are between the ages of 20 and 50 years.
“Physicians tend to look at things from the standpoint of their experience. For example, neurosurgeons look at imaging, internists look at sedimentation rates, etc. When diagnosing back pain, you must look at it in a comprehensive way.”
Kenneth R. Wilske, M.D.
PHYSICAL EXAMINATION
The physical examination is important. It may reveal midline or paraspinal tenderness or spasm and limited range of motion. Back pain that is insidious in onset or does not correlate with the findings noted during the physical examination suggests the possibility of maligiancy. During the physical Examination, it is important to determine whether the pain can be reproduced, radiates, or remains constant in one area. Overt evidence of in- flammation (e.g., redness, swelling, heat, and tenderness) is rarely found in an examination of the spine and strongly suggests infection.
TESTS AND NEUROLOGIC EXAMINATION
The tests employed in evaluating patients who present with acute back pain vary. A neurologic examination is required to detect the presence of irritation of a nerve originating from the spinal cord or involvement of. the spinal cord. Reflexes should be checked for the possibility of radiculopathy. A simple way to rule out the presence of radiculopathy is by instructing patients to lie prone and then palpating the area where the iliolumbar ligaments are located. If tender with radiation of pain, the problem may simply be trigger points. The straight-leg raising test and the crossed straight-leg raising test are specific for detecting spinal cord impingement, most commonly from herniation of the disk, with or without impingement of the nerve. Radiography (x-ray), computerized tomography (CT), and magnetic resonance imaging (MRI) are used to locate lesions and rule out secondary pathology. in some cases, electromyography or a nerve conduction study is required. The most important part of the diagnosis of acute back pain is to rule out secondary causes. Indications that the pain is not primary include recentsignificanttrauma in young patients or minor trauma in elderly patients; age older than 50 years or younger than 20; proonged use of steroids; weight loss; fever higher than 100 F; and a history of cancer, recent infection, or surgical procedure.
“Although common in the emergency setting, mechanical back pain must be a diagnosis of exclusion because of the potential of underlying causes that may be life-threatening.”
Louise B. Andrew, M.D.
Types of Back Pain
In contrast to acute back pain,, chronic pain loses its adaptive biologic function. However, there are many types of back pain. For example, local pain, which is directly on the paravertebral muscles; generalized pain, spreading all over the back even to the neck; and radiating pain with neurologic components such as changes in reflex, sensory, numbness, or weakness in the toes or legs. it is often difficult to determine what is the cause of acute back pain in some patients. The pain may be related to stress on the spine resulting from poor posture, prolonged sitting, depression, job dissatisfaction, or being overweight. The pain may be caused by nerve irritation, by the disk pathology, osteoarthritic changes, or from the nerve being irritated by bone spicules or chemical substances (such as phospholipase A2 or prostaglandins) that are secreted from the disk. Stress on the spinal ligaments or facet joints results in an inflammatory reaction that creates an imbalance, which can result in acute or chronic back pain.
Treatment
The goals of therapy for patients with acute back pain are to control the pain and other symptoms while allowing the injury to heal. Treatment consists of noninvasive or invasive techniques. Generally, noninvasive techniques are preferred and include the use of analgesics, anti-inflammatory agents, oral muscle relaxants, narcotics, counterirritants, exercise, massage, ap- plication of ice or heat, use of a transcutaneous nerve stimulation (TENS) unit, back support or corset, and patient education (Table 1). Invasive techniques include the use of nerve blocks, prolotherapy, epidural injections, short-term steroids, and surgery.
“Treat back pain conservatively during the acute phase. The initial phase is muscle relaxants for the first 2 or 3 weeks. Let nature do the rest.”
J.C. Serrato, M.D.
NONINVASIVE
Noninvasive treatment of acute back pain begins with the use of oral analgesics. Analgesics: Before patients present for treatment of their back pain, most have tried some form of over-the-counter pain reliever (e.g., Tylenol R) or nonsteroidal anti-inflammatory agents (e.g., ibuprofen). According to Dr. Kuritzky, newer COX (cyclo-oxygenase) -2-specific agents offer no advantage for control of symptoms, are expensive, and indicated only for patients who are at risk of gastrointestinal bleeding. Also, oral analgesics are effective in only one of five patients with acute back pain. Oral Muscle Relaxants: The next step in the pharmacologic treat- ment of acute back pain involves the use of oral muscle relaxants, alone or in combination with a short-term systemic nonsteroidal anti-inflammatory agent. Numerous trials have shown that this combination provides a more favorable outcome than the use of a nonsteroidal anti-inflammatory agent alone and that the beneficial effects of the muscle relaxants result from a central mechanism separate from sedation, added Dr. Kuritzky. A few clinicians may disagree with the use of anti-inflammatory agents, but most agree with the use of muscle relaxants to relieve the muscle stiffess of acute back pain. Muscle relaxants control the skeletomuscular spasm, hypertonicity, rigidity, and other symptoms of altered neuromuscular function. When the muscle is relaxed, the back pain often is eliminated. The use of muscle relaxants can shorten the acute stage of the muscular strain or the acute exacerbation of a chronic condition resulting from muscular indiscertion. They also allow movement of the muscle, which promotes healing. The short-term use of muscle relaxants does not cause complications, blood dyscrasia, or kidney problems. However, with the exception of metaxalone, muscle relaxants frequently are associated with drowsiness or sedation that may affect the performance of daily activities. Metaxalone also acts by suppressing polysynaptic spinal cord reflexes without interfering with normal musculoskeletal function, which is important in returning mobility to patients with acute back pain.
Narcotics: Narcotics have a role in the treatment of acute back pain, but there is a real risk of habituation if overused. Short-term and selective use, e.g., in trauma or emergency cases or in patients with burning sciatica and evidence of neuropathy in whom other pharmacologic treatment has been ineffective, is recommended.
Exercise: Exercise is the most important nonpharmacologic, non- invasive form of therapy for patients with acute back pain. In the past, patients with back pain were instructed to rest, and traction may have been recommended. Today, exercise, with rapid return to full range of motion, is the treatment of choice. Increasing muscle strength via exercise may help to prevent the problem from becoming chronic. Exercises that often are recommended for patients with acute back pain include walking, swimming, specific back exercises, and light weightlifting. Exercise is now considered essential to a quick recovery from acute mechanical back pain.
Massage: Massage, by a massage therapist, physical therapist, or family member, may be beneficial for some patients with acute back pain. Manipulation of the spinal area by an osteopath or chiropractor may provide relief and help alleviate pain. Massage therapy isa matter of patient preference.
Application of Ice or Heat: The application of ice or heat is an area of controversy. Some authorities believe that the application of ice obstructs the production of osteoblasts needed to regenerate ligaments and tissues to promote healing. other authorities believe the application of ice or heat helps reduce the pain and allows patients greater mobility.
Tens Unit: The TENS unit works on the basis that the spinal cord has the ability to close itself off from incoming forces of the brain that are stimulated by the use of elec- trical current moving up the chan- nels to the brain, producing endor- phins. The current obstructs the transferring of sensations and signs of pain back and forth from the brain to the peripheral nerves. The TENS unit inhibits pain in approxi- mately 50% of patients, according to Dr. Fathie. Therefore, in some pa- tients, it may be an effective ad- junct to treatment.
Back Support or Corset: The use of a back support or corset depends on patient preference. They are usually prescribed for postoperative patients but may be used in patients who find they help to alleviate pain by providing external pressure or keeping an ice or heat source in place while allowing mobility. However, caution is advised with the use of back support because patients may attempt inappropriate activities believing the brace protects them and it restricts motion, which deconditions the paravertebral muscles.
Patient Education: Education of patients is essential to create a therapeutic relationship and to facilitate recovery. in the absence of secondary pathology, patients should be assured that there is no serious cause of their pain and that they will recover quickly. Patients should be encouraged to exercise cautiously and follow the prescribed treatment regimen.
“I am against the use of anti-inflammatory agents because they curb what the body is designed to do upon injury, which is to inflame. Inflammation is the healing process.”
Marc Darrow, M.D.
INVASIVE
When noninvasive therapy is ineffective in treating acute back pain, the problem may become chronic or require invasive methods. Nerve Blocks and Epidural Injections: Elderly patients with advancing degenerative change and spinal stenosis may benefit from epidural blocks.
Prolotherapy: Injection with dextrose on the iliolumbar and sacroiliac ligaments that proliferates the production of coliagen and stabilizes the back to reduce pain may be effective in some patients.
Short-Term Steroids: Patients with low-grade inflammatory osteoarthritis may be helped by the use of injected steroids.
Surgery: Patients should never undergo surgery for noncomplicated back pain. Surgery is recommended only in the presence of a progressive neurologic deficit or damage to the peripheral nerve. Other indications where surgery may be considered include cases of bowel or bladder incontinence, cauda equinal syndrome, intractable pain, or for occupational reasons. An example of the last indication would be a professional athlete who requires rapid recuperation and who, although probably would recover with conservative therapy in 6 to 12 weeks, would lose $3 million by missing time during the playing season. When sur- gery is indicated, a laminectomy without fusion is the procedure of choice in most patients. There are many advocates of the theory that in the long term, surgery versus no surgery equals the same results.
Conclusion
Back pain is a presenting symptom associated with numerous condi- tions. Ruling out secondary pathology is imperative to the accurate diagnosis and appropriate treatment of patients with acute back pain.