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(Common Spinal Column Problems (for Family Physicians)
1
Mashhad University of
Medical Sciences
Common Spinal Column Problems
By: Dr Amin Azhari
Assistant Professor of Physical Medicine and Rehabilitation
azharia@mums.ac.ir
dr.aminazhari@gmail.com
Cervical Strains and Whiplash Syndromes
Cervical Strains and Whiplash Syndromes
Key points
It is important to rule out
- Fracture
- Joint instability
- Neurologic deficit early in the evaluation process
Long-term comprehensive treatment
- Patient education
- Lifestyle modifications
- Use of psychological interventions to aid in pain
coping mechanisms.
Key Points
Introduction
Mechanism of injury: A combination of forces
Pain generators: Facets, dorsal root ganglia, discs,
ligaments, muscles, vertebral artery, psychosocial factors, and generalized hyperalgesia
Imaging studies: Fractures, ligamentous instability,
significant disc herniation, and degenerative changes such as osteophytes
Clinical Features
History
- Neck pain and stiffness
- Dizziness
- Headache
- In upper limb:
Radiating pain
Numbness
Weakness in the upper extremities and may include
- Cognitive impairment: Maybe included
- It is important to document the onset of symptoms in
relation to the time of injury.
- Factors related to the collision itself, such as amount of
vehicle damage, are not reliably predictive of the degree of pain and injury to the individual
Physical Examination
- Posture
- Gait,
- ROM of the spine and extremities
- Neurologic tests :including
Cranial nerves
Cognitive function
- With any area of injury, the proximal and distal joints
should be evaluated.
For a cervical injury:
Temporal– mandibular joint: Above
Scapula and glenohumeral joint: Below
- In the acute setting, imaging should be done based on the
NEXUS criteria
Physical Examination
Spurling test
Slightly extending the cervical spine
+
Bending the neck toward the painful side.
+
Pressure is then applied through the top of the head (axial loading).
Positive test result: Increased pain and radicular symptoms
- Suggestive : Cervical radiculopathy
The maneuver: Specific but not sensitive
Spurling Test
Treatment
Initially
- Pain control
- Mechanisms to decrease inflammation
- Passive modalities.
As the patient tolerates: more active approaches such as
- Aerobic
- Joint-specific exercise
- Sport-specific activity.
Cervical collars and supportive devices should be reserved
for short-term use only when no instability is present
Treatment
Prognosis
Risk factors for poor recovery
- Female gender
- Low level of education
- Higher baseline scores for neck pain intensity and
somatization
- Lower baseline scores for work-related activities.
Most consistent predictors: Of these
Neck pain intensity
Work disability
Most rigorous studies suggest that half of those with
whiplash-associated disorders report neck symptoms 1 year after their injury
Prognosis
Cervical and Lumbar Disk Syndromes
Cervical and Lumbar Disk Syndromes
- Usually the result of a longstanding degenerative process.
- A careful neurologic examination is mandatory to
determine the clinical level of involvement.
Key Points
Mechanism of cervical or lumbar radiculopathy
- Can be a result of a specific incident/injury
- Usually a manifestation of an ongoing degenerative
process.
Introduction
The result of these processes:
- Unstable joint ( Joint laxity): Result in disc herniation
Describing disc herniation as the end result of a multifactorial,
chronic process rather than an isolated event is helpful in counseling patients and planning effective treatments.
Pathophysiology
Pathophysiology
- There is a fine balance between the vertebrae–disc
complex and the two facet joints.
- Alteration the center of axis of motion of this three-
joint complex: combination of
- Muscle imbalances
- Coordination issues
- Postural abnormalities
- Disc degeneration
- Result: Tissue damage
- fraying of the annulus fibrosis
- micro-trauma to the facet joints and their fluid-filled capsules.
Wolff's law
Wolff's law
States that bone responds to the stressors placed on it
by hypertrophying.
- As the spine seeks a more stable state, facet and
ligamentum flavum hypertrophy may result in a central, lateral recess or foraminal stenosis
In the cervical spine, the uncus is a unique structure that
is a site of osteophyte formation.
A combination of disc herniation, uncovertebral
hypertrophy (disc–osteophyte complex), andfacet hypertrophy may result in stenosis of the foramen,
lateral recess, or central canal.
Clinical Features
- Radicular pain
Other structures may have radiating pain
- facet joints
- myofascial trigger points
- sacroiliac joint
- In the lumbar spine, disc herniations most frequently
increase pain with sitting
- The process is dynamic:
- Although the extent of the herniation can be visualized on MRI, the process is dynamic and subject to pressure and positional influences.
- The clinical picture takes precedent over the imaging studies.
- Thorough neurologic examinations are required to define any deficit that exists, including any potential cauda equina involvement.
Clinical Features
The amount of compression of the nerve root varies according to the
degree of disc herniation (i.e., protrusion, extrusion, sequestered
fragment).
Lumbar Herniation
- More frequently noted to be central or in the paramedian
position in the spinal canal.
- This results in the compression of the nerve root exiting at the next lower level (e.g., an L4-L5 herniation compressing the L5 nerve root).
The exception is when there is a far lateral herniation into
the neuroforamen (e.g., an L4-L5 foraminal protrusion compressing the exiting L4 nerve root).
Lumbar
Herniation
Cervical Disk Herniation
Cervical Herniation
In the cervical spine, disc herniations usually compress
the nerve root at the same level (e.g., a C5-C6 herniation
compressing the C6 nerve root).
Treatment
Treatment guidelines are available.
Evidence-based rules are not well defined.
Treatment
Conservative Approaches
Initially
- Short period of rest
_ Aerobic exercise
- Spine-specific exercises
- Passive modalities and medications may be
included
- Should not be a mainstay of treatment.
- Ergonomic Principles
Conservative
Rehabilitation
Rehabilitation
Recommendations for spine-specific exercises vary
- Family physicians should feel comfortable
initiating a few commonly effective exercises.
Strenghthening Exercises: As the patient progresses.
- Four-point balance exercise
- Lateral plank
Other specific exercises can be included based on individual needs, often with the help of a physical therapist.
Cervical Spine
Neck retraction/Isometric strengthening
Cervical Spine
Lumbar Spine
Supine knee-to-chest/ prone extension initially.
Lumbar Spine
Ergonomic Principles
Ergonomic Principles
Lumbar radiculopathy:
- Limiting prolonged sitting
Cervical radiculopathy
- Limiting static postures such as prolonged
computer use
- Limiting overhead and repetitive upper
extremity work.
Return to Play/Work
Parallel guidelines
Return to work:
Return to play criteria: Include the following general principles:
- Resolution of any neurologic deficit
- Full ROM
- Little or no pain
- The athlete is able to perform adequately in practice
- Athlete should have the proper protective equipment
- Have the confidence to play
- Should not be at significant risk of injury by participating
Return to work/Play
Indications
Surgery
Absolute indications:
- Loss of bowel or bladder control
- Progressive neurologic involvement.
Relative indications:
- Static motor loss
- Intractable pain that causes debilitatin
functional loss
Other indications
- Neoplasm
- Infection
- Congenital conditions or deformity
Spinal Stenosis
Spinal Stenosis
- Most commonly an end result of the degenerative cascade.
- Spinal stenosis most often presents as neurogenic
claudication in older adults.
- Clinical findings need to be confirmed with imaging to
make a definitive diagnosis
- Imaging will not change management in mild symptoms.
Key Points
- A clinical syndrome of buttock or lower extremity pain
associated with diminished space available for neural and vascular structures within the spinal canal
- Important in primary care because it is a common cause
of pain, disability, and back surgery in the elderly population.
- A common source of confusion among clinicians
- Spinal stenosis is both a clinical and radiologic term that must be correlated to determine its clinical significance.
Introduction
Clinical Notes
Clinical Features
Degenerative process
Degenerative Process
- Spinal stenosis occurs because of degenerative
changes in the spinal canal.
- Multifactorial: Originates from a combination of
- Disc bulging
- Hypertrophy of arthritic facet joints
- Hypertrophy of the ligamentum flavum
Clinical Syndrome
Clinical Syndrome
Symptomes
Variable
- Lower back pain
- Lower extremity symptoms ( Pain/Weakness)
- Can be unilateral or bilateral
- Worsens with walking
- Relieved with sitting
Classic presentation: Neurogenic claudication in older adults.
- Slow, progressive disorder
- Typically does not present before age 60 years.
Additional findings in the history
- Improvement of symptoms with flexion
- Worsening with extension
Improving when leaning on a shopping cart in the supermarket.
Physical Examination
Physical Examination
- Physical examination tests are not as reliable as symptoms
in making the diagnosis
- Wide-based gait
- Abnormal Romberg test
- Tests balance and proprioception
- Patient stand with the feet together and the eyes closed.
- Positive test result: The patient will not be able to maintain balance with the eyes closed.
Differential Diagnosis
- Peripheral vascular disease (PVD)
Differing characteristics include
- Postural changes, which should improve pain in spinal
stenosis but not PVD
- The discomfort of vascular claudication may be more
consistently reproducible with ambulation than neurogenic claudication
Ankle-brachial index (ABI)
- If concern for vascular disease persists
- The ABI compares blood pressures from the ankle and
arm both at rest and after exercise.
- Decreased ABI : Suggestive of underlying PVD.
Differential Diagnosis
Diagnosis
- History and examination: Usually enough to make a
presumptive diagnosis of spinal stenosis
- MRI:
- Imaging test of choice to confirm the diagnosis
- It is not necessary to initially obtain imaging
in most cases.
For patients with mild or moderate symptoms, imaging will not change the initial management.
Isolated radiographic findings of spinal stenosis without appropriate symptoms do not make the diagnosis of the clinical syndrome of lumbar spinal stenosis.
Treatment
Based on symptom severity
Goals:
- Relieve pain
- Improve function.
Importantly, the symptoms, not radiologic findings,
should direct the treatment approach.
Classification ; Based on radiologic measurements
- Mild
- Moderate
- Severe: Anteroposterior (AP) diameter of less than 10 mm
Poor correlation between MRI assessment of stenosis and
walking distance, degree of disability, patient-reported pain,
and physician clinical impression.
Conservative
- Physical therapy
- Analgesic medications
- Lumbosacral braces
- Manual therapy
- Weight loss
There is currently no standard of care for conservative treatments,
Physical therapy and exercise may be effective in improving
outcomes as part of a comprehensive treatment strategy.
Pharmacologic agents
- First Line: Acetaminophen/Nonsteroidal antiinflammatory
drugs (NSAIDs)
- Muscle relaxants/ Calcitoniin: Insufficient evidence
- Gabapentin: Limited evidence
Interventional
Treatments
Interventional Treatments
- Epidural steroid injections
Current recommendations support the use of epidural injections for short term relief.
Evidence is not as strong for long-term benefit
Prognosis
Mild to moderate symptoms:
Conservative care is effective
- 70% of the time at 6 months
- Decreasing to 57% at 4 years
Severe symptoms
Conservative care is effective 33% of the time, Surgical Decompression: 8o%
Prognosis
Spinal Decompression
Surgical Approaches
For patients with moderate to severe radicular symptoms,
especially when not benefiting from conservative care.
Patients with primarily axial back pain as opposed to radicular
pain do not typically get as much benefit from surgery.
Patients older than 75 years of age undergoing decompression
surgery have outcomes similar to younger patients and
should be considered for debilitating symptoms
Spondylolisthesis
Spondylolisthesis
Key Points
- Spondylolisthesis is defined as a forward slippage
of one vertebral body relative to the one below.
- The most common underlying causes
- Younger population: Bilateral pars interarticularis defect
- Older adults: Degenerative changes.
Background
- Commonly seen by family physicians
- Both the pediatric and adult population.
- Can be a cause of spinal stenosis.
Definition:
- Spondylolysis is a defect of the pars interarticularis of a
lumbar vertebra.
- Spondylolisthesis is the forward slippage of a vertebral
body relative to the one below.
- There are five underlying causes of spondylolisthesis.
Background
- Types I and II are more common in the pediatric
population
- Type III is more commonly seen in older adults
- Most common types: Types II and III.
Pars Interarticularis Defects
Pars Interarticularis Defect
- Exact etiology is unclear.
- Genetic predisposition plays a role.
- The overall incidence is quite high (Quoted rates of 6%
by age 14 years).
- Clinical significance
- Varies significantly based on the individual
- A slippage greater than 25% tends to correlate with
the presence of pain.
Degenerative Spondylolisthesis
Degenerative
- Major cause of spinal stenosis
- Multifactorial problem similar to other causes of spinal
stenosis.
- Degenerative spondylolisthesis occurs mostly at L4 to L5, as
opposed to spondylolysis, which occurs at L5 to S1 in approximately 90% of cases
Diagnosis
Low Back Pain:
- The most common complaint
- Exacerbated by activities that stress extension of the
spine such as
- Gymnastics
- Football.
In degenerative cases presentation is similar to that of
spinal stenosis.
Imaging
X-Ray:
- Anteroposterior and lateral plain radiographs
are the standard views taken.
- Oblique views can be added if a pars interarticularis
defect is suspected.
MRI
- Can be considered for those with persistent
symptoms or concerning findings on a neurologic examination
Bone scan
- and MRI may be useful if there is a need to determine
the acuity of a pars fracture.
Imaging
Grading
Can be done in two ways
Most commonly expressed as a percentage of the AP
diameter of the top of the lower vertebrae.
There is some subjectivity in this assessment, so caution
is advised when assessing for progression
- Low-grade: Defined as less than 50%,
- High-grade slips are greater than 50%
Grading
Treatment
Pars Defect
Prognosis: Excellent
Variable: Depend on
- Age
- Acuity of the pars defect
- Level of activity
- Degree of impairment
Return to activity (in spondylolysis and spondylolisthesis
caused by pars defects)
- Based on improvement of symptoms rather than
radiologic improvement
Follow-up: Based on age
- Skeletally immature may benefit from serial imaging
every 6 months to monitor for progression
- Near skeletal maturity do not require routine follow-up
Pars Defect
Conservative
Conservative
- Relative rest from sports
- Progressive rehabilitation as symptoms decrease
- Lumbosacral bracing
- Especially in the setting of acute pars fractures
in younger patients
- Less often done in adult patients but can be
used if there are significant symptoms
Surgical Treatment
Surgery
1- Generally reserved for those who have failed
conservative care for 6 months.
2- One notable exception is in skeletally immature
patients with high-grade vertebral slippage.
- Because of the risk of further slippage
Degenerative Spondylolisthesis
Prognosis: Favorable
- Often depends on the degree of neurologic symptoms
present because of spinal stenosis
Conservative
Similar to that for spinal stenosis
Includes
- Progressive aerobic exercise
- Weight reduction
- Analgesic medications
- Specific physical therapy modalities: Can benefit
Lumbar bracing
Strengthening of back flexor and extensor
muscle groups
Back stabilization training
Non Operative
- Having neurologic symptoms at baseline is
predictive of a poorer prognosis when treated non-surgically
Surgery
Indications
- Persistent pain
- Neurologic deficit that affects quality of life
- Resistant to conservative care
- Progressive neurologic deficit
- Bowel and bladder symptoms
Progression of slippage
- Does not correlate well to clinical symptoms
- Typically not used to guide treatment as
much as the clinical presentation
Operative
Vertebral Compression Fractures
Vertebral Compression Fractures
Key Points
- Vertebral compression fractures (VCFs) are often
identified incidentally and are most commonly
asymptomatic
- Most commonly caused by osteoporosis
- can also be caused by underlying systemic pathology.
- Plain radiographs: Test of choice when a compression
fracture is suspected.
Introduction
- Vertebral compression fractures are a common cause of
pain and disability, especially in the elderly population.
- Family physicians play an important role not only in the
treatment of recognized fractures but also in prevention of future fractures.
- A useful concept when considering the pathophysiology
of VCF is the three-column spine theory proposed by Francis Denis in 1983.
Francis Denis Concept
Anterior column comprises
- Anterior longitudinal ligament
- Anterior half of the vertebral body
Middle column consists of
- Posterior half of the vertebral body
- Posterior longitudinal ligament
Posterior column consists
- Pedicles
- Facet joints
- Supraspinous ligaments.
Pathphysiology
- This concept is significant when assessing the stability of a
spinal fracture.
- If two of the three columns are involved, then the fracture is more likely to be unstable.
- Most compression fractures are stable because they involve
a wedge deformity of the anterior column alone. The middle column remains intact to prevent compression of neural elements
Clinical Features
Highly variable
- Most are asymptomatic and identified incidentally.
- It is estimated that just one third of vertebral fractures
are symptomatic
- History of minor trauma: May be as minor as a
cough or sneeze
- Pain
- Most common site for fractures is at the thoracolumbar junction
Fractures superior to T7 and those occurring in patients without osteoporosis should prompt further workup to look for potential underlying systemic disease include
- Malignancy
- Hyperparathyroidism
- Osteomalacia
- Tuberculosis.
Physical Examination
- Decreased ROM typical of many etiologies of back pain
- Localized vertebral tenderness
Not usually helpful in making the diagnosis
- Increased kyphosis
Caused by several factors associated with aging include
- Decline in bone mass
- Weakness of vertebral end plates
- Reduction in axial muscle strength, mostly with spinal extension
These changes can occur with or without vertebral
fractures and thus are not helpful in making a diagnosis.
- Neurologic examination should be normal in an
uncomplicated vertebral fracture.
Diagnosis
Vertebral fracture should be considered a potential
source of back pain in individuals with
- Risk factors for osteoporosis
- A prior diagnosis of osteoporosis
- Red flags for systemic disease predisposing the
patient to vertebral fractures.
Given that most patients present without significant trauma, it
is appropriate to obtain imaging to make the diagnosis when concern for vertebral fracture exists.
Lab Study
If there is concern for a cause other than osteoporosis
- Complete blood count
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein
- Serum calcium
- Parathyroid hormone (PTH)
- Vitamin D level
- Tuberculosis screening may be indicated
Laboratory
Workup
Imaging
Plain radiographs
- Appropriate initial tests when VCF is suspected
- Characteristics Findings
- Anterior wedging of one or more vertebrae
- Vertebral collapse
- Demineralization
- Vertebral end-plate irregularity
- VCF is defined
- Decrease in vertebral height by 20%
or
- At least 4 mm compared with baseline
- Unstable fracture:
- Loss of greater than 50% of vertebral body height and multiple adjacent compression fractures
- Failure of two of the three columns
MRI / CT if
- Neurologic abnormality on examination
- Suspicion for a malignancy-associated vertebral fracture
Bone scan
if there is concern for malignancy
Treatment
Overall goals of management
- Pain control
- Prevention of further fractures and disability.
Treatment
Acute Phase
Acute Management
Management of acute compression fractures is still controversial
- Recent research suggests that an initial trial of conservative
treatment is likely most appropriate
Conservative
Analgesic medication
- Nonopioid analgesic medications should be used initially
- Risks associated with opioids that are especially relevant to the osteoporotic population include falls and constipation
- Nasal calcitonin can be used as an adjunct to analgesic
medications
- It may take up to 2 weeks for optimal pain control.
Bed Rest
Back braces
Physical therapy
- Physical therapy–based approaches center around
rehabilitation of the back extensors.
- This has a role even in the management of acute fractures because isometric exercises of the extensor muscle groups can decrease pain
Interventions
For pain that persists beyond 6 weeks despite
conservative care
- Balloon kyphoplasty and vertebroplasty
- Options for refractory symptoms
- Indications of these procedures are currently not clear
- Some studies have shown quicker pain relief with both procedures compared with conservative care, but others have found no improvement in pain and functional measures at 6 months
- Surgical intervention is normally reserved for
unstable fractures.
Prevention
Prevntion of Future Fx
A comprehensive approach to osteoporosis includes
- Regular exercise
- Exercise should be considered a standard part of osteoporosis management to improve axial stability.
- Spinal extensor exercises can decrease the risk of future vertebral fractures even without an increase in bone mass
- Back extensor strength has been correlated to better quality of life in patients with osteoporosis
- Adequate calcium and vitamin D intake
- Smoking cessation
- Bisphosphonate medications
Myofascial Pain
Myofascial Pain
Introduction
Myofascial pain
- Considered a regional pain syndrome
- Caused by myofascial trigger points
Trigger points are
- Discrete, focal, hyperirritable spots
located in a taut band of skeletal muscle
- The spots are painful on compression and
can produce referred pain
Diagnosis
Diagnosis
Frequently, this is a diagnosis of exclusion, and
Other pathology should be investigated
- Bone abnormalities
- Nerve deficits
- Inflammatory disorders
Comorbidities
- Depression
- Anxiety
- Central sensitization from a previous or
coexisting injury
Treatment
Treatment
Eliminating factors perpetuating muscular overuse
Encouraging activity
More integrative approaches
- Lifestyle issues (Sleep disturbance, mood disorders, dietary
intake, stress reduction)
- Aerobic and specific exercises
- Biomechanical approaches
Modalities
- Manual therapies
- Dry needling
- Trigger point injections
Judicious use of analgesic medicines
- Acetaminophen and NSAIDs are good medication choices
for periodic use.
Chronic pain conditions: Pain that lasts more than 3 to 6 months.
Note: The ill effects of long-term immobilization and lack of
exercise with resultant deconditioning can result in a state that is worse than the original myofascial pain problem.
Chronic Low Back Pain
Chronic Low Back Pain
- Multiple potential pain generators: contributing to
the difficulty of making a specific diagnosis.
- Grouped into
- Mechanical back pain
- Radicular pain
- Pathologic back pain
- Evaluating for common red flag symptoms helps
clinicians efficiently rule out urgent conditions.
- Imaging modalities are not indicated before 6 weeks
of back pain symptoms unless red flag symptoms
are present.
Key Points
Introduction
Importance
- Very common and costly problem
- A source of frustration for both patients and
providers
- Complex problem
- Multiple potential sources of pain
- Magnified when pain becomes chronic
Importance
Sources
Sources of pain
Acute pain
- Based on nociceptive receptors peripherally at
an anatomic site.
- Potential pain generators
- Discs
- Facet joints
- Sacroiliac joints
- Ligaments
- Muscles
- Fascia
Chronic low back pain
- Increased motion
- Decreased cushioning
- Abnormal bone formation
- Weakening of muscles and ligaments
Results
Changes to the nervous system
- Neuron hyperexcitability
- Changes in gene expression, and signal amplification to
the thalamus
Emotional and psychological changes that take
place also color the pain experience
- Taken together, these changes can result in continued
pain signals even when there is no further tissue damage.
- Pharmacologic and physical treatments can be focused at
different target sites
- Peripheral site of pain
- The spinal cord
- Sites of pain modulation in the brain
- Psychological and emotional components directly impact
pain perception.
Results
Diagnostic Approach
- Only 15% of patients have a specific identifiable cause
of back pain
Classifications
- Multiple classification systems
- There is no evidence that one classification system
should be used over another
- All guidelines have the approach of ruling out (First)
- Tumor
- Infection
- organic causes
- Surgical emergencies
Then proceeding with management of mechanical-type back pain.
American pain Society
APS categories
- A commonly used approach
- Recommended in 2007 by a joint statement from the
American College of Physicians and the American Pain Society.
- It uses the following three categories:
1- Nonspecific back pain
2- Radicular pain
3- Red flag–associated symptoms
Imaging
Imaging
Early imaging is not indicated unless red flags are present.
Advanced imaging
- Most commonly MRI
- When more invasive treatments are likely but does
have downsides
- MRI may lead to more surgery without improving
outcomes and the “labeling” of a condition that may
not in fact fully explain symptoms
Treatment
Treatment Approach in primary care
Facts
Facts
Therapeutic approach remains challenging
There is a long list of potential therapies.
Symptomatic improvement often does not happen quickly
A good place to start is determining the treatment goals.
- In chronic pain of any type, “curing the pain” is often
not a reasonable goal
- Consider both patient and provider goals in this process
- If a patient is having difficulty with this process, a
question to shed light on patient values can be, “What do you want your health for?”
Self-Care Education
Central to the treatment approach is helping the patient become more
active and functional,
- This likely reduces pain and disability while lowering the number
of visits and cost
- Requires changes to existing lifestyle habits, such as
- Increasing physical activity
- Losing weight.
Rehabilitation exercises
- Should progress from passive to more active therapies
- as the pain moves from acute to more chronic
- as the patient progresses and regains function.
- Aerobic exercise directly impacts
- Functional status in addition
- Improving mood and possibly pain perception
American College of Sports Medicine (ACSM) recommends
- 150 minutes of moderate-intensity exercise per week
- For patients who are not at this level of exercise, this goal can
become part of the treatment plan.
Medication
Medication
Medication options for nonspecific back pain start with
- Acetaminophen as a first-line recommendation.
- NSAIDs and weak opioids (such as codeine) are
second-line choices.
- NSAIDs should be cautiously used in elderly patients because of an increased risk of heart disease and renal failure
Insufficient pain relief
- consider a tricyclic antidepressant
- Muscle relaxant medications may be useful for the
short term but have not been shown helpful in chronic management of low back pain.
- Anticonvulsant medications such as gabapentin
may be indicated for neuropathic pain but do not have evidence of effectiveness in more general musculoskeletal pain
Opioids
- A common source of tension for primary care physicians
- In general, opioids can be considered as a backup plan when
other modalities and medications have failed to give adequate pain relief and pain is still having an impact on function.
- Risks of opioids include nausea, constipation, sedation,
hyperalgesia, misuse, and addiction.
- Opioids have been shown to improve pain but have not been
shown to improve function more than other analgesics
- The chronic use of opioids remains controversial.
- It is best to use opioids with defined functional goals in
mind, which again should be made mutually with patients.
- Several tools are available to clinicians to help determine the
future risk of medication abuse.
- The diagnosis, intractability, risk, and efficacy (DIRE)
- The screener and opioid assessment for patients with pain (SOAPP) screening
The SOAPP may be more accurate in predicting risk of abuse.
If the decision is made to start opioid medications, this can be viewed
as a “trial of therapy.” If functional goals are not being achieved,
side effects are limiting, or there is evidence of aberrant use,
the trial of therapy should be stopped.
Opioids
Goals of office visits
- Monitoring ongoing treatments
- Monitoring medications for side effects
- Helping the patient stay engaged as an active participant
in his or her care.
- One tool that can be useful in this process is the SMART goals.
Goals of Visits
Worsening of Pain
Refracory
Pain
- First step is reevaluating the diagnosis and making sure
no new red flag symptoms are present.
Then consideration should be given to a change in
therapy, additional workup, or specialist consultation.
Consider a psychology referral if a patient has
completed one treatment course and still has significant disability or high levels of psychological stress
KEY TREATMENT
Key Treatment
- An initial treatment approach should include
- Information on self-care
- self-care information should include instructions on how to best remain active
- Course of physical therapy
- Manual therapy
- Acupuncture
- Acetaminophen is the first-line medication choice with
- NSAIDs and weak opioids being second line.
- Consider a tricyclic antidepressant for patients with
persistent or refractory pain
- Opioid medications have been shown to improve pain but
have not been shown to improve functional measures
more than other analgesics