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20 Articles in Volume 20, Issue #2
20/20 with Peter Staats, MD: The Future of Pain Medicine
Ask the APP: How useful and practical are pain assessment tools?
Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?
Axial Spondyloarthritis: Updated Medication and Imaging Recommendations
CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using A Checklist
Chronic Low Back Pain: Can We Find a Treatment Consensus?
Chronic Pain and Coronavirus
Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.
Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?
Diagnosis Is Everything: Low Back Pain As a Symptom of an Underlying Condition or Conditions
Editorial: From Just Say No, to Say Now and Say Know
Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
Experts Roundtable: Finding a Bottom Line in Back Pain Care
Inside the Potential of RNAi to Target the Etiology of hATTR Neuropathy
Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options
New Migraine Medications: Oral Gepants, Ditan Tablet, and More
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
The Emotional Impact of Chronic Low Back Pain
The Rise in Tianeptine Abuse: Our Next Kratom Problem?
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

Experts Roundtable: Finding a Bottom Line in Back Pain Care

We asked practitioners across the spectrum of pain disciplines to share how they would tackle a hypothetical low back pain case:
Pages 31-34

Approaches to treating low back pain vary across disciplines, so we asked practitioners across the spectrum of pain care, from anesthesiology to physical therapy, to share how they would tackle a hypothetical case. 

The Case

A patient aged 47 years presents with a history of lumbar pain. He is slightly overweight and has experienced recurring low back pain for 2-plus years; the pain is axial with occasional radiation down the left leg and he is now seeking professional care. He has tried OTC and prescribed pharmacological options with temporary relief but wants to move toward other treatment options in hopes of obtaining better long-term relief. Imaging shows moderate multilevel degenerative disc disease and facet arthropathy. He has been referred by his primary care doctor to see a specialist.

Clinical approach responses are below. Roundtable participants include: Ramon Cuevas-Trisan, MD, Tiziano Marovino, DPT, MPH, DAIPM, Stephanie A. Neuman, MD, David M. Glick, DC, DAAPM, CPE, FASPE, John A. Campa, III, MD, and Jack Stern, MD, PhD. See, also, why there is such a lack of clinical consensus on low back pain.

 

The evaluation of this patient requires obtaining additional history, including:

  • the presence of “red flags” that may suggest serious pathology (eg, incontinence, saddle anesthesia,
    nocturnal pain, fever, progressive leg weakness)
  • specific pharmacological treatments previously tried (including opioids and any suggestive history of a substance use disorder)
  • a brief occupational history and effects of this condition on his work performance
  • the patient’s beliefs about what is causing the problem.

    The last point is crucial to better understand the individual’s thoughts about the condition and various management options. Initial questions should be followed by a focused physical exam that, at a minimum, includes:

  • a visual inspection and palpation of the back for tenderness
  • assessment of posture
  • a focused peripheral neurological exam (including reflexes, sensation, and motor testing)
  • assessment of lumbar range of motion
  • the use of special maneuvers such as Straight Leg Raise to test for potential sacroiliac, hip, or other pain generators.

    After ruling out any concerning neurological compromise, the focus should be on physical rehabilitation through an exercise program to address this patient’s specific problems. Initial pain control may be addressed with physical therapy modalities and NSAIDs. However, these approaches should only be used to help relieve the pain in order for the patient to regain some function and engage in an active exercise program.

    Similarly, interventional procedures (eg, epidural steroid injections), acupuncture, and chiropractic manipulations (when indicated and only on a very limited basis) may be used as a “means” to the “end” – that is, active exercise therapy. These exercises, guided by a knowledgeable physical therapist, should focus on core and gluteus musculature strengthening, proper posture, and stretching of any shortened segments, such as the deep hip flexors. Offending bad habits, including poor posture when sitting or lifting, should also be assessed and addressed. A maintenance exercise program should be prescribed for the patient to continue performing on a long-term basis after a physical therapist makes sure that patient is using proper form. The patient should engage in a consistent aerobic exercise routine. Depending on his preferences, active exercising through widely available programs of yoga, pilates, Tai-Chi, and Qigong may be recommended, always de-emphasizing the use of “passive” treatments.

    Finally, it is also important to assess any patient concerns regarding imaging studies. The provider should explain the findings and provide reassurance about how common (and expected) they may be. The use of chronic opioids should be avoided in the vast majority of cases as there is no medical evidence for their efficacy on a long-term basis. This point applies to repeated interventional procedures as well. Surgical management should be reserved for patients with progressive neurological deficits in the presence of anatomical pathology that is concordant with the patient’s complaints and physical exam findings.

This case resembles a typical patient profile in the clinic I serve, where we specialize in non-invasive pain therapies for the musculoskeletal (MSK) system. The majority of our patients present with some form of prior medical workup which may include radiography, MRI, and/or EMG testing. Given what we know about the association between imaging and patient symptoms, these findings are not always informative and, too often, confuse patients and mislead providers. Imaging should serve to confirm and not establish a diagnosis, especially when there is no injury as part of the history. In this case, the imaging may simply be reaffirming age-related spinal changes.

My recommendations often include an upfront commitment to 10 to 12 weeks of progressive resistance exercise with a focus on trunk strength and stability. In the short term, we focus on symptomatic relief targeting localized paraspinal tenderness using modalities such as:

  • phonophoresis (US + diclofenac creme)
  • generalized paraspinal tenderness using pulsed EMF
  • tight (hypomobile) spinal segments using manual mobilizations/HVLA and activator methods
  • muscle tightness/spasm/trigger points using acupuncture/cupping/compression and massage
  • postural faults and poor body mechanics
    with breathing and corrective exercises
  • patient education on fear avoidance/kinesiophobia significant reinforcement of positive behaviors such as compliance with home exercise program, weight loss, and smoking cessation.

    I prefer to blend traditional with alternative treatments based on patient beliefs and expectations. These approaches may include conservative spinal decompression, cold laser, shockwave, and various forms of phototherapy. Patients can be taught useful strategies to mitigate future pain episodes by identifying possible etiological factors, along with factors that maintain and/or amplify the problem. I would also instruct the patient on proper footwear, stretching, and body mechanics for prevention, along with how to use ice/heat and home pain devices to better manage recalcitrant symptoms.

    There should be a focus on de-medicalizing symptoms since it is known that up to 80% of typical chronic pain problems are related to behavioral/lifestyle choices versus pathology. These choices may be modified with emphasis on regular exercise, weight management, stress management, and restoration of proper sleep. A core goal should be to reduce the over-reliance on medications including polypharmacy, something many senior patients present with.

My initial approach, when seeing a new patient, is to obtain a thorough history. In this middle-aged gentleman, I would want more details regarding his pain – does the leg pain follow a specific distribution and are his symptoms consistent with discogenic/radicular pain? Or, is this spondylosis and facet mediated, sacroiliac joint based, musculoskeletal, or of another etiology? What are the modifying factors? I often find patients can give much direction as to their pain etiology by sharing what worsens and improves their pain.

Additionally, I would conduct a thorough physical exam to search for neurological changes and positive provocative measures positive. I would determine whether the obtained imaging is a standard lumbar AP and lateral x-ray, or if advanced imaging is available. If there is a radicular component to the patient’s pain and exam suggests radiculopathy, I would obtain an MRI for further guidance as well.

Once I have a confident diagnosis, I would discuss with the patient all possible options for pain improvement including conservative measures (eg, physical therapy, chiropractic care, acupuncture, massage, pain psychology), medication options (eg, opioid and non-opioid pain adjuncts), injection options, and potential surgical options (ie, do we need to consider neurosurgery referral or spinal cord stimulation?).

In this patient, who has already tried OTC and prescription medication, my initial plan would likely involve referral to physical therapy and discussion of healthy lifestyle (ie, exercise, weight loss, smoking cessation, if applicable). Given the axial nature of his pain, imaging demonstrating degenerative disc disease and facet arthropathy, I may suspect his pain to be facet mediated (recognizing that physical exam and radiologic findings have yielded inconsistent results in correlating findings with facet pain). If I had a high clinical suspicion for facet pain, I would likely offer diagnostic medial branch blocks and, if those are successful, proceed to radiofrequency ablation. If history, exam, or additional imaging provided different information than that presented here, my treatment plan would be curtailed as such.

As far as the presented back examination, facet arthropathy and degenerative disc disease can lead to inflammation of local root, and when it does, my experience is that there will be local muscle guarding at the involved segments (think multifidus muscle spasms) that are either occurring as a result of facilitation of the root directly, or involutory muscle guarding to act as a protection mechanism.

So beyond the provided history and interpreted MRI, it is essential to conduct a visual, palpatory, and provocative examination of the entire region to help identify any clinically relevant features of the problem (eg, spasms; tender points). What symptoms elicited, or resolved, when performing neurological and orthopedic maneuvers? Can that pain response be localized to a particular level?

The next step would be to put the pieces together and decide what might be best for this patient at this time. This approach would include diving more into the patient’s history, including any trialed medications and the patient’s response.

Although rather generic in presentation, it is highly likely conservative treatment is warranted in this instance. Manual therapy may be reasonable. To maximize the potential for clinical effectiveness, such treatment should be determined specifically by the exam findings. The same consideration would be given to what I might consider from an interventional standpoint. In these cases, examinations are required to make an informed judgment as to differing treatment options, such as medial branch versus intra-articular facet injection, or interlaminar versus a transforaminal epidural injection. (In cases where root and facet involvement are suspected, we often think outside the box and combine manipulation with an injection.) In the presented case, if the exam suggests hip or sacroiliac joint involvement, a local injection of the affected joint would seem reasonable.

Patient education on diet and exercise would be recommended as well, as loss of weight may help to strengthen the patient’s core and prevent rapid decline of symptoms. In overweight patients, entrapment of the lateral femora cutaneous nerve is common, and can result in pain numbness and tingling to the anterior lateral thigh, as opposed to posterior thigh for lower lumber/sciatic type pathologies. There are other clinical scenarios where patients present with low back pain that has no significant pathology in the low back and it turns out to the thoracolumbar junction. These patients often receive countless treatments targeting the low back without success and, when the cephalad area is finally treated area, it is like turning off a switch (assuming there is no surgical sequela as well).

Overall, the taking of a patient’s history should be very detailed – it leads the clinician to better know where to look and how best to treat in a highly patient-centered manner.

In my view, the key history points for this patient are his age (47), that he has had recurring low back pain over 2 years with only temporary relief from medications, that there is no mention of any acute lumbar injury or recurring lumbar loading events (eg, recurring heavy lifting), and that his pain is axial with occasional radiation down the left leg. This suggests a gradually progressive process (eg, degenerative or neoplastic) at the L3-4 spinal segmental level (disc and/or facet lesion) or below that level.

Imaging showed moderate multilevel degenerative disc disease and facet arthropathy. If MRI was the only imaging modality, then neoplasm is less likely; however, the presence of facet arthropathy suggests a gradually progressive degenerative process that may ultimately stenose the neuro foramina, leading to nerve root impingement and radiation of symptoms.

No mention is made of any particular neuro-foraminal stenoses (would indicate possible nerve root impingement), disc tears (which could explain axial pain), disc endplate edema (would indicate currently contributing disc lesion and spinal segmental level), or disc osteophyte complexes (which would strongly suggest prior disc rupture and healing). In many cases, these abnormalities are in the “findings” section of the report and not mentioned in the conclusions or impressions—always read the entire report. What is crucially missing here is no functional information regarding, for instance, gait disturbance, focal weakness, numbness, tingling, sphincter integrity, or erectile dysfunction.

To proceed, I would order additional diagnostic tests including bilateral lower extremity EMG and nerve conduction velocity studies and potentially a conventional lumbar-CT myelography. It is remarkable how many times this older, tried and true modality will clarify a diagnostic conundrum when MRI does not. Pending these results, I would consider one of the following interventions: facet steroid injections, epidural translaminar or transforaminal steroid injections, or a lumbar medial branch nerve radiofrequency ablation for facet-mediated pain. Only in extreme cases, would I recommend surgical correction, such as lumbar foraminotomy and facet fusion and/or intervertebral segmental titanium cage fusion. 

See Dr. Campa's additional tips on assessment and treatment for lumbar pain.

 

Provider as Patient: A Unique Perspective from Surgeon Jack Stern, MD, PhD

Dr. Stern serves on the clinical faculty, neurosurgery, at Weill Cornell Medical College, in New York, NY, is co-founder of Spine Options in White Plains, NY, and Author of the book, Ending Back Pain

Ironically, despite diagnosing and treating cases of low back pain for the past 35 years, I am sitting with rather severe back pain as I write this response. My pain began years ago after a “special type” of massage therapist walked on my back. Resulting in severe pain, I ultimately had a facet injection that relieved the pain with long-lasting effect. Recently, I had another massage, which was little bit more aggressive than usual and I believe the same facet joint was disrupted.

In clinical practice, I have seen this situation in golfers and professional tennis players because they torque their bodies and put huge amount of strain on the facet joints.  What I have learned over the years as a practitioner and as a patient, is that it is hard to come by “practical pain management.” In fact, I try to avoid using the words “low back pain” as they tend to be more  descriptive than diagnostic. One does not treat a symptom; one treats a diagnosis.

From a surgical perspective, the most common cause of low back pain is degenerative disc disease (DDD), which we know occurs with age. The diagnosis is frequently made through imaging. There is good evidence that in individuals who have DDD, particularly if it is confined to one or two levels, the use of an interbody cage between the discs to replace the disc, and then screws and rods to keep those interbody devices in place, may be beneficial. In my own practice, I have found this to be true. 

However, in someone who frequently consults as a second opinion, I have found that the indications for fusion have become very “loose” and sometimes the smallest indications of degeneration are used to justify a spinal fusion. In addition, it is quite clear from the literature that the more levels of the lumbar spine that are fused, the poorer the results. It saddens me when I see a patient who is scheduled for a L3 or L4 fusion because of disc degeneration, as in all likelihood the surgery is not going to provide benefit. Spinal fusion may, however, play a positive role in the treatment of symptomatic kyphosis and scoliosis.

Another condition I see often is spondylolisthesis, in which the vertebrae are not aligned, compromising the nerves and making patients symptomatic. Spondylolisthesis can be either degenerative or traumatic. In both instances, there is frequently a positive role for decompressing that area. Regarding “minimally invasive surgery” in general, however, a number of studies show quite convincingly that the results of these procedures are no better and no worse than standard surgery, aside from less post-operative pain.

 

Read a related debate on the use of spinal cord stimulation (SCS) for low back pain from AAPM 2020 featuring Dr. Neuman and Dr. David Provenzano.

Last updated on: April 8, 2020
Continue Reading:
Chronic Low Back Pain: Can We Find a Treatment Consensus?
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