Nonoperative Spine Care for Back Pain

Educational Objectives

The goal of this program is to improve the diagnosis and management of common spine conditions. After hearing and assimilating this program, the clinician will be better able to:

1. Evaluate for common spine conditions that qualify for nonoperative treatment.
2. Diagnose common spine conditions.
3. Recommend appropriate physical therapy regimens based on disease and patient characteristics.
4. Prescribe pharmacologic interventions, such as medications and injections, to manage spine conditions.
5. Identify emerging novel techniques for management of spine issues.

Summary

Spine conditions: diagnosis — multifactorial (difficult to accurately diagnose); abnormalities identified on magnetic resonance imaging (MRI) are often inconsistent with the pathology described by the patient; consolidate data from imaging studies, physical examination (PE), and medical and treatment history to make an accurate diagnosis; patient history and demographic information are the most important aspects for diagnosis; age and the presence or absence of radicular symptoms significantly influence diagnosis; intervertebral disc issues are common in young patients, whereas older patients are more likely to have arthritic or joint-related spinal issues; spinal issues have bimodal distribution and are difficult to diagnose based on imaging alone, despite the correlation between imaging abnormalities and symptoms

Discogenic low back pain: presentation — pain in the lower back may extend to the buttocks and worsens with prolonged sitting (increases axial load on spine without permitting proper weight distribution to legs); often worse in the morning and painful during transition and forward flexion/lifting, as this puts increased strain on anterior columns of the spine; pain is intermittent and episodic and improves with age; common in young and healthy patients; pain is primarily axial and does not radiate down the legs; diagnosis — PE might reveal paravertebral muscle spasms and pain in range of motion (forward flexion) but is otherwise unremarkable; x-rays are often normal or may reveal loss of disc height; MRI typically shows disc degeneration, eg, loss of disc height and disc hydration (dark spot on T2-weighted imaging), annular tear (bright spot) in outside layers of the disc, and/or Modic changes

Facet arthropathy: presentation — chronic pain in the lower back with a band-like distribution that worsens with twisting and transitions; may present with arthritis in multiple joints; impacts the facet joints in the posterior elements of the spine; common in older patients; diagnosis — PE may reveal positive facet loading (test is not particularly sensitive or specific) but is primarily helpful for ruling out diagnoses, eg, sacroiliac (SI) joint problems, pain from hip joint, or a compression fracture; MRI likely reveals facet joint arthritis, osteophytosis, joint-space narrowing, joint effusion, and acute inflammation (increased short-TI inversion recovery [STIR] signal in joint)

Pars fracture (spondylolysis): common in young athletes, especially gymnasts; presents with back pain; challenging to treat and often heals poorly; may be a congenital defect; use MRI to detect increased STIR signal in acute abnormalities (compared with chronic defects that may be congenital); treat with rest and bracing; differential diagnosis includes gross spondylolisthesis associated with spondylolysis, which can cause nerve injury

SI joint pain: presentation — severe pain in the lower back and buttocks; common in older patients following spinal fusion; diagnosis — imaging is not useful unless recent trauma rules out sacral insufficiency fracture (use MRI); PE is gold standard for diagnosis (requires 3 positive provocative maneuvers)

Provocative maneuvers: FABER test — patient is supine with one leg fully extended while the other is abducted and flexed and externally rotated at the hip; increase load on SI joint by applying pressure to the medial aspect of the flexed knee and the contralateral anterior superior iliac spine; reproduction of pain indicates a positive test; thigh-thrust test — often performed in conjunction with the FABER test; patient is supine with one leg fully extended while the other is flexed at the knee and slightly internally rotated, with axial load applied downwards toward the hip at the knee joint; distraction test — patient is supine with both legs fully extended; axial load is applied to the bilateral anterior superior iliac spine; compression test — patient is rolled into lateral decubitus position; SI joint is compressed with downward pressure on the ilium; Gaenslen test — most complicated; patient is supine with one leg dangling off the table while the other is flexed at the hip and knee; the patient lifts his knee to his chest, placing load on the SI joint; Fortin finger sign — test is positive if the patient points to SI joint

Prevalence: one of the most overdiagnosed spine conditions; caused by SI joint hypomobility or hypermobility; prevalence increases with age and varies as a result of differing diagnostic criteria; most common in pregnant women, followed by patients who have undergone lumbar spinal fusion (especially longer fusions that extend towards L5 or the sacrum), and patients with seronegative spondyloarthropathy (eg, ankylosing spondylitis)

Axial back pain: commonly confused with issues in joints, eg, shoulder with neck, hip joint with lumbosacral spine, and spinal stenosis, which can present with axial pain; 2 major categories of axial back pain include disc and posterior elements (facet joints, fractures, and SI joint)

Radicular pain: diagnosed with concordant imaging findings on MRI; differential diagnosis includes peripheral nerve entrapment; can be caused by spinal stenosis in central canal or neuroforaminal stenosis; spinal stenosis can be caused by vertical vertebrae subluxation, osteophytes associated with the disc or facet joints, hypertrophy of the ligamentum flavum, cysts, buckling of the ligamentum flavum, synovial tumors, infections, and cysts or lipomas on the facet joints; other causes of radicular pain include epidural disorders, lipoma, angioma, meningeal disorders, intradural ossification, diabetes, tumors infections, tabes dorsalis, and disc herniation; diagnosis — chemical irritation causing pain often cannot be detected on MRI; description of pain (eg, electric sensation traveling down the leg with numbness, tingling) can help determine whether the pain is emanating from the spine

Dermatomal patterns that correspond to irritation of specific nerve roots: L2 nerve root radiates from the back and buttock to anterior groin; L3 nerve root radiates to the anterior thigh and stops at medial knee; L4 nerve root radiates down the lateral thigh, transitions to the anterior shin, and stops at the ankle; L5 nerve root radiates to the lateral thigh and calf into the dorsum of the foot and into the big toe; S1 nerve root radiates down the posterolateral thigh and calf into the bottom and lateral aspects of the foot

Physical therapy: least invasive and most likely to provide long-term benefits; almost universally recommended, regardless of diagnosis; patients should perform exercises daily over lifetime; most insurance companies require ≥6 wk of conservative care (eg, physical therapy) within the past 6 mo before authorizing, eg, injections or further diagnostic tests; core strengthening and stretching can improve a variety of spine conditions; McKenzie method — for young patients with acute disc injury or pain; emphasizes a centralization phenomenon, in which pain originating from the spine often refers distally and, through targeted repetitive movements, the pain migrates back towards the spine; it is a directional preference-guided method emphasized on comfortable positions (how to do maneuvers); most patients with acute disc problem have a directional preference for spinal extension; exercises should be performed in prone position with lumbar extension; general hip girdle strengthening program — for patients with pain in the buttocks; weak hip abductors can cause overuse of the piriformis muscle and hip external rotators, which then must stabilize the hip (leads to pain); treatment focuses on hip stabilization, strengthening, and abduction; McGill Big 3 — recommended for older, frail patients; general core strengthening program (can be easily modified); perform every day; includes basic crunch, side bridge, and bird dog

Other physical modalities: acupressure — involves needle insertions and manipulation with the fingers at specific acupuncture points; back schools — education and skills programs; involve exercise therapy, in which lessons are given to a group of patients and supervised by therapists; include individualized educational interventions; yoga and pilates — provide long-term pain relief; interdisciplinary rehabilitation programs — combine coordinating physical, vocational, and behavioral components of varying intensity and content; more invasive therapies — massage; low-level laser therapy; percutaneous or transcutaneous electrical nerve stimulation; spinal manipulation — includes basic osteopathic manipulation; velocity and movements can vary; traction — pulling to stretch the lumbar or cervical spine; may involve inversion techniques with free weights or a pulley pulling on a harness around the lower rib cage and iliac crest; evidence — suggests spinal manipulation may be helpful for acute low-back pain; interdisciplinary rehabilitation may be helpful for subacute low-back pain; there are inconsistent findings for chronic back pain because of the high variability of modalities and phenotyping back pain; multifactorial and patient-specific

Medications: most analgesic agents have evidence of short-term benefits in patients with lower back pain; acetaminophen (eg, Actamin, Q-Pap, Tylenol) is considered first-line therapy (has a low risk profile)

Nonsteroidal anti-inflammatory drugs (NSAIDs): compared with acetaminophen, NSAIDs have more evidence for efficacy and higher effect size for axial pain; compared with placebo, NSAIDs may be more effective for pain improvement; recommended for acute pain flare; prescribe for 1 wk to decrease systemic inflammation, then use as needed; should not be prescribed for regular use for >1 wk because of the high risk profile (eg, impacts kidney and cardiac health, can cause gastritis and ulcer)

Opioids: less commonly used; ideally limited to acute refractory pain (eg, recent trauma, acute fracture); systemic reviews show no improvement in radicular pain with opioids vs placebo

Anticonvulsants: gabapentin and pregabalin; generally not approved by the US Food and Drug Administration for treatment of lower back pain, with or without radiculopathy; often used to treat back pain with radicular pain; combination of pregabalin plus celecoxib (compared with celecoxib alone) can significantly improve back pain

Muscle relaxants: baclofen, tizanidine, and cyclobenzaprine are commonly prescribed in patients with back pain and muscle spasms; largely experimental; there is insufficient evidence available

Systemic corticosteroids: there is no evidence supporting efficacy in treatment of spine conditions with or without radicular pain; compared with placebo, steroids do not provide more improvement in pain; associated with significantly increased risk for adverse events, yet are commonly prescribed

Caveat: it is difficult to determine which medication is most appropriate because trials typically have involved mixed groups of patients with nonspecific back pain with or without radicular pain, representing numerous diagnoses

Injections: targeted therapy with various procedures designed to address specific problems; most common injections are epidural steroid for radicular pain and radiofrequency ablations for pain from facet or zygapophyseal joints; SI joint — the third most common site for injection; performed under fluoroscopic guidance (gold standard; ultrasound guidance is an option); steroid is directly injected into the joint, targeting the inferior aspect of the joint; there are 2 joint lines, with the medial joint line representing the posterior aspect of the joint; fluoroscope is obliqued contralateral to the targeted joint until the joint lines overlap/intersect to form a target; 10% of patients require ipsilateral oblique; check the depth on lateral view and use anteroposterior view to inject contrast, filling both joint lines; flow to superior aspects of the joint may be poor if there is profound osteophytosis; joints can hold ≈2 mL of fluid; use a concentrated steroid solution; lateral branch block — thermal radiofrequency nerve ablation; posterior elements of the sacrum and SI joint are innervated by the dorsal ramus of L5 and lateral branches at S1, S2, and S3; another option is cooled radiofrequency ablation; described techniques include palisade, bipolar, and monopolar; piriformis muscle — pain in the piriformis muscle of the buttock caused by hip abductor weakness; steroid can be directly injected at myotendinous junction around the tendon using ultrasound or fluoroscopic guidance

Emerging therapeutic procedures: neuromodulation techniques include spinal cord stimulators, dorsal root ganglion stimulators, and peripheral nerve stimulators; basivertebral nerve ablation; targeted botulinum toxin (Botox) for patients with spasticity after a major neurologic injury can be helpful in some spine conditions, eg, piriformis syndrome; percutaneous lumbar decompression — percutaneous procedure that is image guided; with setup of an interlaminar epidural steroid injection, a device is used to remove some of the ligamentum flavum posterior to the epidural space (decreases pressure on the descending spinal nerves); primarily used to treat canal stenosis caused by hypertrophy of the ligamentum flavum; spacer implantation (eg,Vertiflex procedure) — a percutaneous procedure performed under fluoroscopic guidance; interspinous spacer is inserted between the spinous processes and forces the spinous process in deflection, indirectly opening the spinal canal to alleviate spinal stenosis

Summary: back pain and issues that cause spine-related pain require better phenotyping to improve and develop therapeutic procedures; spinal issues are complicated and often represent numerous diagnoses, with overlap between diagnoses; all patients present with imaging abnormalities that must be correlated with their symptoms and findings on physical examination to develop the most accurate diagnosis; the majority of spine care involves managing patient expectations; individualize care by testing various targeted procedures, spinal manipulative activities, physical therapy regimens, and anti-inflammatory medications; surgical procedures are available for most issues, but the effect size is limited (eg, removing part of a disc, inserting hardware)

Readings

Barreto TW, Lin KW. Noninvasive treatments for low back pain. Am Fam Physician. 2017;96:324-327; Chou R et al. Systemic pharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med. 2017;166:480-492; doi: 10.7326/M16-2458; Cohen SP et al. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Rev Neurother. 2013;13:99-116; doi: 10.1586/ern.12.148; Enthoven WT et al. Non-steroidal anti-inflammatory drugs for chronic low back pain. Cochrane Database Syst Rev. 2016; 2:CD012087; doi: 10.1002/14651858.CD012087; Hart E et al. The young injured gymnast: a literature review and discussion. Curr Sports Med Rep. 2018;17:366-375; doi: 10.1249/JSR.0000000000000536; Oliveira CB et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27:2791-2803; doi: 10.1007/s00586-018-5673-2; Paige NM et al. Association of spinal manipulative therapy with clinical benefit and harm for acute low back pain: Systematic review and meta-analysis. JAMA. 2017;317:1451-1460; doi: 10.1001/jama.2017.3086; Patrick N et al. Acute and chronic low back pain. Med Clin North Am. 2014;98:777-789, xii; doi: 10.1016/j.mcna.2014.03.005; Roberts SL et al. Anatomical comparison of radiofrequency ablation techniques for sacroiliac joint pain. Pain Med. 2018;19(10):1924-1943. doi:10.1093/pm/pnx329; Urits I et al. Low back pain, a comprehensive review: pathophysiology, diagnosis, and treatment. Curr Pain Headache Rep. 2019;23:23; doi: 10.1007/s11916-019-0757-1; Yolcu YU et al. Use of hybrid imaging techniques in diagnosis of facet joint arthropathy: A narrative review of three modalities. World Neurosurg. 2020;134:201-210; doi: 10.1016/j.wneu.2019.10.082.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. In his lecture, Dr. Barrette presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Barrette was recorded exclusively for Audio Digest. Audio Digest thanks Dr. Barrette for his cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

NE130501

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.