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Low Back Pain: Richard A. Deyo, MD, MPH, discusses the clinical examination for low back pain.
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Low Back Pain: Richard A. Deyo, MD, MPH, discusses the clinical examination for low back pain.
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Upload Date:
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives section. Today I have the pleasure of speaking with Dr. Rick Deyo about a condition most of us experience at some point in life, low back pain. Dr. Deyo, why don't you introduce yourself to our listeners. >> Yes. Hi, this is Rick Deyo. I'm a Professor of Medicine and Family Medicine at Oregon Health and Science University. >> Dr. Deyo, what do we know about the prevalence of low back pain and the common diseases or conditions associated with low back pain?
>> Well, low back pain is a symptom that's nearly ubiquitous and most of us will have it at some time during our lives. Best estimates are that at least two-thirds and maybe 80 percent of us will have back pain at some point as adults. Happily, most of the episodes of back pain are short lived and only a small fraction actually go on to become chronic pain. The unfortunate thing, I think, for us as physicians is that perhaps a majority of the time it's very difficult to make a very precise pathoanatomical diagnosis, and we often end up with a fairly vague and nondescript diagnosis of back pain that's very nonspecific.
However, there are a few things that we're concerned about, important neurologic deficits that might point to a herniated disk or spinal stenosis. We always are concerned about underlying systemic diseases, the most common of which is probably metastatic cancer. So all of those things are running through our minds. I think age becomes important for some of these conditions. Certainly for older adults, spinal stenosis and spinal compression factors become an important consideration for back pain, even though those are quite unusual in younger adults.
>> Are there important demographic characteristics? You mentioned age. >> Yeah, the age is important. There doesn't seem to be much difference among genders. Men and women seem roughly equally susceptible to getting back problems, and I think probably the most important demographic difference really is the age. >> Which history and physical examination findings are helpful when assessing the clinical significance of low back pain, and which findings are not helpful? >> Yeah. Well, I think probably the most useful initial question is whether the patient is having back and leg pain, or back pain alone.
Certainly the patients who have back and leg pain, especially pain that radiates below the knee, are patients where we have to be concerned that there may be nerve root compression, and most often that is a result of a herniated disk or spinal stenosis, although other things can cause that. So I think finding out first if there is pain, numbness or tingling that radiates below the knee is an important first question.
The distinction between patients who have nerve root problems from herniated disks and spinal stenosis can sometimes be challenging, although patients with herniated disks are usually younger, patients with stenosis are usually older. And patients with spinal stenosis usually report that their symptoms are better when their spine is flexed, typically in a sitting position, and their pain is worse when they're standing or extending the spine. And in contrast, patients with herniated disks typically report that they're better when they're standing and the pain is worse with spine flexion or sitting.
>> Are there findings that are not particularly helpful? >> Well, there are a number of physical exam findings that aren't particularly useful that are commonly recorded. We've done studies that examine the reliability of things like muscle spasm or soft tissue tenderness, and these are simply not reproducible from one clinician to the next. The same would be true for tests of sacroiliac dysfunction, which don't seem to be terribly reproducible, nor do they correlate well with known pathology in the sacroiliac joint.
And finally, range of motion has been one of the traditional measurements that's often reported in studies of back pain, but diagnostically that seems to be not terribly specific, and maybe useful for monitoring therapy, but probably not so much for diagnosis. >> Overall, how useful is the clinical examination in assessing the likelihood of a herniated disk or cancer among patients with back pain? >> Well, those are two very important diagnoses that we'd like to make.
For patients with a herniated disk, the history really is the most important part of the clinical evaluation, and these are the patients who have sciatica, they have leg pain that radiates below the knee. Typically the pain is worse with coughing or sneezing, it's often worse with forward flexion. And the physical examination often reveals limited straight leg raising. And because the most common sites for herniated disks are at the lowest two lumbar levels, these are the L5 and S1 nerve roots that typically are involved, a good screening neurologic examination would be to check ankle reflexes and to check foot and toe dorsiflexion.
Those are the functions that are most typically affected by those nerve roots. Straight leg raising is a sensitive test for herniated disks, but not very specific. And there's a crossed straight leg raising test, that is raising the leg opposite the one with sciatica, and if that reproduces the sciatic symptoms, then that's a very specific test, specific for herniated disks, although not very sensitive.
Most patients won't have that finding. When it comes to cancer, again, the history is often the most important part of the evaluation. Certainly, it's important to ask about a history of cancer, and we sometimes forget that. The most common sites of metastatic cancer to the spine would be the prostate, the lung and the breast. So those are worth inquiring about. Patients who have unexpected weight loss, patients who have pain that's worse at night when they're lying down, those are red flags, if you will, for a patient who may have a higher likelihood of cancer.
>> Could you describe the reference standard tests for low back pain associated with herniated disks, with metastatic cancer and with infection? >> Well, for all of those conditions perhaps the best single test, at least in clinical practice, is the MRI. MRI is quite sensitive for herniated disks and for metastatic cancer and for infection, and is probably the test of choice.
In some research studies it's been important to try to verify, for example, a herniated disk with surgical findings. The problem there, of course, is that we don't do an operation on patients with normal imaging just to prove that they don't have a condition. So there's a, if you will, a verification bias there, but the gold standard, in a sense, would be the findings at surgery. Or in some cases simply the cumulative clinical picture and time course of symptom resolution may be important.
But for those systemic diseases like metastatic cancer and infection, I think MRI is the most important test initially, although in some cases biopsy or aspiration may be necessary to confirm the diagnosis. >> Is there anything else that JAMAevidence users should know about low back pain? >> Well, I guess I would hope that primary care physicians would feel confident that a good history and physical examination can be very effective at helping to rule out cancer or major neurologic deficits and, therefore, imaging is often unnecessary for patients who have back pain, unless the pain becomes unusually persistent or some of these red flags appear in the history or physical examination over time.
>> Well, thank you, Dr. Deyo. >> You bet.
