Low Back Pain Algorithms

[hrmm]

Anyone have any good algorithms/tables for the differential diagnosis of low back pain?

Eg. pain with walking downhill -> spinal stenosis; pain with back extension -> facet joint arthropathy; etc.

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[lobelsteve]

Rock is hot. Sunny.
Rock is wet. Rainy.
Rock is under white stuff. Snowy
Rock cannot be seen. Foggy. Or night. Or both.

 

[clubdeac]

DePalma had some "algorithms":

IDD--> midline pain worse with sitting, flexion, bearing down--->B TFESI x 2-4, if no relief proceed to discogram or FAD. If one or two contiguous levels consider neurosurgical referral. If one contiguous level, neurosurgery or intradiscal treatment. If two noncontiguous levels medication management at which time he would refer out.

Facet mediated pain--> paramedian pain worse with extension/standing---> facet injections x2, if short lived but positive response proceed to comparative medial branch blocks followed by RFA if indicated

SIJ pain---> paramedian pain, worse with sitting, sitting to standing, ttp over sacral sulcus---> SIJ injections x 2 followed by either diagnostic lateral branch blocks vs. RFA

 

[SSdoc33]

algorithms, IMHO, are useless. every patient is different, and they need to be treated based on their history and exam. they are great for insurance companies and people who dont know what they are doing, so they can look at a piece of paper and try to make a treatment decision.

 

[hrmm]

algorithms, IMHO, are useless. every patient is different, and they need to be treated based on their history and exam. they are great for insurance companies and people who dont know what they are doing, so they can look at a piece of paper and try to make a treatment decision.

You gotta start somewhere. Not everyone knows what they are doing from day 1. And a little guidance (although not the hard and fast rule) can be helpful to get to where you apparently are in your career.

 

[Medos]

You can take a look at the book Osteopathic treatment of low back pain and sciatica caused by disc prolapse. This work represents the result of 25 years of treating disc prolapse. Very richly illustrated —nearly 800 drawings, photographs and diagrams— and rigorously documented, the work provides the expert the standards guiding on the research of the lesions and dysfunctions and it describes a large number of osteopathic techniques: HVT, soft tissue techniques, muscle energy, functional techniques, Jones´ strain-counterstrain techniques, spray and stretch and myofascial release techniques. Hope it´s useful!

 

[freddydpt]

Anyone have any good algorithms/tables for the differential diagnosis of low back pain?

Eg. pain with walking downhill -> spinal stenosis; pain with back extension -> facet joint arthropathy; etc.

OK, just to illustrate a point, both your examples lead to pain due to extension, where stenosis and facets can be an etiology of pain... facets can also contribute to the stenosis. This may or may not have an impact on the nerve root depending on how large the facets are and if the growth caused anterolisthesis. There may or may not be instability at the level which can be contributing to pain (discogenic pain - rare in my opinion - or intermittently hitting a nerve root but not seen on MRI). This may also be causing muscle spasms or strain which may be the predominant cause of the patient's pain.

You have to be very careful with "algorithms" because many patients have multiple pain generators. So even in your example, you can see, the "algorithm" did not divide out what caused the patient's pain.

Get really good at physical exam. Learn your facet loading - learn when it is positive, but especially when it is false positive... man this post could go on forever, but I'll hold back for now.

 

[geauxg8rs]

The only algorithm that is ever true in medicine

If it is wet and it aint yours don't touch it

 

[clubdeac]

OK, just to illustrate a point, both your examples lead to pain due to extension, where stenosis and facets can be an etiology of pain... facets can also contribute to the stenosis. This may or may not have an impact on the nerve root depending on how large the facets are and if the growth caused anterolisthesis. There may or may not be instability at the level which can be contributing to pain (discogenic pain - rare in my opinion - or intermittently hitting a nerve root but not seen on MRI). This may also be causing muscle spasms or strain which may be the predominant cause of the patient's pain.

You have to be very careful with "algorithms" because many patients have multiple pain generators. So even in your example, you can see, the "algorithm" did not divide out what caused the patient's pain.

Get really good at physical exam. Learn your facet loading - learn when it is positive, but especially when it is false positive... man this post could go on forever, but I'll hold back for now.

I'm interested in how you differentiate a "false positive" facet loading maneuver

 

[NJPAIN]

So am i

 

[freddydpt]

I'm interested in how you differentiate a "false positive" facet loading maneuver

Many (most) patients have such a weak core, when they arch for a facet loading maneuver, they are co-contracting their extensors reproducing muscle pain. If I'm unsure if it's true positive in standing (in other words, if their site of pain doesn't localize to where I would expect after reviewing the MRI - or if no MRI available and I'm suspecting more muscle) then I have them arch their lumbar spine, palpate the paraspinals and have them relax their back and I support their weight - or if pt is too big, I'll perform the maneuver in sitting. If pain persists then, to me, that is a true facet loading. If it doesn't, then I squeeze the muscle and/or have them flex forward to give resistance to the paraspinals to confirm muscle.

 

[powermd]

Many (most) patients have such a weak core, when they arch for a facet loading maneuver, they are co-contracting their extensors reproducing muscle pain. If I'm unsure if it's true positive in standing (in other words, if their site of pain doesn't localize to where I would expect after reviewing the MRI - or if no MRI available and I'm suspecting more muscle) then I have them arch their lumbar spine, palpate the paraspinals and have them relax their back and I support their weight - or if pt is too big, I'll perform the maneuver in sitting. If pain persists then, to me, that is a true facet loading. If it doesn't, then I squeeze the muscle and/or have them flex forward to give resistance to the paraspinals to confirm muscle.

Agree completely on this.

Patients with painful postural muscles/tendons can have pain with extension and rotation as well. I am more apt to believe this in younger patients whose spines do not feel restricted in ROM when I rotate them. Sometimes they report pain opposite the side rotated to (i.e. stretch pain). In these cases I will often inject the lumbar ES tendon sheath over the sacrum under US, and sometimes the same sheath above the PSIS. I had a female patient in her early 50s who was set for lumbar RF but came back for me to evaluate "severe low back/buttock pain" after the last MBB wore off. She reported the pain feeling "lower" than her usual low back pain, and most aggravated by postural activities (dishes, bed making, vacuuming). 100% relief with said tendon sheath injections. Only question now is do we bother with RF.