Low Back Pain

In this episode of PodMD, Specialist Pain Medicine Physician and Specialist Anaesthetist Dr Liam Ring will be dicussing the topic of low back pain, including what low back pain is, how a patient would typically present, the risks of the condition, when to refer and more.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    Today I’d like to welcome to the PodMD studio Dr Liam Ring

    Dr Liam Ring is an Australian trained Specialist Pain Medicine Physician. He has a special interest in multidisciplinary and interventional pain medicine.

    Today, we’ll be discussing the topic of low back pain.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Liam, thanks for talking with us on Pod MD today.

    Liam: Thanks for having me.

    Question 1
    The topic of today’s discussion is low back pain. Can you describe for our listeners what low back pain is?

    Liam: Well, I guess most practitioners would be quite familiar with low back pain, I guess the better way I would describe it as lumbar spinal pain. I mean, basically it’s pain of a persistent nature anywhere in the lumbar spine or felt by the patient coming from the lumbar spine, going into any part of the lower body. But also in some instance, I guess can also refer up their spine.

    Question 2
    How would a patient with acute low back pain typically present?

    Liam: Well, I guess they’d generally be describing a pain that’s been disabling them or irritating them in some way, uh, for a protracted period of time. Generally it’s associated with a lot of frustration, and distress.

    Question 3
    What are the risks of the condition?

    Liam: I mean the primary risk for any practitioner is to make sure that we rule out reg flag pathology. Um, it’s important to note that the incidence of that is very, very low, you know, we’re talking less than, or approximately 1%, uh, and it’s important. Any person with a new presentation of lumbar spinal pain, we need to rule those things out. Um, the main causes or pathology that we need to be ruling out is cancer fractures, uh, neural compression or some type of inflammatory disorder. Uh, and there’s certain historical features that should tweak our interests. So, uh, if someone has a history of malignancy and presents with new back pain, that’s certainly something we’d have a low threshold for, well, all of these conditions, if someone has a risk for any of these conditions, we certainly need to, uh, have a low index of suspicion for investigating them.

    Uh, so the significant historical feature for patients with a risk of cancer is those that have a pre pre-existing history of malignancy, um, for fracture, it relates to a mechanism of injury. So it has to be a high impact type injury. Um, if they have contusions or abrasions associated with an injury, um, if they’ve, if it’s a high speed motor vehicle accident or a fall from a height particular, particularly greater than about one meter, uh, if they’re an elderly person or if there’s someone at risk of osteoporosis, namely those on a long-term steroids, um, for neurological compression, uh, the one most people are aware of quarter Aquinas syndrome, so altered power and altered sensation in the lower limbs, uh, associated with urinary retention, uh, fecal incontinence, um, and reduced anal tone, uh, but any focal neuropathy, uh, so weakness or reduced sensation in a, in a or myotomal distribution is important. And then for the inflammatory disorder group, um, it’s usually something that’s insidious, it’s usually in the young population, less than 40 years of age and the Cardinal features or stiffness in the morning that is quite severe, that then progressively improves over the course of the day associated with lots of other constitutional symptoms, symptoms like malaise, fatigue, uh, things like that.

    Question 4
    What are the management options?

    Liam: From my perspective, management encompasses, um, first of all, assessing whether or not it is a spinal and referred pain, uh, or radicular pain or red flag associated pathology, pain or pain associated with red flag conditions, red flag conditions, well, you know, there’s good surgical treatments, uh, disease modifying agents or antibiotics, or, you know, surgery to decompress spines. So you really need to get them to the relevant specialists. Um, and they can be cured for radicular pain, spinal pain and referred pain. Um, treatments could be better, uh, or management options could be better sort of encompassed under the umbrella of, I mean, first of all, education and setting realistic expectations and reassurance broadly, uh, then it would be, uh, um, physical strategies, psychological, psychological strategies of which there’s a hell of a lot of overlap.

    Um, and then, uh, interventional options, medications kind of being last. Uh, education, I think is key and reassurance is key for a lot of people with low back pain. Um, all of the guidelines would suggest well reinforce the importance of that, uh, for anyone presenting with any new, uh, like acute or subacute, low back pain. Uh, but whilst the evidence is out there, I think the delivery is not really, uh, being done in the community and that’s because it just takes time. Uh, and there’s not time in emergency departments. There’s not time in GP practices. Um, but if the time is taken, uh, to listen to the patient, uh, and then to educate them about back pain, reassure them that, um, in the case of acute low back pain, uh, the vast majority improve with time.

    Uh, so that should be reassuring to a lot of people. Uh, most people though, you know, want some concrete, uh, strategies to help improve their function. Um, so giving them guidance on graded activity, giving them guidance on slowly returning to normal, um, is the broad advice that’s recommended. Uh, but oftentimes that’s best reinforced by referring them to a physical therapist, like a, physio-therapist like an exercise physiologist who ideally has a little bit more time to reinforce what you’ve already started and to then give them concrete examples on how to exercise and gradually returned to normal, uh, and progress through that, um, with, you know, frequent reassessments, uh, what’s important from my perspective is that you’re picking professionals of like physical therapists that are actually well-educated in pain that can, uh, not just give a patient guidance on exercise, but also give them some education around pain.

    The next psychotherapy, uh, is a tricky one to introduce early, uh, with patients with lumbar spinal pain. Um, but if someone does have a preexisting psychological condition, which in and of itself has been quite disabling, um, acute episodes of pain will naturally them, uh, and trying to encourage them to link up with preexisting providers, uh, would be helpful, uh, or if they’ve never linked up with someone before trying to identify a psychological provider, uh, who has some understanding of pain would be helpful, um, with regards to, uh, medications, the overarching emphasis should be on trying to identify, uh, the simplest combination of agents, whether they be simple analgesics or, uh, possibly even opioids.

    But the aim is to try and temporarily reduce symptoms, to enable an upgrade of activity with an agreed plan to wean them off over a short term. So it’s very, it’s key to communicate, uh, and come to an agreement with a patient about, um, medications only being something in the short term and not something that we rely on in the long term. Finally with interventions, um, for acute lumbar spinal pain and referred pain, or even persistent lumbar spinal pain and referred paint, um, interview mentioned focused on, uh, the facet joints could potentially be helpful or the sacroiliac joints potentially as well.

    Um, so what I’m talking about there is a D innovation of the facet joints or sacroiliac joints, um, in my, my hands and in my experience, this is best introduced in a setting where a person has already been reassured and educated and guided by a multidisciplinary team.

    Question 5
    Are there any instances where surgical intervention is appropriate?

    Liam: So in the event of radicular pain and radiculopathy, um, if a patient’s got quite overt radiculopathy, uh, or severe intractable radicular pain, that would be, uh, the time to consider referring them to a surgeon, uh, and, um, decompression or targeted microdiscectomy, uh, can be quite efficacious in that population. Um, prior to that, though, in terms of, if someone does have severe radicular pain, uh, despite, uh, engagement with a multidisciplinary team and appropriate education, reassurance and guidance, et cetera, um, uh, epidural steroid injection can be helpful in that population.

    So where I was just talking earlier about, with regards to referred pain and spinal pain or referred pain, if they’re optimized from a multidisciplinary perspective, but struggling despite their symptoms, introducing interventions, they’re similarly in a group of patients where they have severe radicular pain, despite education reassurance, uh, they’re still struggling with their symptoms.That’s the time to introduce an epidural steroid injection. And if that does not help, uh, then early referral to a spinal surgeon or neurosurgeon would be appropriate.

    Question 6
    Have there been any developments in management in the last years or are there any in trials or development now?

    Liam: Epidural, uh, spinal cord stimulation, or, uh, dorsal root, uh, stimulation is a modality that’s emerging over recent years. Uh, historically these modalities were only indicated in patients who had persistent lumbar spinal pain and leg pain, uh, following previous surgery. Uh, but there’s been studies done, particularly in the UK of native backs. I E patients with, uh, who have never had spinal surgery, uh, and in, uh, uh, multidisciplinary center there, uh, who does a high volume of stimulation. Uh, they have been getting some quite good results in putting stimulators in patients rather than them going to the expense, uh, and the morbidity and mortality associated with actual, uh, open surgery.

    Question 7
    When should a GP refer?

    Liam: In the setting of acute lumbar spinal pain in the absence of any concerns with regards to red flag conditions. Um, my advice would be that, uh, primary physicians, whether that be an emergency departments or, or in general practice, uh, should be referring their patients early to physical therapists who understand pain well.

    In the setting of chronic lumbar spinal pain, um, assuming that they have already seen a physical therapist, um, if there is, uh, concerns with regards to radicular pain, radiculopathy, uh, MRI scanning an early referral to a surgeon for assessment regarding their suitability for surgery, uh, plus or minus considering an epidural steroid injection before that, or as part of that surgeons management would be the way to manage them. Um, and for lumbar spinal pain and locally referred pain, um, if they’ve been adequately educated, spent time with a physical therapist, but still struggling, I would suggest early referral to a, to a local pain specialist.

    Question 8
    What role does the GP play in the management of the condition?

    Liam: Uh, well, the GP, uh, being the primary care for a patient, I mean, first of all, ideally they’re the, they’re the clinician involved in the initial assessment of the patient with the onset of the condition. Um, but it may be that the patients are presented to an emergency department, uh, either way, if they have presented to an emergency department, I would hope that that patient then returns to their GP shortly afterwards, uh, for early management, um, early on the GP ideally could, uh, be the coordinator of a multidisciplinary team around that patient.

    Concluding Question
    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on low back pain.

    Liam: I mean, we, we all understand the importance of ruling out red flag conditions and that should be done initially. Um, so that’d be the first take home message because, uh, it’s inherent on all of us whilst it’s infrequent. We need to rule that out. Um, if someone doesn’t have risk factors for red flag conditions, uh, the second take home message from my perspective would be to emphasize the importance of education, uh, and reassurance, uh, understanding that that takes time. Uh, but it’s very important, uh, time well spent early on.

    Uh, the third, uh, message would relate to emphasis of management towards self-management strategies, uh, rather than medication interventions, historically medication interventions have been the focus early on, uh, but I would be encouraging, uh, clinicians to try and emphasize, uh, self-management strategies guided by, uh, appropriately trained allied health professionals, uh, with reinforcement and support by medical professionals.

    Thanks for your time and the insights you’ve provided.

    Liam: Thank you.

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.