Among the most common reasons for seeking medical care , low back pain is best addressed when primary care and specialty providers work collaboratively. To help end the cycle in which patients go from one potential solution to another without finding relief, physical medicine specialist Patricia Zheng, MD, breaks down the evidence to illuminate which signs indicate the need for referral, whether imaging studies actually help, and techniques to meet patients’ immediate and longer-term needs.
My name is Patricia Jiang. I'm a assistant professor here uh in the department of orthopedic Surgery at UCSF. And perhaps a little bit contrary to expectation. I am not a surgeon by training. I am a psychiatrist. And so along with doctors about Devran Connor O. Neal and Peter woo re comprise of the non operative spine service. And in the surgical department we provide a variety of services. And this includes doing some diagnostic and therapeutic procedures. This includes E. M. G. Nerve conduction studies. So tests that utilizes a little bit of electricity to study the health of patients, nerves and muscles. So two mg nerve conduction studies we are able sometimes to objectively find evidence of things like carpal tunnel syndrome, cubicle tunnel syndrome, cervical and lumbar sacral radical apathy. As well as ruling out other findings that may need more neurology evaluations such as purple poly neuropathy or things like myocarditis. We also do a variety of diagnostic and therapeutic injections and some of these are under ultrasound guidance uh such as you know, joint injections, parrot tenderness injections, even para neural injections. And of course we do X ray guided injections such as epidurals to set targeting interventions and the such um like you. However, a lot of the time we in the non operative spine service actually still spend in clinic business with patients. And part of the reason is that it is not easy being a bad patient these days, a lot of our patients present first to their primary care providers. So people like you and they are bewildered by the amount of pain they're having and they're seeking a definitive diagnosis and a quick fix. And while for some patients we are able to help with that for a lot of others, they have no idea that they may be embarking on a rather long and arduous journey. And you know, our back pain patients are not only seeking care through the medical system, some of them are going to acupuncturists and chiropractors and massage therapist recommended by their loved ones. And um even within the medical system, the primary care provider might be helping them access radiology, imaging studies, physical therapist, uh neurologist, orthopedic surgeons, neurosurgeons and pain management specialists. And despite all this care and effort, some of these patients will end up back in the primary care physician office stating I'm still in pain and I still do not know what's going on. And that in essence, is why the non operative spine service was created. Because our job within the department is to how to be almost like, um, you know, some rangers, because we want to help our patients understand better the lay of the land and have some idea of the past that they can take to better understand their pain and seek out some relief from their pain. And we can do this of course without working closely with our primary care colleagues. And so the focus of this presentation really is how do we best partner with all of you to provide the best care we can for these low back pain patients? The first time I actually give this lecture was about four years ago when I first started here at UCSF. And um it was a lecturer to some of the internal medicine residents as well as faculty members. And I remember spending a lot of time putting together an hour long presentation where I really tried to highlight the menu sha of spying history taking and uh Like put together a 15 minute detailed comprehensive examination of spying patient. And I remember going out getting coffee after the presentation with a good friend who I've known ever since medical school. And I was like, Sarah, how was that presentation? Was hopeful. And you know, there are being the sweetest. She was like, oh yes! I learned so much. I didn't even know there were six physical examination for the Sacred Elliott joined alone. But as I was talking soon, Sarah brought up the fact that you know, there are so many wonderful things about being a primary care provider. But one of the things is you're responsible for so much more than the back alone. And so if you had taken 15 minutes in your busy day to examine the patient, I think you wouldn't be able to get through all the other things you do want to cover with a patient from their heart and they're learn health to, you know, preventative health, to everything else that's going on in a primary care physician visits. And so I realized I really needed to do better when I give such talks. And so over the years I've tried to trim down the agenda a little bit more and I'm hoping this will be much more relevant and practical for for your this. And so today I really want to just take the time to talk about some indications for urgent spine work up and how to get that type of work up. I want to review the latest low back pain guidelines from the American College of Physicians, really geared at the primary care setting. And I want to talk a little bit at the very end about what can you expect when you refer these patients to a so let's start with just talking a little bit about what should you get worried? When do you need to urgently refer these patients for work? The answer to really is just these two things. So obviously if you have something that was resulting acute structural instability say this. I'm honestly a lot of a surprise that there are aero science but here they are. Something is going on very structurally with the spying where there has been an entire dislocation and fracture. Obviously things like this should probably not end up in your primary care office. They should end up in the E. D. But if you're suspecting a bad fracture some sort of dislocation, someone coming to you with terrible neurological injury that is not you know this is urgent work up go to the E. D. Another more subtle occurrence might be something like a cada coin a syndrome. So again I remember in the low back and this is the standard of you from the side we're looking at bones were looking at discs. Were looking at the end of the spinal cord. We're looking here at the kata coin the collection of nerve roots and these are the nerves are eventually going to go down your legs and to supply legs to supply strength and sensation. So some people can develop a very large disc protrusion that literally is impending on all these nerves. And that could be called a Coiner syndrome resulting in about our bladder dysfunction, severe pain, numbness, weakness down the legs, saddle anesthesia so they cannot feel when they're wiping in the peroneal area. Those surgical emergencies they need to go to the E. D. Of course sometimes within people do the easy just because their home maybe on friday night and the clinic is about it closed and these patients are not able to manage your pain. So I think more commonly than actual structural instability where pathology like caught up in a center which I'm going to cover in a little bit is not very common. Um What we usually send two people to the E. D. For is if they really had intractable pain and they are not able to seek care. And so sometimes they end up in the E. D. Just because we need to somehow make it more manageable spying urgency. So kind of more things we want sooner follow up may include onset of neurological changes that are not that catastrophic. Right? So weakness that's like a four out of five where numbness that's affecting function. Um These findings may not need to go to the E. D. Um What we would want to do is for them to follow up with a surgeon preferably in kind of a quick expedited fashion so that if the patient does not get better quickly, then we will have a surgical option. And the reason for that, as you can imagine is if there is terrible nerve pinching in the low back, that's causing weakness and numbness. We may want them to see a surgeon because we do not want the nerves to be compressed for too long because there are some studies which show the longer the nerve is compressed and the studies vary about how long we should let them get continually compressed. But if it is too long that we do worry that even after decompression they may not have full return of function. And so um there's many ways you can do this. Hopefully you have some accessible providers that you can urgently get these patients into. I reach out to our spine center scheduling team and this is what they recommended for me if anyone needed to get them into one of our spine surgeons in an expedited fashion, we have an email that people can directly email and mark it urgent. And those emails are read daily and we'll be able to contact you and where the patient to schedule or if you fax it, this is actually our back line backs, that's direct and you mark it as urgent, then the scheduling team can get these patients in for an urgent evaluation. So most of our patients, as you can imagine, do not fall into the categories I just outlined. And so I wanted to take some time and discuss some of the recommended guidelines out there, especially the ones that are relevant to the primary care setting. And you know, I do want to again take a step back and say overall, most of the patients that appear to a primary care physician for back pain would get better regardless of treatment just with time. And this is something that was emphasized in a joint clinical practice guideline put out by the American College of Physicians with American pain society. Um it's a great series. A lot of my next slide are from articles in this exact one by Chou and colleagues in 2007 or in subsequent ones where they kind of delved into um even more detail about certain topics regarding primary care manager, low back pain. And so one thing I did was I tabulated some of the reasons why we are worried about back pain patients and the reasons probably would be to avoid missing diagnosis such as this. And what I did in this table for you is I outlined some pathology that we would be obviously more worried about and want to make sure we know about. I tabulate the prevalence of these conditions, which if you just looked down this column, they're not very highly prevalent conditions at all. I discussed some of the history and physical exam findings you might want to watch out for and then some of the imaging and other studies you might want to think so. You know, we're always worried and I have patients who come to me worried that they might have a cancer cause of back pain. This is honestly not very common, especially in the primary care setting, where only .7% of the patients presenting with terrible back pain have eventually end up with a diagnosis of cancer. The things that might prompt you to think about this obviously would be things like weight loss fever age, which in one study was actually just greater than 50. But the number one factor that might make you want to think that there could be a cancer cause of low back pain more is actually a history of cancer. And the positive likelihood ratio of finding cancer in the spine with acute severe back pain. Uh if you do have a recent history of active cancer is 14.7 and that's actually a lot higher than even unexplained weight loss or failure to improve or age older than 50. Um You know, you could consider X rays mris may be more helpful and some people have actually done. Some research will show that screening with the E. S. R. Or maybe a Crp can be helpful because if those lab values are normal than suspicion for cancer ideology will be lower. We worry about compression fractures, they are somewhat more likely than, say cancer. Obviously you've been springing this more for in patients who are older and who have existing history of osteoporosis. People worry about spinal infections and there should be a suspicion for this. There's a history of fever, ivy, drug use, active infection, other areas of the body that's poorly controlled. But again you see it's only .01%. It's not very common. I've had recently a handful of patients whom I eventually found out I had ankle losing spondylitis. Um Risk factors for this will be family history. Um It would be kind of back pain that's associated with a lot of stiffness. These patients wake up with hours of stiffness so things you can do. X rays can sometimes be good screening tools but I'm also running some room to logical laps right. Yes. Are c. r. p. h. l. 27 Spinal stenosis 3% in the primary care population much higher. In my specialty clinic you're looking for craddock a Tory features. So these patients often say I'm okay if I'm sitting down and lying down but if I stand up and I'm trying to walk the pain can get quite debilitated and I need to sit down and stop and only then can I get some relief. And of course I just mentioned you know then we really don't want to miss because studies have shown that you really want to urgently where at least semi urgently decompress these patients Would be caught a coin a syndrome very very rare in the primary care setting .04% you're looking for again the bowel bladder changes, data, anesthesia weakness. And the thing is a lot of these patients will tell you they're having urinary retention and there's actually been one study that your patient does not have urinary retention. The probability of Kata coiner syndrome is actually very low as in one in 10,000. So that's always something I asked if I have a suspicion for possibly harlequin a signal whether they're actually having urinary retention. Um I love this updated guy lying again by the pro team in 2011 that highlights kind of you know, if people present with these findings, what type of immediate imaging would you need and I leave this table for you to kind of Peru's and um I'm happy to send you some of the citations. But you know for a lot of the patients who present to your clinic with acute back pain, you may not need to get an M. R. I. As per the guidelines in the immediate setting. And part of this is you're gonna maybe find out that it's gonna be hard to get insurance approval for this because the insurance approvals also are based on the guidelines set by these large societies. But the other thing and sometimes I use this to talk to patients. Um you know, they're having some studies. These two in particular which have shown that early imaging do not result in better outcomes for patients and in fact they can be related with higher disability. So some patients when they find out that they have AIDS related changes in the spine, they actually do worse. And so, you know, for me, I do not require at Emory for to see a patient in clinic. I'd rather see the patient discuss it. And if we need to get an MRI then I would like to follow up with my patients quite soon after so I can set them a, you know, I can set their mind at peace that there are very common age related changes associated in the spine and they do not need future intervention and surgeries and may not dispose these patients to chronic pain. And the thing is I kind of alluded to a lot of times after we get an M. R. I. We see a lot of age related findings in the spine. But 85% of the patients that prime uh that presented the primary care providers, we never end up with a very single definitive diagnosis. So they are eventually termed non specific low back pain. And so for these patients we really just go through the gamut of treatments in order to try to find the them the best relief from the least invasive such as physical therapy, escalating to maybe medications and injections and surgery. And so I really like how the A. C. P. Also put together a clinical guideline a series about non invasive treatments that are recommended. An evidence base for acute sub acute and chronic low back pain. You see that you know for acute sub acute low back pain up here the first line treatment will be um you know, heat, eyes, acupuncture, manual manipulation. Um We can try things like anti inflammatories and muscle relaxants for patients that go on to have chronic low back pain, exercise, multidisciplinary rehabilitation, what I do, that's the most important. I'm combined with anything else the patient will be interested in in terms of acupuncture yoga, um chiropractor tree and for this not be enough. Then we can consider things such as insects or traMADol or deluxe city. And the thing that you know, I don't want you to think that a low back pain is destined for a lifetime of continued symptoms. You know I do want to emphasize for some of these patients a little bit physical therapy and time already help to heal the back pain. And sometimes if that's not enough, the interventions can be helpful. And of course for its very certain what the back pain is coming from, where if they do have neurological deficits, then surgery would be indicated and can have great um, outcomes. And the thing that I like to emphasize my patients is that overall the body is capable of great healing. And a lot of the things that I'm offering patients is just to help speed up the recovery or manage their symptoms there so that their body can heal itself. And so I have here some cuts of memory of a very sweet farmer from the central valley and he came to me because all of a sudden he was developing right block and groin pain. And I took a look at the spine and this is the sagittal cut from the side. And this is the actual cut where I'm striking to his belly. And you can see because I give you an arrow sign here that there is a pretty noticeable dis carnation here on the right side that is concordant with for his symptoms would be. And if I were to look a little bit above where I was and a little bit to the side of where I was, you can see the disk. Our nation even extend into this area, which is where the nerve is basically coming out before it's gonna come and innovate that growing area and the anterior side. And um, we eventually ended up doing some physical therapy and the injection and the patient was actually doing really, really well. Um, but 11 months later he started to have some return of back pain. Um We got another imaging and you can see this is the L. Five S. One because this is where he actually had prior surgery. But when I went back and looked at that same L. 12 disc, that disk has basically disappeared. You know the disk, it doesn't go back into its parent disk. But even a large discrimination like what I showed you before and it's no longer a present here. They sometimes can resort. And so what happens is the body recognizes this is somewhere it shouldn't be and actually choose it up somewhat. And so what can only this time we got the M. R. I. And we started a patient on some anti inflammatories and his symptoms actually contained uh entirely disappeared. And likely is because you know, he might have tweaked his back. But right now there's no more nerve compression. And cities have shown like this one by Maine where he looked at 48 patients was quite noticeable discrimination. But they followed them out with serial imaging that 31 out of the 48 had more than 75% decrease in the size of the discrimination. Um about 18 to 40 months out. And in fact, what's really interesting is that the larger the disk, so here we have in this road large disks, um the more likely it was that the disk will be resolved. So sometimes I look at someone's, this gonna be like, wow, this looks very large and you're having a lot of dysfunction. But as long as your neurological impact, it is okay to try non operative treatment. And perhaps I'm even a little bit more optimistic, especially in a younger patient that this might get resolved. And the one other good news is uh this is a Japanese study that was performed in 1996 and you can see that even if there is no change in M. R. I. So no change in M. R. I. Um out of these 28 patients that they followed serially over time, 15, only 15 of them had worsening outcome requiring surgery for 13 out of the 28 core. The M. R. I didn't show any changes in the disk at all. Third thing of them actually did great and was avoid able to avoid surgery and have a significant improvement in their simple and so um you know uh what I like to tell my patients is that sometimes especially if you're not having an urgent indications for surgery, if you're not having neurological deficits are persisting. We do want to give you some time and see if your body can heal and if you're not getting better with this time. And some of the conservative treatment we first talked about that evidence based at the beginning of this presentation then um we're happy to see you in specialty and so I would like to end a little bit with when should we refer low back pain patients are special And sometimes you know patients come to me and they've already had a very very thorough work up by their primary care physicians where you know this patient was a 41 year old male. He's been having quite severe left lateral thigh pain, left lateral leg pain going to the foot. The M. R. I. Demonstrated a large left L. 45 disc. Our nation that was pinching the nerve both centrally in the lateral recess as well as outside where the nerve was actually coming out. Um He could not tolerate physical therapy here and knew he wanted. The injection patient came to me. These are pictures that we actually take from the X ray guided injections so exactly where the medication is flowing which is into this general area around uh where the nerves are getting pinched And you know um definitely happy to see these patients. But we're happy especially in the non operative service to see patients. I may not need surgery. Right more recently I had a 56 year old male had sharp paying down the right leg the disk, the M. R. I just show a pretty noticeable disk that's pinching the nerves. As you can see. You know here are the nerves on the left side. The nerves on the right side will be where the these discs are. But the patient had done really well and the pain and weakness had pretty much resolved. But the patient still wondering, you know, what's going to happen now is they're gonna come back? What do I need to do? How to program to prevent this from worsening? We're coming back and so we're happy to have a discussion with those patients and kind of give them our understanding of the literature and what are the options. And you know, I'm even happy to see patients who are not having terrible dysfunction, but want to talk about preventative issues because all of you guys are engaged in preventative care. And I do think cancer prevention sometimes is much better than a pound of treatment later down the line. So we recently had a 42 year old female who had scoliosis was raising. Her youth is actually not a bad curve now at all. But she has ongoing uh, episodic back pain. um and she's not having terrible pain now, but wants to get pregnant and wonder what she can do to kind of get her body ready for. Happy to see that. And, you know, eventually we're here to help, Right? I'm gonna be honest. Um not my favorite type of patients, you might have some yourself, some patients that come and it's almost hard to know where to start because they have paying a numbness everywhere, both sides down the legs, down the but um but you know, that's why we're here. We're happy to take a look at these patients, see if it's coming from a final origin, see if there's any way we can try to alleviate their pain. We often work closely with primary care providers and also our pain management colleagues to try to manage these patients as best as we can in a multidisciplinary way. So um I really like this cartoon, you know, it helps me to remind me that I'm not, our patients are straightforward and some of them needs a little bit more counseling than others. Um but that's why we're here and we're not only here now in SAn Francisco um you know the Orthodox department really we are trying to send providers out to where our patients are. So now we have satellite connects in SAn Matteo where I go once a week we have satellite clinics in Berkeley and we're going to have 1/5 member of our team joining soon and she will be primarily based in marin. So if you have any need um for non operative spine service, I began put our names down here. These are our regular contact numbers and facts numbers for any urgent referrals that you might want us to take a look at, feel free to email us. That goes directly to the scheduling team, as well as fax us and mark it urgent. And we'll be happy to expedite the follow up with either one of us who want our surgeons if needed.