#368 Back Pain Update with Dr. Austin Baraki From The Curbsiders With Links To Additional Resources

For  outstanding imaging guidance for low back pain, please see the detailed 22-page PDF, American College of Radiology ACR Appropriateness Criteria® Low Back Pain.

For imaging guidance on management of vertebral compression fractures, please see the 27 page PDF, American College of Radiology ACR Appropriateness Criteria® Management of Vertebral Compression Fractures.

In Dr. Baraki’s opinion, motor weakness is a significant finding that should raise alarm, as opposed to paresthesias or radicular pain which are not necessarily as concerning.*

*I [Dr. Wade] will ask the patient to walk on their heels and to walk on their toes to test distal muscle strength. To test proximal muscle leg strength, you can ask the patient to rise from a chair.

For a detailed YouTube video of the neurologic exam of the lower extremities, please see Lower Limb Neurological Examination – OSCE guide (Latest), 9:36, Feb 25, 2015, from Geeky Medics.

In this post I link to and excerpt from The Curbsiders#368 Back Pain Update with
Dr. Austin Baraki: Who to Image, How to Treat, and More! NOVEMBER 28, 2022 By CYRUS ASKIN

All that follows is from the above resource.

 

Back pain is one of the most common concerns our patients bring to us in the outpatient setting.  It’s a lot more complicated than rest, ice, and NSAIDs!  Fortunately, we have pain expert, strength coach, and academic internist Dr. Austin Baraki (Austin Baraki, MD (@AustinBaraki) / Twitter) to help us develop a comprehensive, patient centered approach to help our patients manage their pain and lead healthier lives. Take control of your patients’ back pain!

Back Pain Pearls

  • Perform risk stratification for biomedical conditions requiring urgent imaging or surgical evaluation, as well as psychosocial factors that impact who will likely recover well on their own, or who may require more intensive support. The STarT Back tool is a helpful guide for this.
  • Provide education and advice regarding prognosis and self-management strategies, with an emphasis on more active strategies (e.g., physical activity and exercise) over passive strategies (e.g. rest, massage, etc.).  Explicit exercise prescriptions are more effective than simply telling your patients to “move”.
  • Reserve imaging for suspected serious underlying pathology that would require an immediate change in management, such as severe neurological deficits/weakness, spinal infections, malignancies, or fractures. Radicular pain in the absence of neurological deficits does not require immediate imaging, and is managed similarly to non-specific back pain.
  • Be VERY mindful of the language you use when you discuss back pain with your patients, as the specific diagnostic labels you assign, or the way you explain imaging studies and prognosis can have a significant impact on your patients’ perception of their back pain, their expectations, and their long-term outcomes.
  • The Pain-Calculator can guide evidence-based shared decision making regarding the use of medications for back pain.
  • Many patients believe any degree of pain reflects damage or injury, and must therefore be avoided. Instead, it is important to emphasize that it is not necessary to be “pain-free” before returning to movement and activities the person enjoys.

The first step in evaluating patients with acute low back pain is to risk stratify patients that may have a serious process that necessitates urgent action or may progress and cause serious disability.  This evaluation, commonly framed through the lens of “red flags”, is aimed at determining whether urgent imaging or surgical evaluation is warranted.  When evaluating the patient, Dr. Baraki emphasizes the importance of pre-test probability and environment (for example, a patient with persistent low back in the clinic is different from a patient in the ED following a high-speed motor vehicle collision).   A significant proportion of patients presenting with back pain may have one or more “red flag” features, even though they do not have a serious underlying cause for their back pain.

In Dr. Baraki’s opinion, motor weakness is a significant finding that should raise alarm, as opposed to paresthesias or radicular pain which are not necessarily as concerning.*

*I will ask the patient to walk on their heels and to walk on their toes to test distal muscle strength. To test proximal muscle leg strength, you can ask the patient to rise from a chair.

For a detailed YouTube video of the neurologic exam of the lower extremities, please see Lower Limb Neurological Examination – OSCE guide (Latest), 9:36, Feb 25, 2015, from Geeky Medics.

In the clinic, 90-95% of patients will not have a single, nociceptive source for their pain.  For the primary care clinician, these can be initially classified under the category of non-specific low-back pain (Bardin et al, 2017).

 

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