Low back pain with a normal xray

1. Acute Low Back Pain
with a normal X-ray
Spiro Antoniades, M.D.
Spine conference
11/11/21

3. 25 yo man acute LBP
After lifting a dresser up
Steps, stiff painful cannot
Put on his socks no sciatica

4. Disabling
Uncertainty: better, worse, chronic,
etiology?
Common

5. Too much treatment, too little treatment, wrong treatment

11. Pfirmann: Spine 2001 Sep 1;26(17):1873-8.

15. Annulus Fibrosus

17. Herring

18. Fine fiber nerve ending staining in a rabbit disc
The outer 3mm is innervated

19. Load with respect to posture of spine

23. Schmorl Node

25. Age versus degenerative changes on MRI on
ASx patients

29. Tae Chi
Yoga
Mindfullness based
Stress reduction techniques

33. Catastrophization: imagery, worst case
scenario, anxiety,

35. reassurance

36. History
Provoke, palliate, quality, region, severity, timing
(onset/consistency/episodes: frequency of and length of episodes)

38. 45 yo man acute LBP
After picking up a pencil
With h/o mild LBP for 20 y

39. Red flag
 Nocturnal pain
 Pain at rest improves with activity
 Progressive neurological deficit
 Suspicious for cancer or infection

42. Inflammation of the disc
Anti-inflammatory: steroids v NSAID (ibuprofen/meloxicam)
Muscle relaxer: valium, Flexeril, soma, metaxalone,
analgesic: Tylenol, tramadol, hydrocodone, oxycodone
Gabapentin, Cymbalta

45. High index of suspicion
 H/O cancer
 Osteoporosis/steroids/immunosuppression
 AS
 10/10
 Weight loss
 IVDA
 UTI/sepsis

46. Intuition
is usually
right

49. 35 year old woman with 7 month history of LBP right
posterior thigh pain with new onset right vaginal numnbess

50. Cauda Equina Syndrome

54. Differential Diagnosis Back Pain
Not from the Spine
 Pregnancy
 Pregnancy with Labor
 Menstrual Period
 UTI
 Abdomen (cholecystitis, pancreatitis, aortic
aneurysm, peptic ulcer disease, nephrolithiasis,
pelvic inflammatory disease, diverticulitis)
 Inflammatory Arthropathy: Ankylosing
Spondylitis, Lymes
 SI joint: infection, AS, hyperparathyroidism
 Depression

57. Pancreatitis

58. Labor
Pregnancy
Menstrual period

62. AAA

68. AS

69. Sacroiliitis
 30 year old man with LBP HLAB27+

71. Synovitis, subchondral edema, iliac side more common

73. Brown tumor

75. Psychosocial Issues
 Fear
 Anxiety
 Financial problems
 Anger
 Depression
 Job dissatisfaction
 Family problems
 Stress

76. DSM-IV TR criteria for Major
Depressive Episode (5 Sx for at
least 2 weeks)
 1. Depressed mood
 Markedly diminished interest or pleasure in all or
almost all activities
 >5% weight loss or gain, change in apetite
 Insomnia or hyper somnia
 Psychomotor agitation or retardation
 Fatigue or loss of energy
 Feeling of worthlessness or inappropriate guilt
 Diminished concentration or indecisiveness
 Recurrent thoughts of death or suicide

77. 66 wf LBP urosepsis(E Coli blood and urine) claustrophobia

81. Occult Fracture
75 wm severe! LBP S/P cement 6 months ago
65 year old man with
Recurrent LBP that is
severe

84. Tumor: vertebral body
 Vertebral body met

85. Epidural metastasis

86. Thanks!

92. 48 year old man with three week H/O severe neck pain with no improvement with
2 weeks of prednisone/narcotics/muscle relaxers

95. 75 year old man severe neck pain

99. 48 year old woman severe LBP for six months despite swimming,
NSAID, PT, muscle relaxers, opiates, injections

101. 21 male severe! neck pain for three months with multiple ER
visits for narcotics/physical therapy visits/feels clumsy/ three
day history of difficulty walking following fall