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Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions

www.tnpj.com The Nurse Practitioner • December 2016 31

ow back pain (LBP) ranks fi fth as the reason pa- tients present for healthcare provider visits in the United States and second as the most common

chief complaint.1 It is prevalent among all age groups, rang- ing from adolescents to older adults.2 The annual healthcare costs and economic losses associated with LBP in the United States exceed $90 to $100 billion.3,4 LBP remains the most common reason for disability among patients under age 45.

The prevalence for continued pain or disability from LBP is 60% to 80% after 1 year.3,4 Patients with a prior his- tory of work absenteeism showed a 40% prevalence for future occurrences.3,4 Therefore, it is imperative for pri- mary care providers (PCPs) to have a clear knowledge re- garding the diagnosis and treatment of a variety of lumbar diagnoses, as patients’ LBP treatments typically begin under their care.

■ Presentation Nonspecific LBP (NSLBP) is typically described as a mechanical type of pain that varies with patients’ physical activity and posture.2 NSLBP is unrelated to a recognizable pathology, osteoporosis, structural deformity, or radicular syndrome.2 It may be related to degenerative changes in the intervertebral disk, facet joints, vertebral endplate sclerosis, or presence of osteophytes and is typically seen among working-age patients.2

Patients with NSLBP experience back pain that is in- creased by changes in position, upon fl exion, and/or with numbness and weakness.4 Pain noted with prolonged sitting is a key factor in differentiating it from lumbar stenosis.5 The association between degenerative disk disease and LBP, based on cross-sectional studies, is signifi cant and typically related to aging and environmental factors.2,4 One study of

Evidence-based practice guidelines for the diagnosis and treatment of

lumbar spinal conditions

www.tnpj.com The Nurse Practitioner • December 2016 31

Abstract: Low back pain remains one of the most common patient complaints.

It can exist alone or with the presence of lower extremity symptoms. Review

of evidence-based guidelines will assist primary care providers in the

identifi cation and treatment of various lumbar disorders in addition to

ruling out specifi c lumbar spinal pathologies.

Keywords: back pain treatments, low back pain, lumbar radiculopathy, lumbar spinal stenosis

By Robert L. Metzger, DNP, APRN, FNP-BC

32 The Nurse Practitioner • Vol. 41, No. 12 www.tnpj.com

Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions

retrospective chart reviews indicated that the presence of midline LBP, located directly over the spinous processes, was associated with an 84% accuracy for degenerative disk disease as the source of LBP.6

LBP with lower extremity pain exists in approximately 25% to 57% of all lumbar cases.7 Lumbar stenosis is typi- cally acquired through degenerative changes or changes from

pathology or prior surgery and is described as narrowing present in the spinal neuroforaminal spaces, lateral recesses, or central canal, but typically refers to narrowing of the central canal.5,8 Although narrowing of the neuroforaminal canals or central canal is present, there is a poor correlation between the degree of narrowing and symptoms, as some patients remain asymptomatic.9

An important factor to consider when discussing patient symptoms is that the canal space increases in fl exion and decreases in extension and loading; therefore, patients with lumbar stenosis tend to do better with forward fl exion, such as when pushing a grocery cart.8,10 Degenerative lumbar stenosis is uncommon for individuals under age 50, and the diagnosis and severity are largely dependent on the history and physical exam.10

Symptoms of lumbar stenosis include wide base gait, presence or absence of LBP, and neurogenic claudica- tion.5,9-12 Neurogenic claudication is described as radiating pain into the bilateral or unilateral buttock, anterior thigh,

or posterior pain down the leg to the calf and sometimes to the feet that is worsened with standing, walking, or extension and improved with sitting and bending forward.5,9-12 Neu- rogenic claudication can include a sensation of weakness and/or heaviness, paresthesias, fatigue, hamstring tightness, and occasional nocturnal cramps.9 Neurogenic claudication is the most common fi nding for lumbar stenosis and can

severely impact patients’ functionality, affecting their quality of life.12

Lumbar radiculopathy is defi ned as pain radiating from the lower back into the legs, which is the result of disk ma- terial beyond the disk space margins causing nerve root impingement.13 Lumbar disk herniations are the pri-

mary cause for lumbar radiculopathy. Symptoms of lumbar radiculopathy include radiating pain from the lumbar re- gion, which is primarily unilateral and greater than symp- toms of LBP. Some patients with radiculopathy only experi- ence leg pain without any back pain.

Patients can also experience pain that is worse during rest or in the night, numbness or paresthesias that follows a der- matomal distribution (mostly along L4-S1), muscle weakness typically present below the knee, and possible patellar or Achilles refl ex changes.13,14 Poorer prognoses are noted in patients who have LBP greater than or equal to their radicu- lar symptoms.15

■ Evaluation of LBP: History and physical exam Providers should classify NSLBP from back pain with ra- dicular symptoms based on symptoms, including whether the pain is above or below the knee.2,15-17 An accurate his- tory and physical exam are the most appropriate tools to determine this. The history should include the patient’s personal description of symptoms, including specifi c loca- tions (midline, lateral, bilateral) and the degree of pain on the pain visual analog scale.2,15-17 It is important for provid- ers to ask patients regarding the presence or absence of leg pain, whether unilateral or bilateral, because approximate- ly a quarter to one-half of lumbar cases present with lower extremity pain.7

Determining leg pain can also aid in diagnosing between lumbar stenosis and radiculopathy. Other history items to consider include diffi culties with activities, including walk- ing, sitting, standing, fl exion, and extension; sensorimotor defi cits; aggravating or alleviating factors; and prior benefi - cial or failed treatments, especially in response to specifi c medication regimens.2,15-17

The physical exam should include inspection and palpa- tion of the spine for alignment, tenderness, and/or erythema or edema.18,19 Motor assessment should include the patient’s

The association between degenerative disk

disease and LBP is signifi cant and typically

related to aging and environmental factors.

Muscle strength testing 18

Muscle strength is graded on a scale from 0 to 5 follow-

ing the criteria listed below. Normal strength should be

graded as a 5/5, whereas no muscle contraction would

be a 0/5.

5 Normal strength (full resistance)

4 Movement possible against some resistance by

examiner

3 Movement possible against gravity but not against

examiner’s resistance

2 Movement possible but not against gravity (test in

horizontal plane)

1 Muscle fl icker but no movement

0 No muscle contraction

Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions

www.tnpj.com The Nurse Practitioner • December 2016 33

gait patterns, including regular, tandem, heel walking, and tiptoe.18,19 Inability to lift the foot when stepping or dragging it is indicative of probable involvement at L4/L5, as is LBP reproduced on heel walking.18,19 LBP with tiptoeing typi- cally indicates L5/S1 involvement.18,19 Muscle strength test- ing should be performed to evaluate for weaknesses, graded on a scale of 0 to 5 (see Muscle strength testing).18,19

A tactile sensory exam should be used to detect derma- tomal deficits. Neurologic testing includes deep tendon refl exes, Babinski refl ex, clonus signs, and straight-leg raise testing, which is indicative of nerve root impingement.13 A positive straight-leg raise reproduces pain in the lower extremity, not in the lower back.20 An important fi nding in the current evidence is that a positive straight-leg raise should only be used along with other positive fi ndings to determine a diagnosis because the positive straight-leg raise test alone lacks diagnostic utility.20

The description of a dermatomal distribution pattern on history is a key factor in determining lumbar radicu- lopathy, which when combined with one or more positive neurologic findings on physical exam, can confirm the diagnosis (see Positive neurologic findings on physical exam).14 Rectal assessment is needed for a patient complaint of saddle paresthesia or bowel incontinence.18,19 Cardiovas- cular assessment should include auscultation for abdominal aorta bruits or evaluation of any lower extremity vascular anomalies, such as decreased pulses or pitting edema.18,19

■ Diagnostic exam Routine use of radiologic imaging, which includes basic X-ray images, is not warranted based on clinical guidelines.2 This is primarily due to the patient’s exposure to radiation, poorer patient outcomes, and pathology identifi cation, which can lead to a perception by some patients that their back pain is a more serious condition (commonly called the “labeling effect”).2 Diagnostic imaging should be reserved for patients with progressive neurologic involve- ment or if the PCP is suspicious of an underlying pathology.2

Patients presenting with concerns for pathology or fracture, such as a his- tory of trauma, should have two-view X-ray imaging (ante- rior-posterior and lateral) performed immediately, with the addition of fl exion/extension views for any concerns of spi- nal instability.4 If neurologic involvement or other serious underlying pathology is plausible, the study of choice is magnetic resonance imaging (MRI).13 This is followed by computed tomography (CT) scan or CT scan with myelo- gram for patients unable to undergo MRIs; CT scan with myelogram is preferred over CT scan if there is concern for

neurologic impingement.13 Contrast with MRI or CT scan is only needed if patients have had prior lumbar surgery.21

■ Differential diagnoses for LBP The primary goal in the evaluation of LBP from evidence- based guidelines is to first rule out serious pathology or underlying conditions, which are present in about 5% of cases. These conditions or pathologies consist of spinal can- cer, spinal fracture, spinal infection, or cauda equina syn- drome.17,21 Spinal cancer is suggested by age over 50, prior history of cancer, insidious onset, unexplained weight loss, night pain, pain at multiple sites (which can occur at rest), urinary retention, and unresponsiveness to prior care.2,17

Spine fracture is suggested by age over 50, osteoporosis, trauma, and chronic corticosteroid use.2,17 Spine infection is suggested by fever, history of I.V. drug use, prior or current infections (possibly from prior lumbar epidural injections), and immunocompromise.19 Cauda equina syndrome is suggested by acute or worsening radicular symptoms, sen- sorimotor defi cits (including impaired foot dorsifl exion [foot drop]), saddle paresthesias, and bladder and/or bowel incontinence.16,17

Providers should classify patients’ LBP as radicular or nonradicular to assist in determining an appropriate diag- nosis.2,15-17 The major causes of nonradicular LBP include

lumbar strain/sprain, myofascial pain, and lumbar disk degeneration. Major causes of LBP with radiculopathy in- clude lumbar disk protrusions and lumbar stenosis. Ra- dicular pains from lumbar stenosis are typically bilateral, helping to differentiate it from radiculopathy stemming from disk protrusions, which are typically unilateral.10

Providers should also be able to differentiate neuro- genic claudication from vascular claudication to aid in the diagnosis of lumbar stenosis. Patients whose symptoms are

Positive neurologic fi ndings on physical exam14

• Numbness, paresthesias, and/or abnormal refl exes

that are consistent with the described dermatomal

distribution from the patient’s history

• Positive straight-leg raise testing (typically unilateral)

• Babinski’s sign or clonus sign

The primary goal in the evaluation of LBP

is to fi rst rule out serious pathology or

underlying conditions.

34 The Nurse Practitioner • Vol. 41, No. 12 www.tnpj.com

Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions

relieved upon standing alone, located typically below the knee, unchanged by fl exion of the spine, and have a fi xed duration of walking typically have vascular claudication.10,22 Other possible causes of LBP include ankylosing spondyli- tis, aortic aneurysm, pancreatitis, or renal calculi.4,17

■ Treatment options Once the LBP has been identifi ed as radicular or nonra- dicular, the provider can develop a treatment plan. Most cases of NSLBP, and even lumbar radiculopathy, resolve

after a few weeks of treatment.8 Current treatment options for LBP have a minimal impact on outcomes, are typically short term, and rarely change the longer-term prognostic path for patients.3

The goal of treatment for LBP includes pain relief, im- provement of function, reduced work leave of absence, and prevention of chronicity.8 Common treatment options in- clude the use of oral or topical medications, exercise, spinal manipulation therapy, traction, transcutaneous electrical nerve stimulation (TENS), heat, back supports, acupunc- ture, biofeedback, spinal injections, and lastly, surgery.1-3,8,17

■ Pharmacologic management Medication management of NSLBP should be decided after weighing the factors of allergies or adverse reactions of the medication; the duration and severity of the symptoms; the expected benefi ts; the prior response to various medica- tions; comorbidities; and the medication’s cost-effi ciency.1 Medication management remains one of the most recom- mended treatments for NSLBP, either acute or chronic.23

The fi rst choice of treatment consists of short-term use of acetaminophen due in part to its decreased incidence

of gastrointestinal (GI) adverse reac- tions and myocardial infarction (MI). Due to the risk of hepatotoxicity from acetaminophen, patients should be screened for any hepatic contraindica- tions.1-3,17

This should be followed by the short-term use of traditional nonsteroi-

dal anti-infl ammatory drugs (NSAIDs) with the understand- ing that these medications carry an increased risk for gastric bleeding and ulceration, MI, and renal adverse reactions (see Common medications for LBP management).1-3,8,17,24,25 Naproxen has the lowest risk of cardiac events.1 NSAIDs should be avoided in patients over age 75 due to their risks.1 If used, NSAIDs can be administered with misoprostol or a proton pump inhibitor to reduce GI risks.1

Weak opioids may be administered in select cases where patients are unresponsive to the fi rst two recommendations or have a high risk for use of NSAIDs with moderate-to-severe pain. Their use remains controversial with limited evidence of benefi ts and serious adverse reactions, such as respiratory depression, abuse, and addiction potential.1,2,8,16,17 The use of tramadol is contraindicated with concurrent use of a selective serotonin or norepinephrine reuptake inhibitor due to the risk of serotonin syndrome.1

Some other classes of medications employed in the treatment of NSLBP include skeletal muscle relaxants and antiepileptic medications.1,25 Although utilized by many providers, evidence-based studies show insuffi cient evidence for the recommendation of these medications for NSLBP.1 They may be more useful for patients with LBP and radicu- lar symptoms. Skeletal muscle relaxants, as an adjunct to analgesic medications, have been shown in trials to be more effective than analgesia alone.1

Little evidence exists in the literature for the use of oral or systemic corticosteroids in the treatment of NSLBP due to the risk of infection, avascular necrosis, and various other metabolic, endocrine, cardiovascular, or ophthalmo- logic changes.1,2,26 Corticosteroids are best reserved for severe acute LBP and should be used cautiously in chronic back pain conditions.

Common medications for LBP management1 ,25

Acetaminophen

Traditional NSAIDs

• Etodolac

• Diclofenac

• Naproxen

COX-2 inhibitor NSAID

• Celecoxib

Weak opioids

• Tramadol

Muscle relaxants

• Baclofen (FDA off-label use for LBP)

• Tizanidine

• Methocarbamol

• Cyclobenzaprine

Antiepileptics

• Gabapentin (FDA off-label use for LBP)

• Topiramate (FDA off-label use for LBP)

The goal of treatment for LBP includes pain

relief, improvement of function, reduced work

leave of absence, and prevention of chronicity.

Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions

www.tnpj.com The Nurse Practitioner • December 2016 35

■ Nonpharmacologic management Nonpharmacologic recommendations for persistent NSLBP include spinal manipulative therapy (SMT), supervised exercise, acupuncture, and cognitive behavioral therapy (CBT).2,3,8,27 SMT, although supported as benefi cial by some studies for the short-term treatment of acute pain, has no clinical benefi t after a 6-month duration, with some stating withdrawal of failed treatment after 8 weeks.16,27

Other reviews of SMT showed no further benefi t from this treatment over any other treatments.5 Exercise programs are not recommended for patients with acute LBP; however, they were found to be effective in both the prevention and treatment of chronic LBP, with no evidence found that one type of exercise is more benefi cial than another.27

Acupuncture showed evidence to be beneficial for short-term relief of back pain in conjunction with other treatments; however, when used alone, it was not benefi cial except in patients suffering from depression.28 Many pa- tients question the use of lumbar corsets for reduction in pain. Although they can assist in reducing pain during episodes, prolonged use may cause a reduction in spinal function and deconditioning of the paraspinal and ab- dominal muscles.8

Clinical evidence states that other procedures, such as the use of TENS, intradiscal electrothermal therapy, radiofre- quency facet joint denervation, or percutaneous intradiscal radiofrequency thermocoagulation, lack recommenda- tion.2,3,16 There is limited data supportive of surgery for NSLBP, and it has been widely overutilized and criticized.2

■ Patient education and prevention Evidence-based practice for NSLBP, lumbar stenosis, and lumbar radiculopathy indicates that all treatment should begin with basic patient advice regarding the diagnosis. This promotes self-management, provides reassurance that the condition is not a serious disease, and provides encourage- ment to remain active through activities, such as walking, cycling, or swimming. Steady activity progression is recom- mended. Discouraging bed rest or em- ploying no more than 2 days duration of bed rest is recommended due to the possibilities of the loss of bone mineral density, muscle wasting, and joint stiffness.2,3,8,16,17

The inclusion of the patient in shared decision-making is important in the treatment of LBP, which allows informed choices in their care. Benefi ts of shared decision-making include patient autonomy, a therapeutic relationship, im- proved patient satisfaction, and improved patient participa- tion.29 Although underutilized in most care settings, shared

decision-making is a useful tool in the treatment of back pain, especially when it comes to decisions regarding sur- gery.29

In order to prevent the progression of acute NSLBP to chronic back pain, all providers, most important those in primary care settings, should recognize and evaluate patients for psychosocial risk factors (see Psychosocial risk factors).2,16 Providers should employ the use of CBT, which is a cost- efficient option for both the patient and provider with documented sustained results on pain.2,3,16

■ Specifi c treatment options for lumbar stenosis and radiculopathy In relation to the treatment of lumbar spinal stenosis and lumbar radiculopathy, the treatment options remain similar. For spinal stenosis, conservative management should remain the fi rst option. The use of medication management, corre- sponding to those for NSLBP, is one option.5,10 Limited evi- dence exists for the benefi t of SMT in patients with stenosis.5 Exercise therapy consisting of spinal stretching and strength- ening should be employed to prevent deconditioning.10

Invasive therapies, including 30% of all epidural spinal injec- tions, are employed for patients with lumbar stenosis, with only limited, short-term benefi t of no more than 3 weeks based on evidence-based guidelines for patients with neuro- genic claudication.5,10

Prior to beginning invasive interventions, such as spi- nal injections or surgery, correlation with spinal imaging is recommended. For patients who have failed conserva- tive treatments, referral to a specialist for consideration of

Psychosocial risk factors2

• Inappropriate attitudes and beliefs about back pain

• Fear-avoidance behavior

• Anxiety

• Depression

• Workers’ compensation claim status

• Litigation status

• Socioeconomic factors

• Malingering pain

• Persistent request for opioid medications when

inappropriate for treatment

Treatment for NSLBP includes short-term use

of acetaminophen because of its decreased

incidence of GI adverse reactions and MI.

36 The Nurse Practitioner • Vol. 41, No. 12 www.tnpj.com

Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions

surgical decompression, typically with lumbar laminectomy, has been shown to be supported by the guidelines based on long-term follow-up studies.5,6,10

For lumbar radiculopathy, conservative treatments are recommended for the first 6 to 8 weeks beginning with patient education and avoidance of bed rest.5 There is lim- ited evidence supporting the use of analgesics, no evidence supporting muscle relaxants, and no support of the use of antidepressants for patients with lumbar radiculopathy but typically medication management is provided following the same guidelines for NSLBP.13 In addition, traction, corset use, acupuncture, physical therapy, and SMT have little or no evidence for or against their recommendation based on

best practice guidelines, although the North American Spine Society stated a short-term structured exercise program can be presented to patients with mild-to-moderate radicu- lopathy.8,13 Secondary treatment of an epidural corticoste- roid injection was recommended for short-term benefi t for patients with lumbar radiculopathy, but there was a lack of evidence supporting more than a series of three repeated injections.8,13,16,17

Once again, prior to beginning invasive interventions, such as epidural injections or surgery, correlation with spinal imaging is recommended. Clinical evidence indicates insuf- fi cient data to support the use of intradiscal electrothermal annuloplasty, plasma disk decompression/nucleoplasty, in- tradiscal high-pressure saline injection, or low-power laser for the treatment of lumbar radiculopathy.13 For patients who have failed conservative treatments, referral to a special- ist for consideration of surgical discectomy has been shown to be a cost-effective treatment supported by the guidelines, especially for those with progressive muscle weakness or altered bladder or bowel function.13

■ New research on causal factors for LBP New research is discovering various types of treatment op- tions evaluating possible causal factors for NSLBP and back pain with radicular symptoms. An increase in tumor necrosis factor-alpha is one probable cause.2 Genetic predisposition has been documented involving changes to interleukin-1; aggrecan, the vitamin D receptor; genes responsible for vari- ous collagen fi bers, including I, IX, XI; matrix metallopro- teinase 3; and many proteins.2,4

Obesity has been recently studied as a causal factor in relation to increased mechanical load, systemic chronic infl ammation, association of increased abdominal obesity causing metabolic syndrome changes that may affect the disk material, and a decrease in spine mobility.10,30 Lastly, a small association between smoking status and NSLBP has been identifi ed in cohort studies, with many relating this to changes in the vascular supply to the intervertebral disk.2,4,10

■ Educating patients Because LBP is one of the most common diagnoses present- ing to primary care offi ces, NPs can see the importance in performing excellent history and physical exam to assist in

clarifying pathology from back pain with or without radicular symptoms. In addition, with the variety of pharma- cologic and nonpharmacologic treat- ments employed for LBP, providers will need to make educated decisions on how to best manage these conditions.

Educating patients on their diagno- sis and maintenance of an active lifestyle, including them in the decision-making and assessing for psychosocial risk factors, can assist in preventing the progression from acute to chronic pain. Through the review of evidence-based prac- tice, extracting the recommendations from the research, and employing these recommendations into everyday practice, providers can improve outcomes for patients with LBP.

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70(4):387-402.

2. Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specifi c low back pain. Lancet. 2012;379(9814):482-491.

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8. Walker J. Back pain: pathogenesis, diagnosis and management. Nurs Stand. 2012;27(14):49-56.

9. de Schepper EI, Overdevest GM, Suri P, et al. Diagnosis of lumbar spinal stenosis: an updated systematic review of the accuracy of diagnostic tests. Spine. 2013;38(8):E469-E481.

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11. Cook C, Brown C, Michael K, et al. The clinical value of a cluster of patient history and observational fi ndings as a diagnostic support tool for lumbar spine stenosis. Physiother Res Int. 2011;16(3):170-178.

Prior to beginning invasive interventions, such

as epidural injections or surgery, correlation

with spinal imaging is recommended.

Evidence-based practice guidelines for the diagnosis and treatment of lumbar spinal conditions

www.tnpj.com The Nurse Practitioner • December 2016 37

12. Ammendolia C, Stuber KJ, Rok E, et al. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. Cochrane Database Syst Rev. 2013;(8):CD010712.

13. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopa- thy. Spine J. 2014;14(1):180-191.

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15. Kongsted A, Kent P, Albert H, et al. Patients with low back pain differ from those who also have leg pain or signs of nerve root involvement —a cross-sectional study. BMC Musculoskel Dis. 2012;13:236

16. Herndon CM, Zoberi KS, Gardner BJ. Common questions about chronic low back pain. Am Fam Physician. 2015;91(10):708-714.

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20. Scaia V, Baxter D, Cook C. The pain provocation-based straight leg raise test for diagnosis of lumbar disc herniation, lumbar radiculopathy, and/or sciatica: a systematic review of clinical utility. J Back Musculoskelet Rehabil. 2012;25(4):215-223.

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29. Jones LE, Roberts LC, Little PS, Mullee MA, Cleland JA, Cooper C. Shared decision-making in back pain consultations: an illusion or reality? Eur Spine J. 2014;23(suppl 1):S13-S19.

30. Wertli MM, Held U, Campello M, Schecter Weiner S. Obesity is associated with more disability at presentation and after treatment in low back pain but not in neck pain: fi ndings from the OIOC registry. BMC Musculoskelet Disord. 2016;17:1-14.

Robert L. Metzger is an FNP at the Parkland Health & Hospital System, Department of Orthopedics at the Orthopedic Spine Clinic, Dallas, Tex.

The author and planners have disclosed that they have no fi nancial relation- ships related to this article.

DOI: 10.1097/01.NPR.0000508169.67852.bb

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For more than 203 additional continuing education articles related to

Advanced Practice Nursing topics, go to NursingCenter.com/CE.