Approach to patient with back pain

1. Approach To Low Back Pain
Presented by
Abdulaziz Bagasi – R2 Family Medicine NGH
Supervised by
Dr.Ahmed Sabban
28th February 2019
1

2. Objectives
• Introduction
• Epidemiology
• Definitions and Terminology
• Risk Factors
• Differential Diagnosis
• Approach to patient with low back pain (Hx ,Px ,investigations)
• Management
2

3. How common is LBP ?
3

4. Introduction
• 84 % of adults have low back pain at some time in their lives
• Most of them are self-limited.
4

5. Epidemiology of Low Back Pain in Saudi Arabia
• A computer based literature search
• A total of Twelve articles was used for this study
• From March 2014-2015.
• Seven studies were cross sectional and found a prevalence ranging
from 53.2% to 79.17%.
Awaji, M. (2016). Epidemiology of low back pain in Saudi Arabia. Journal of Advances in Medical and Pharmaceutical Sciences, 6(4),
1-9.

6. Definition
 Low back pain (LBP)
Musculoskeletal pain or stiffness of lower back and lumbar
spine.
• LBP by duration
Acute LBP → < 6 weeks
Subacute LBP→ between 6 weeks and 3 months
Chronic LBP → > 3 months
6

7. Normal Anatomy & Physiology
7 background

8. Terminology (1)
• Spondylosis: Arthritis of the spine
• Spondylolysis: A fracture in the pars interarticularis where the vertebral body and the
posterior elements protecting the nerves are joined.
• Spondylolisthesis : If left untreated, spondylolysis can weaken the vertebra so the fractured
pars interarticularis separates, allowing the injured vertebra to shift or slip forward on the
vertebra directly below it.
• Spinal stenosis: Narrowing of the vertebral canal by bone or soft tissue elements.
• Radiculopathy: Impairment of a nerve root, usually causing radiating pain, numbness,
tingling, or muscle weakness .
8

9. Normal Anatomy & Physiology
9

10. Terminology (2)
• Sciatica
– Pain radiating down posterior or lateral leg below the knee
– The most common cause for sciatica is lumbar disk herniation
– Symptoms that increase the specificity of sciatica:
1. Pain that is worse in the leg than in the back
2. Typical dermatomal distribution of neurologic symptoms
3. Pain that is worse with the Valsalva maneuver
10

11. Terminology (3)
• Cauda equina syndrome
11

12. Cauda Equina Syndrome
12

13. Terminology (4)
• Kyphotic curves : outward curve of the thoracic spine
• Lordotic curves : inward curve of the lumbar spine.
• Scoliotic curving : sideways curvature of the spine and is always abnormal.
• A small degree of both kyphotic and lordotic curvature is normal
13

14. MCQ1
What is the specific
diagnosis of this pt’s LBP?
A. Nonspecific LBP
B. Spinal stenosis
C. Spondylolisthesis
D. Malignancy
14

15. MCQ1
2. What is the specific
diagnosis of this pt’s LBP?
A. Nonspecific LBP
B. Spinal stenosis
C. Spondylolisthesis
D. Malignancy
15

16. MCQ2
A 62-year-old man presents with complaints of leg pain. He notes that the pain is
primarily in his buttocks and thighs. It is worse when he is walking but improved when
he sits. On examination his vital signs are normal, he has no peripheral edema, and his
pedal pulses are intact. The most likely diagnosis to explain his symptoms is which one
of the following?
A) A dissecting aortic aneurysm
B) An incarcerated inguinal hernia
C) Intermittent claudication
D) Myasthenia gravis
E) Spinal stenosis
16

17. Spinal Stenosis
17 background

18. Risk factors for LBP ?
18

19. Risk Factors
 Increasing age
 Smoking
 Muscle weakness in back and/or abdomen
 Psychosocial factors
 Stress, anxiety
 Occupational factors
 Manual material handling, bending/twisting
 Job dissatisfaction
 Overweight
 Repetitive lifting
 Chronic Steroid use
 Sedentary lifestyle
19

20. Differential Diagnosis
diagnosis20

21. MCQ3
3. Which of the following is not indicative of inflammatory back pain
such as ankylosing spondylitis?
A. Insidious onset
B. Onset before 40 years of age
C. Pain for more than 3 months
D. Morning stiffness
E. Aggravation of pain with activity
21

22. Goal of evaluation
To identify features that discriminate between “benign” cases and
“serious pathologies” which need immediate further evaluation

23. DD of LBP by Severity
23
Other etiologiesLess serious, specific
etiologies ( Less than 10 %)
Serious systemic etiologies
(less than 1 % )
Nonspecific back pain (>85
%)
Ankylosing spondylitis :
features suggesting an
inflammatory etiology
(morning stiffness,
improvement with
exercise, pain at night)
Compression fracture :
commonly by osteoporosis
Cauda Equina Syndrome :
by herniation or disk
Back pain in the absence of
a specific underlying
condition that can be
identified
OsteoarthritisRadiculopathy : from
degenerative changes in
the vertebrae, disc
protrusion
Metastatic cancer (breast,
prostate, lung, thyroid, and
kidney,MM)
Mostly musculoskeletal
pain
Scoliosis and
hyperkyphosis
Spinal stenosisSpinal infection :
• Spinal epidural abscess
• Vertebral osteomyelitis
Psychological distress

24. Copyrights apply

25. 25
Approach to patient with low back pain

26. Case
• Abdulaziz is a 27 year old.
• Came to PHC complaining of lower back pain.
How to approach this patient ?
26

27. Analysis of the pain:
1- Site.
2- Onset.
3- Duration.
4- Character.
5- Radiation.
6- Aggravating factors.
7- Intensity.
8- Relieving factors.
9- Ass. Symptom.
• Screening for Red flags.
• Systemic review.
• Medical & surgical history.
• Medication.
• Family history.
• Social history.
• Psychosocial stressors at home
or work
• ICEE
History (1)

28. What are the Red flags
for LBP

29. History (2)
29
• Red flags for cauda equina syndrome (CES):
Motor or sensory deficit
Saddle anesthesia
Bilateral sciatica or leg weakness
Difficulty urinating and retention
Fecal incontinence
Additional indicators of nerve root problems
• Unilateral leg pain
• Pain radiates to foot or toes
• Numbness and paresthesia
• Straight leg raising test positive

30. History (3)
• Other Red flags:
Onset at age < 20 or > 55
Pain which is:
 Unrelated to time or
activity (nonmechanical)
 Thoracic
Widespread neurologic
symptoms
Spinal deformity
Unexplained weight loss
Fever
Significant trauma
IV drug use
Previous hx of steroid use
Previous history of:
 Osteoporosis; cancer;
immunosuppression
Failure to improve after 4-6
weeks of conservative
therapy
30

31. -Fecal incontinence -Saddle anesthesia
-Urinary retention
-Immunosuppression -Intravenous drug use
-Unexplained fever
-Osteoporosis
-Significant trauma at any age
-Chronic steroid use
-History of cancer
-Unexplained weight loss
-Focal neurologic deficit
-No improvement after six weeks of conservative
management
Cauda equina
syndrome
Infection
Fracture
Neoplasm
Any of the
above

32. 32

33. MCQ4
It is recommended that all patients with low back pain be risk-
stratified with an initial assessment to identify red flags. All of the
following signs and symptoms are considered red flags in this
situation, except which one?
A) Fever
B) History of cancer
C) Onset after heavy lifting
D) Onset after a fall
E) Urinary retention
33

34. Physical Exam (1)
34
• General: posture, pain behavior
• General inspection of lower back
 Deformities, symmetry, redness, swelling
• General palpation of lower back
 Tenderness, deformities, warmth, tone
• Gait
• Range of motion (ROM) testing

35. Physical Exam (2)
35
• Neurologic exam
 Evaluate sensation, strength, and reflexes
• Provocative tests
 Straight-leg-raise test (SLR)
if (+) may indicate neurologic involvement

36. Physical Exam (3)
36
 Straight-leg-raise test (SLR)
• Positive test
– Sciatic pain at 30-70 degree
– Aggravation of pain dorsiflexion of the foot
– Relief of pain by knee flexion
- if positive indicates lumber nerve root compromise.
- not specific, but SLR is the most sensitive test→ negative result helps rule it out
 Crossed SLR
- Examiner observes for radiating pain in affected leg while lifting patient’s opposite
uninvolved leg
A positive crossed SLR test is more specific for lumbar disk herniation, and it complements
the sensitive uncrossed SLR test

37. Physical Exam (4)
37
• Red flags by examination:
Saddle anesthesia
Loss of anal sphincter tone
Weakness in lower extremities
Fever
Vertebral tenderness
Limited spinal ROM
Neurologic abnormality

38. Back to the case
• History
o Abdulaziz is a 27 year old.
o Came to PHC complaining of lower back pain since 7 days
o Diffusing dull aching pain, started after lifting heavy object at home, relieved by
Ibuprofen
o Prolong sitting or moderate activity aggravate the pain
o No radiation , numbness or leg pain
o No fever , weight loss , or hx of trauma
o No urinary or fecal incontinence
o Not on steroids or any medication
o No abdominal pain , nausea or vomiting
o No hx of surgeries
38

39. Back to the case
• On examination
o Uncomfortable, prefer to stand.
o Has full ROM except for limited forward flexion of the back
o Tenderness on paraspinous muscles.
o SLR & crossed SLR test are negetive.
o Lower limb neurological exam: Normal tone, power , reflexes, and sensation.
39

40. What investigations
should we do for Mr.Aziz
?

41. LBP testing
• Do not routinely obtain imaging studies or other diagnostic
tests in patients with nonspecific LBP
(ACP Strong recommendation, Moderate-quality evidence)
41

42. When to do testing in patient
with LBP ?
42

43. Imaging
• Perform diagnostic imaging in LBP if severe or progressive
neurologic deficits or serious underlying conditions suspected.
(ACP Strong recommendation, Moderate-quality evidence)
• MRI (preferred) or CT recommended if :
• Neurologic deficits
• Suspected serious condition (cauda equina syndrome, cancer)
• X-ray not routinely recommended but may be considered if :
• Suspicion for cancer or vertebral compression fracture
• Suspicion for ankylosing spondylitis (bamboo sign)
43

44. Bamboo spine of ankylosing spondylitis
44

45. Labs
• In patients with "red flags" especially if symptoms are
consistent with infectious or inflammatory etiologies
CBC
ESR
CRP
45

46. Copyrights apply

47. Diagnosis ?
47

48. So Mr. Abdulaziz most likely diagnosis is Back
Strain
48

49. MCQ5
A 41-year-old sedentary man with frequent flare-ups of back pain presented to you 6
weeks ago with the acute onset of low back pain radiating to the left leg. His neurologic
examination at the time was normal, but he did not respond to conservative therapy. X-
rays are normal. Which of the following is the most appropriate next step?
a. Flexion and extension radiographs
b. Magnetic resonance imaging (MRI)
c. Electromyelography
d. Bone scan
e. A complete blood count (CBC) and erythrocyte sedimentation rate (ESR)
49

50. Explanation 5
The answer is b. (Mengel, pp 300-306.) MRI is indicated for people
whose pain persists for more than 6 weeks despite normal radiographs and
with no response to conservative therapy. Flexion/extension films would
not be helpful in identifying more concerning causes of pain. EMG is not
indicated without neurologic involvement. A bone scan and/or ESR should
be considered in those with symptoms consistent with cancer or infection.
50

51. 51

52. Management of LBP
52

53. • Patient Education
1st line treatment: maintain overall activity.
• Pharmacological
NSAIDS, paracetamol, muscle relaxants
• Non-pharmacological
Heat , exercise, massage, lumber support, acupuncture ,manipulation, traction and
Cupping (Hijama)
• Surgery
Referral for red flags
severe ± treatment failure
53
Management principles

54. • Remain active
Advice to stay active recommended and associated with improved
pain and functional status compared to bed rest in patients with acute
low back pain (LBP)
(Strong recommendation, Moderate-quality evidence; level 2 [mid-level] evidence)
• Further education
Benign nature of LBP
Provoking/aggravating factors
If posture → correct, lifting techniques, etc.
54
Patient Education (1)

55. Lifting Technique

56. Pharmacotherapy (1)
1. NSAIDS
 Initial therapy (1st line) — a trial of short-term (two to four weeks)
• Beware of GI and renal toxicity→ long-term use; at risk pt’s
• Try start taper by end of wk1, stop by end wk2 for most pts
o Ibuprofen (400 to 600 mg four times daily)
o Diclofenac (50-100mg bid )
o Naproxen (250 to 500 mg bid)
2. Paracetamol
 1 gram tid-qid (max 4g/day in pt’s without liver disease)
 High-quality evidence that acetaminophen showed no benefit compared with placebo in
acute low back pain
56

57. Pharmacotherapy (2)
3. Muscle relaxants
 Second-line therapy — For patients with pain refractory to initial pharmacotherapy
 Efficacy – Muscle relaxants provide symptomatic relief with acute low back pain
 Beware of ADE: drowsiness, dizziness
o Chlorzoxazone 250 mg and paracetamol 300 mg (Relaxon) TID
o Cyclobenzaprine 5-10mg po q8hr
o Baclofen 5mg po q8hr
57

58. Pharmacotherapy (3)
4. Opioids or Tramadol
• 3–5 days course may be given for severe pain not relieved by NSAID.
• Effective for neuropathic pain
• Do not routinely offer opioids for managing acute low back pain
• Side effects : risk of dependence , drowsiness , nausea and constipation.
o E.g. Hydrocodone/acetaminophen: 5/500 mg PO q4–6h
o Oxycodone/acetaminophen: 5/500 mg PO q4–6h
• Tramadol
 is an opioid agonist
 similarly to opioids limiting use for a few days.
58

59. Pharmacotherapy (4)
5. Systemic glucocorticoids
 In acute nonspecific back pain :
 No evidence to support the use of systemic glucocorticoids
 In acute lumbosacral radiculopathy who do not respond well to
analgesics and activity modification :
 May provide partial pain relief
 A course of oral prednisone (60 to 80 mg daily) for 5-7 days, followed by
discontinuation over 7 to 14 days.
6. Topical agents
 No evidence to support the use of lidocaine patches in LBP.
59

60. Recommended or not in LBP?
60

61. 1. Heat therapy
Associated with short-term pain reduction in patients with acute or
subacute LBP
(level 2 [mid-level] evidence)
No such benefit seen with ice therapy
61
Non-pharmacological (1)

62. Recommended or not in LBP?
62

63. 2.Exercise-based therapy for low back pain
 For acute LBP
 Acute low back pain (LBP) (<4 weeks) has a very good prognosis.
 Exercise has not been shown to be more beneficial for acute LBP when compared with other
conservative treatments.
 Patients should be advised to avoid bedrest and stay as active as possible.
 For subacute and chronic LBP
 Systematic reviews have concluded that exercise may have modest benefits for pain relief and
improved function in patients with subacute and chronic LBP
 Physical therapy
 In general, No need to refer patients with acute low back pain for physical therapy.
 Early referral to a physical therapist may benefit patients with acute back pain who are at higher
risk of developing chronic back pain (eg, poor functional or health status, psychiatric
comorbidities).
63
Non-pharmacological (2)

64. Recommended or not in LBP?
64

65. 3. Massage
Safe and may be relaxing for some patients
 For acute LBP
 Insufficient evidence
 For subacute and chronic LBP
 Evidence of short-term improvement in symptoms for subacute and chronic LBP, but no long-
term benefits
65
Non-pharmacological (3)

66. Recommended or not in LBP?
66

67. 3. Lumbar supports
o The role of corsets (lumbosacral orthoses, braces, back supports and abdominal binders)
in the treatment of patients with low back pain is controversial
 In acute LBP
 No evidence to suggest that lumbar supports have therapeutic value
 In chronic LBP :
 Not routinely recommended, may provide some benefit for patients with subacute LBP
who are actively engaged in recommended therapies.
67
Non-pharmacological (3)

68. Recommended or not in LBP?
68

69. 4. Acupuncture
o Recommendations from guidelines, some recommending against acupuncture,
and some not making a recommendation for or against acupuncture
 ACP guideline (2017) : recommends non-pharmacologic therapies including acupuncture as
initial therapy for patients with chronic low back pain
 NICE guideline (2016) : does not recommend acupuncture for management of low back pain
 In acute LBP
 Limited and inconclusive evidence to support acupuncture for acute LBP.
 In chronic LBP :
 Reduces chronic low back pain compared to no acupuncture.
69
Non-pharmacological (4)

70. Recommended or not in LBP?
70

71. 5. Spinal manipulation
o A form of manual therapy that involves the movement of a joint beyond its usual end range
of motion, but not past its anatomic range of motion , high-velocity movement of the joint is
frequently accompanied by an audible cracking or popping sound.
 In acute LBP
 May reduce pain and disability, but evidenced inconsistent
(level 2 [mid-level] evidence)
 In chronic LBP
 May slightly improve pain and function at 6 months in patients with chronic LBP.
(level 2 [mid-level] evidence; ACP Strong recommendation, Low-quality evidence)
71
Non-pharmacological (5)

72. Recommended or not in LBP?
72

73. 6. Traction
o Is a form of decompression therapy that relieves pressure on the spine, can be performed
manually or mechanically.
 In acute LBP
 May provide short-term pain relief in patients with low back pain with or without sciatica.
(level 2 [mid-level] evidence)
In chronic LBP
 mechanical traction is not recommended for use in chronic low back pain.
(APS Good-quality evidence)
73
Non-pharmacological (6)

74. Recommended or not in LBP?
74

75. ‫بالحجامة‬ ‫التداوي‬ ‫فضل‬
‫صحيحه‬ ‫في‬ ‫البخاري‬ ‫روى‬(5269)ِ‫ن‬ْ‫ب‬‫ا‬ ِ‫َن‬‫ع‬ ٍ‫ر‬ْ‫ي‬َ‫ب‬ُ‫ج‬ ِ‫ن‬ْ‫ب‬ ِ‫د‬‫ي‬ِ‫ع‬َ‫س‬ ‫عن‬ُ َّ‫اّلل‬ ‫ي‬ ِ‫ض‬َ‫ر‬ ٍ‫اس‬َّ‫ب‬َ‫ع‬
َ‫ل‬‫ا‬َ‫ق‬ ‫وسلم‬ ‫عليه‬ ‫هللا‬ ‫صلى‬ ‫النبي‬ ‫عن‬ ‫ا‬َ‫م‬ُ‫ه‬ْ‫ن‬َ‫ع‬:
"ٍ‫ة‬َ‫ث‬‫ال‬َ‫ث‬ ‫ي‬ِ‫ف‬ ُ‫ء‬‫ا‬َ‫ف‬ِ‫الش‬:ِ‫م‬ ِ‫ة‬َ‫ط‬ْ‫َر‬‫ش‬َ‫و‬ ٍ‫ل‬َ‫س‬َ‫ع‬ ِ‫ة‬َ‫ب‬ْ‫َر‬‫ش‬َ‫ن‬ ِ‫ة‬َّ‫ي‬َ‫ك‬َ‫و‬ ٍ‫م‬َ‫ج‬ْ‫ح‬ٍ‫ار‬
ِ‫ي‬َ‫ك‬ْ‫ل‬‫ا‬ ِ‫َن‬‫ع‬ ‫ي‬ِ‫ت‬َّ‫م‬ُ‫أ‬ ‫ى‬َ‫ه‬ْ‫ن‬َ‫أ‬َ‫و‬" .
75

76. 7. Cupping (Hijama)
o From Sunnah, used for all conditions, especially musculoskeletal pain
 Dry pulsatile cupping and minimal cupping may each reduce short term pain in patients with nonspecific
chronic low back pain
(level 2 [mid-level] evidence)
o Based on randomized trial, 110 adults (mean age 49 years) with nonspecific chronic low back pain were
randomized to 1 of 3 interventions for 4 weeks and followed for 12 weeks.
o Result : pulsatile dry cupping and minimal cupping each associated with improved scores on physical component
subscale of Short Form-36 quality-of-life questionnaire compared to control at 4 and 12 weeks.
http://www.dynamed.com/topics/dmp~AN~T906249/Acupuncture-and-related-therapies-for-chronic-low-back-pain#sec-Cupping
76
Non-pharmacological (7)

77. 7. Cupping (Hijama)
 Cupping might slightly reduce pain in patients with chronic low back pain
(level 2 [mid-level] evidence)
o Based on systematic review of low-to-moderate quality trials
o 6 trials assessed effect of cupping on patients with low back pain (median treatment duration 3 weeks)
o All trials had ≥ 1 methodologic limitation including unclear randomization, unclear allocation concealment, unclear
blinding of patients and providers, and unclear reporting of dropout rate
o Result :
 Cupping associated with slight reduction in pain compared to medication use in analysis of 4 studies with 430
patients
 Cupping associated with reduction in pain compared to usual care at 3-month follow-up (in 1 trial with 98 patients
http://www.dynamed.com/topics/dmp~AN~T906249/Acupuncture-and-related-therapies-for-chronic-low-back-pain#sec-Cupping
77
Non-pharmacological (7)

78. Cupping (Hijama)
78

79. MCQ6
You are seeing a 34-year-old special education teacher, who complains of
pain in her lower back following an injury at school, where she hurt her back
after lifting some therapy mats to store them for the night. Which one of the
following has not been shown to be useful in the prevention of back pain?
A) Attending a formal “Back Education” school
B) Modifying the work site to minimize the risk of injury
C) Staying active with regular physical activity
D) Utilizing a back belt when lifting
79

80. What are the indications of referral for LBP
patients ?
80

81. 1. Not improving in 4 to 6 weeks
2. Loss of bladder and/or bowel function
3. Red flag suggesting fracture, tumor ,infection
Urgent
• Cauda equina syndrome
• Infection ( osteomyelitis , epidural abscess)
Elective
• Disc herniation

82. Take Home Massage (1)
• Clinicians should conduct a focused history and physical examination to help
categorizing patients with low back pain. (strong recommendation)
• The history should include assessment of psychosocial risk factors, which
predict risk for chronic disabling back pain.
(strong recommendation)

83. • Clinicians should not routinely obtain imaging or other diagnostic tests in
patients with nonspecific low back pain.
(strong recommendation)
• Advise patients to remain active, and provide information about effective self-
care options.
(strong recommendation)
• Clinicians should perform diagnostic imaging and testing when severe or
progressive neurologic deficits are present or when serious underlying
conditions are suspected.
(strong recommendation)
Take Home Massage (2)

84. MCQ7
1. Which of the following statements is true regarding the pathogenesis of
LBP?
A. the anatomic structures causing LBP are identified clearly
B. approximately 10% of patients with acute LBP will eventually require
surgery
C. in up to 90% of cases of LBP, a definite anatomic or pathophysiologic
diagnosis cannot be made
D. patients with acute LBP and no previous surgical procedures have a 20% to
25% chance of recovering after 6 weeks, regardless of the treatment used
E. none of the above statements is true
84

85. MCQ8
The presence of a “bamboo spine” on spine radiographs, elevated
ESR, and a positive test for HLA-B27 supports the diagnosis of
which one of the following conditions?
A) Ankylosing spondylitis
B) Multiple myeloma
C) Pott disease
D) Reiter syndrome
E) RA
85

86. MCQ9
You are seeing a 40-year-old woman who reports the gradual onset
of low back pain over several months. The pain is associated with morning
stiffness that improves throughout the day. On examination, there are no
neurologic deficits. Which of the following is the most likely cause?
a. Back strain
b. Inflammatory arthropathy
c. Disk herniation
d. Compression fracture
e. Neoplasm
86

87. Explanation 9
The answer is b. (Mengel, pp 300-306.) Inflammatory conditions
(rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome) which
cause back pain are rare, but have characteristics that are helpful in differentiating
them from other causes of pain. Inflammatory conditions generally
produce greater pain and stiffness in the morning, while mechanical
disorders tend to worsen throughout the day with activity. A disk herniation
might be associated with radiation and neurologic symptoms. A compression
fracture would begin suddenly, and a neoplasm is unlikely to get
better throughout the day.
87

88. MCQ10
A 30-year-old woman with frequent back problems was putting her groceries into her
trunk and had a recurrence of low back pain. She has tried acetaminophen for 2 days
without relief. On examination, her range of motion is limited, and she has tenderness to
palpation of the lumbar paraspinal muscles. Which of the following treatment options is
best?
a. NSAIDs and return to normal activity
b. Opiate analgesia and limited activities
c. Oral corticosteroids
d. Bed rest for 3 to 5 days
e. Spinal traction
88

89. Explanation 10
The answer is a. (Mengel, pp 300-306.) It is recommended that
patients with low back pain maintain usual activities, as dictated by pain.
Neither prolonged bed rest nor traction has been shown to be effective in
returning people to their usual activities sooner. NSAIDs are effective for
short-term symptomatic pain relief. Muscle relaxants appear to be effective
as well. Opioids may be indicated in pain relief for those who have failed
NSAIDs, but are significantly sedating. Steroids can be considered in those
who have failed NSAID therapy.
89

90. 90

91. Any Questions?
91