What is the best approach to manage back pain in patients with spina bifida?

Management of Back Pain in Patients with Spina Bifida

A multidisciplinary, biopsychosocial approach using stratified care is the most effective strategy for managing back pain in patients with spina bifida, with treatment tailored based on pain severity, functional impact, and risk of chronicity. 1

Initial Assessment and Management

Assessment

• Evaluate for specific causes of back pain in spina bifida patients, including spinal deformities (kyphoscoliosis present in 62.2% of cases), tethered cord, and musculoskeletal imbalances 2
• Assess neurological function, as deficits are often asymmetric and may change over time 3
• Use the STarT Back tool after 2 weeks of pain to stratify patients based on risk for developing persistent disabling pain 1
• Evaluate impact on function, mobility, and quality of life, as these are primary goals of management 3

Initial Management

• Advise reactivation and avoiding bed rest 1
• Provide appropriate pain relief medications 1
• Implement self-care strategies with comprehensive patient education 1
• Review improvement within 2 weeks from onset of pain 1

Stratified Care Approach

Low-Risk Patients

• Encourage self-management strategies 1
• Provide resources including online materials, telephone helplines, and paper-based information 1
• Consider spinal manipulation, which has shown benefit even in patients with low baseline disability 4

Medium-Risk Patients

• Refer to physiotherapy for a patient-centered management plan 1
• Focus on strength training, particularly targeting muscles affected by the spinal lesion level 5
• Implement exercise programs that incorporate individual tailoring, supervision, stretching, and strengthening 1

High-Risk Patients

• Refer for comprehensive biopsychosocial assessment within a multidisciplinary team context 1
• Consider intensive interdisciplinary rehabilitation, which is moderately effective for chronic back pain 1
• Implement cognitive-behavioral therapy approaches 1
• Review no later than 12 weeks; if no improvement, consider referral to specialist pain center or spinal center 1

Special Considerations for Spina Bifida Patients

• Maintain flexibility of the hip as a main goal, as findings from gait analysis have shifted focus from radiological criteria to functional improvement 3
• Prevent joint contractures through early prophylactic treatment 3
• Support verticalization and gait even when loss of ambulation is expected later 3
• Address common comorbidities that may exacerbate back pain, including bladder dysfunction (present in 75% of cases) and pressure sores 2
• Consider the neurological level of the lesion when developing treatment plans, as L3 function (quadriceps) is a functional milestone for modified independent ambulation 3

Advanced Interventions

• For patients who don't respond to standard approaches after 12 weeks, consider referral to specialist pain centers 1
• Complex medication management may include opioids and neuropathic pain medications when appropriate 1
• Consider referral to specialist spinal surgical service for cases with progressive deformity or neurological deterioration 1
• Implement high-intensity cognitive behavioral therapy for persistent pain 1

Pitfalls and Caveats

• Avoid assuming that "physical therapy for all" is an effective approach; instead, use stratified care to direct resources appropriately 1
• Don't rely solely on radiological criteria for treatment decisions; focus on functional improvement 3
• Avoid making early prognosis about walking ability in young children with spina bifida, as neurological symptoms are often asymmetric and may change 3
• Remember that signposting to advice alone is insufficient; direct support, reinforcement, and frequent contact are usually needed 1
• Consider that lower baseline pain-related disability may predict non-response to physiotherapy but not to spinal manipulation 4