From the Guidelines
For a patient with back pain and a history of spina bifida occulta, begin with a thorough assessment to determine if the pain is related to the spina bifida or has another cause, and manage the condition based on the latest guidelines from the American College of Physicians and the American Pain Society 1.
Initial Assessment and Management
The patient's back pain may be unrelated to the spina bifida occulta, as this condition is typically asymptomatic. A thorough assessment should include a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause 1.
- Start with conservative management including NSAIDs like ibuprofen (400-600mg three times daily) or naproxen (500mg twice daily) for pain relief.
- Physical therapy focusing on core strengthening and proper body mechanics is essential.
- Recommend activity modification to avoid aggravating activities while maintaining general movement.
Considerations for Imaging and Referral
If pain persists, consider muscle relaxants such as cyclobenzaprine (5-10mg three times daily) for short-term use (1-2 weeks) 1. For patients with moderate to severe pain, consider referral for imaging studies to rule out complications like tethered cord syndrome, which can occasionally occur with spina bifida occulta.
- Magnetic resonance imaging (MRI) is the preferred imaging modality for evaluating patients with persistent back and leg pain who are potential candidates for invasive interventions 1.
- Neurological symptoms such as leg weakness, bladder/bowel dysfunction, or sensory changes warrant urgent neurological or neurosurgical evaluation, as these may indicate complications requiring surgical intervention.
Patient Education and Self-Care
Provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options 1.
- Encourage patients to stay active and avoid bed rest.
- Provide self-care education and recommend lifestyle modifications to manage back pain.
From the Research
Diagnosis and Treatment of Spina Bifida Occulta with Back Pain
- Spina bifida occulta can manifest as chronic low back pain and unpredictable neurologic deficit, making diagnosis and treatment challenging 2.
- A case report of a 46-year-old male with spina bifida occulta at the 5th lumbar spine level, who was initially diagnosed with chronic low back pain and treated with epidural steroid injections, highlights the importance of MRI examinations in characterizing intraspinal and perispinal abnormalities 2.
- The use of intraoperative neurophysiological monitoring can assist in identifying the level for decompression and resolving pain, as seen in the case report of a patient with spina bifida occulta at the 5th lumbar spine level 2.
Radiological Insights and Diagnosis
- Incidental detection of thoracic spina bifida occulta at the first thoracic vertebra following a sports injury has been reported, highlighting the importance of radiographic, CT, and MRI findings in diagnosis 3.
- A prospective study of children with non-specific low back pain and anomalies in the LS spine, including transitional vertebra and/or spina bifida occulta, found that degeneration of the intervertebral disc was a common cause of low back pain 4.
- A retrospective cross-sectional study of young people with low back pain found that spina bifida occulta was the most common lumbosacral dysplasia, frequently involving the S1 segment, and that abnormal laminar growth direction and laminar stenosis were common laminar morphologies in spina bifida occulta 5.
Current Treatment Paradigms
- A review of current treatment paradigms for spina bifida occulta and aperta discusses the challenges of timely diagnosis and treatment, as well as the latest advances in fetal repair of spina bifida aperta (myelomeningocele) 6.
- The importance of MRI examinations in characterizing intraspinal and perispinal abnormalities, and the use of intraoperative neurophysiological monitoring in identifying the level for decompression and resolving pain, are highlighted in the treatment of spina bifida occulta 2, 6.