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A Comprehensive Approach to Lower Back Pain

A Comprehensive Approach to Lower Back Pain

Patients who present with lower back pain to Akhil Chhatre and Ashot Kotcharian in the Johns Hopkins Spine Program leave their appointments with a specific diagnosis and individualized treatment plan.

The physiatrists—who are also trained in spine and musculoskeletal management—perform a thorough history and physical exam to narrow down the diagnosis. Kotcharian and Chhatre check the internal rotation of the hips and the sacroiliac joints, as well as the lumbar range of motion, extension and rotation.

“If movements like forward flexion provoke pain, I know it’s likely disc-mediated pain,” Kotcharian says. “If straight back extensions or extension with rotation cause pain, then I think about facet joint syndrome.”

Kotcharian and Chhatre also evaluate motor strength and reflexes in the legs, clonus in the legs or feet, and signs of neural tension. “Maneuvers like the straight leg raise or slump-sit put tension on the nerves and provoke pain if there’s disc herniation,” says Kotcharian. 

Imaging crucial to a diagnosis of spinal stenosis, facet joint syndrome or disc herniation, such as X-ray, MRI and EMG scans, are ordered if the patient hasn’t had the tests.

When there are clear indications for surgery, like bowel-bladder incontinence due to spinal cord compression, progressive weakness or myopathy, or refractory pain, the physiatrists consult with surgical experts at The Johns Hopkins Hospital.

When the evaluation uncovers a systemic diagnosis, like rheumatoid arthritis or ankylosing spondylitis, the physiatrists will coordinate care with a Johns Hopkins rheumatologist. Further, if the evaluation finds amyotrophic lateral sclerosis or multiple sclerosis, they connect with a Johns Hopkins neurologist.

“A lot of neurological conditions can present with pains and aches, and we may be the first to diagnose these because of the nature of our training and assessment,” says Kotcharian.

Once they elicit a diagnosis, the physiatrists develop a treatment plan that includes diagnosis-specific exercises and a prescription for physical therapy. They also make referrals, including orthotics, nutrition and pain psychology—all of which are provided within The Johns Hopkins Hospital.

Kotcharian says nutrition is important to the diets of patients with pain. “Some patients have highly inflammatory diets; others have diets that interact with medications. Still others may need to lose weight,” he says.

If medication or other interventional procedures are necessary, the physiatrist can schedule fluoroscopic-guided injections or radiofrequency ablation, all of which are available within their practice.

“This comprehensive approach addresses not just symptom relief but also functional restoration and improvement,” says Kotcharian. “In many cases, we can fix the problem with conservative management and leave surgery as a last resort.” 

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