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Approach to low back pain

Low back pain is one of the most common reasons for seeking medical attention. The majority of episodes are self-limited, but some suffer from chronic or recurrent courses. Almost any structure in the back can cause pain, most commonly the intervertebral discs and facet joints. A thorough history and physical exam are important to determine the likely cause and guide appropriate treatment. Imaging such as X-rays, CT, and MRI may help identify structural abnormalities but often are not needed for typical mechanical low back pain.

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Approach to Low Back Pain Dr Sushil Sharma
An Important Issue • One of the most common reasons for seeking medical attention, second only to respiratory issues • 84% of adults will have low back pain at some point • Wide variety of approaches for treatment – Suggests that optimal approach is unsure • Most episodes are self-limited • Some suffer from chronic or recurrent courses, with substantial impact on quality of life
Epidemiology  Almost any structure in the back can cause pain, including ligaments, joints, periosteum, musculature, blood vessels, annulus fibrosus and nerves  Intervertebral discs and facet joints most commonly affected  85% of those with isolated low back pain do not have a clear localization  Usually called “strain” or “sprain”  no histopathology, no anatomical location  Men and women equally affected  Age of onset 30-50 years
Epidemiology • Leading cause of work disability in those < 45 years • Most expensive cause of work disability in terms of worker’s compensation • Multiple known risk factors: – Heavy lifting, twisting, vibration, obesity, poor conditioning
Biomechanics • Load bearing – Lateral and posterior shear, axial compression, and flexion : Disc – Anterior shear and axial torque : Facets – Facet joint load bearing in lower lumbar spine (20%). It bears load mostly in extension • Ligaments – Have elastic physical property that allows the ligament to stretch and resist tensile forces. – Strongest ligaments : Anterior longitudinal ligament and the facet joint capsules. – Interspinous-supraspinous ligament complex : Intermediate strength – Weakest of all is the posterior longitudinal ligament.
Biomechanics • Abdominal cavity and its surrounding muscles stabilize the spine for activities such as lifting. Intradiscal pressure
Deyo R and Weinstein J. N Engl J Med 2001;344:363-370 Common Pathoanatomical Conditions of the Lumbar Spine
Deyo R and Weinstein J. N Engl J Med 2001;344:363-370 Low Back Pain : Etiology
97% 2% 1% Low Back Pain Mechanical Visceral Tumor, Infection
Low Back Pain….The Patient History Physical Exam Diagnostic Studies
History A doctor who cannot take a good history and a patient who cannot give one are in danger of giving and receiving bad treatment Anonymous
History • Obtain a description of the pain in meticulous detail • Ask the patient to demonstrate the site of pain • Personality of the patient and his or her activities • Correlate the pain to the disability – Mild, moderate, severe • Assess the possible source of pain. • Onset, duration, and progression of the symptoms. MacNab Sign
History • Ask – Radiation of pain (to leg) – Paresthesia – Morning stiffness – Bowel & Bladder symptoms – Treatment received
History • Red flag sign
History • Mechanical Back Pain – The sudden onset of pain after provocative activity with an intermittent course subsequently is highly suggestive of a mechanical basis for the symptoms. – Mechanical back pain is almost always aggravated by general and specific activities and is relieved by rest.
History • Prolapse Intervertebral Disc – Spread of pain to leg suggests nerve root compression – Pain aggravated by coughing or sneezing – Referred pain is rarely felt below the knee, whereas pain due to root irritation may spread to the calf or even into the foot. – Pain from first and second lumbar root involvement is easily confused with hip disease because it concentrates around the groin – Discogenic pain is frequently increased by maintaining one posture over a period of time: prolonged walking, prolonged sitting, or prolonged standing. • With good history there is 80% chance you will know the diagnosis (you will improve the odds another 10% by doing the physical examination, and another 5% by ordering fancy, expensive tests)
History • Any evidence of neurologic compromise? – Cauda equina syndrome is a medical emergency • Usually due to tumor or massive herniation compressing the nerves of the cauda equina • Urinary retention with overflow, saddle anesthesia, bilateral sciatica, leg weakness, fecal incontinence – Sciatica caused by nerve root irritation • Sharp/burning pain down posterior or lateral leg to foot or ankle; can be associated with numbness/tingling • If due to disc herniation often worsens with cough, sneeze or performing the Valsalva
History • Any evidence of neurologic compromise? – Spinal stenosis is caused by narrowing of the spinal canal, nerve root canals, or intervertebral foramina • Most commonly due to bony hypertrophic changes in facet joints and thickening of the ligamentum flavum • Disc bulging or spondylolisthesis may also cause • Back pain, transient leg tingling, pain in calf and lower extremity that is triggered by ambulation and improved with rest • Can differentiate from vascular claudication through detection of normal arterial pulses on exam
Physical Examination • The first prerequisite is that the patient must be undressed. • Thorough examination • A cursory examination is worse than no examination at all, because it may give the false hope that the lesion is minor.
Gait • Observe gait – Antalgic gait : Hip or knee disease – Shuffling gait : Neurologic disorder of rigidity or spasticity – Walks slightly flexed : Spinal canal stenosis • Ask the patient to – Walk on heels : L5 – Walk on tiptoe : S1
Spine Contour • Look at the patient from the side and behind • Sagittal plane malalignment : Kyphosis • Coronal plane malalignment: Scoliosis • Step off: Spondylolisthesis
Movement • Forward flexion (90◦) – Decreased • PIVD • Lumbar spondylosis • Extension (30◦) • Lateral flexion (30◦) • Rotation (40◦) • Rigid spine: Late stage of AS
Movement • Reversal of normal spinal rhythm : Disc degeneration associated with a posterior joint lesion.
Neurological examination • Neurologic examination – L5: ankle and great toe dorsiflexion – S1: plantar flexion, ankle reflex • Dermatomal sensory loss – L5: numbness medial foot and web space between 1st and 2nd toes – S1: lateral foot/ankle
Motor Examination • Tone • Power L1,2 Hip flexion L3,4 Knee extension L4 Dorsiflexion L5 Great toe extension S1,2 Plantarflexion
Motor Examination
Motor Examination Grade Remarks 0 No movement 1 Flicker 2 Movement if gravity eliminated 3 Movement against gravity 4 Movement against resistance but weak 5 Normal strength
Sensory Examination L1 L2 L3 L4 S1 L5
Nerve Root Stretching Test  Straight leg raise: for those with sciatica or spinal stenosis symptoms  Patient supine, examiner holds patient’s leg straight  Elevation of less than 60 degrees abnormal and suggests compression or irritation of nerve roots  Reproduces sciatica symptoms (NOT just hamstring)  Forced dorsiflexion of the ankle produces pain is highly suggestive of root tension  Ipsilateral straight leg raise sensitive but not specific for herniated disk  Crossed straight leg raise (symptoms of sciatica reproduced when opposite leg is raised) highly specific  Disc herniation lying in the axilla or medial to the root
Bow String Test • Most reliable test of root tension is the bowstring sign • Firm pressure with thumbs in the popliteal fossa. • Radiation of pain down the leg or the production of pain in the back is pathognomonic of root tension
Femoral nerve stretch test • Lumbar root tension (L3,L4) • Patient prone • Hip extended & knee slightly flexed • pain may be felt in front of the thigh and the back • Done to exclude higher disc prolapsed (rare)
Reflex • Knee jerk (L3,L4) • Ankle jerk (S1,S2) • Babinski reflex • Clonus
Examination • Hip joint • Peripheral pulse • Abdominal examination • Rectal examination • Calf girth, Thigh girth • Chest expansion
Investigations • Laboratory tests are useful as a screening mechanism  Tests  Hb, TC,DC,ESR, and CRP  Serum chemistries, especially calcium, acid and alkaline phosphatase, and serum protein electrophoresis.  HLA-B27 antigen  Indication  Significant non mechanical component to their pain  Systemic symptoms such as fever  Atypical pain pattern or distribution  Not responding to standard conservative treatment directed at the mechanical causes of low back pain  Older patients (age >55 years)
Bone Scan • Technetium-99m-labeled phosphorus (99mTc) most commonly used • Indications – Localize metastatic bone lesions – Early detection of bone infection (67Ga, Indium-111- Labeled Leukocytes) – Osteonecrosis – Study of failed joint prostheses – Investigation of unexplained bone pain – Dating of fracture age
Radiograph • AP and lateral L-spine if no clinical improvement after 4-6 weeks • Perform x-rays if: – Significant trauma – Incapacitating back pain – Age>50 yrs – Unexplained weight loss – Hx of cancer – Fever – Neurologic deficits – Excessively anxious patient – Clinically apparent spinal deformity – Hx & Exmn suggestive of A.S. (Ask for sacroiliac joint view) – Severe pain (despite Rx for more than 2 weeks)
Radiograph • Radiographs have limited function in diagnosis and treatment. • The main function of a radiograph is to exclude serious disease, such as infections, ankylosing spondylitis, and neoplasms. • Reading the X-ray – Nonskeletal areas • Retroperitoneal area • Kidneys and ureters • Abdominal aorta. – Skeleteal • Sacroiliac joints • Survey the pedicles and vertebral bodies for erosions • Structural defects
CT and MRI – Gold standard imaging technique for investigating disc pathology, tumor and infection. – Also able to image herniated discs and spinal stenosis, which cannot be appreciated on plain films – Beware: herniated/bulging discs often found in asymptomatic volunteers  may lead to overdiagnosis/overtreatment (False positive) – CT scanning, and MRI are part of an operative procedure; they are not routine radiographs to be ordered without hesitation – If a clinician is in trouble with spine differential diagnosis to the point where frequent myelogram/CT scans and MRI are part of the practice routine, then a careful clinical examination is missing.
CT vs Myelography
MRI • Gold standard imaging technology for investigating spine • Sagittal T1 – Root canals (foramina) – Facet joints – Vertebral bodies – Spinal cord • Sagittal T2 – CSF – Internal structure of disc – Osseous structures are poorly seen on T2- weighted image. • Axial T1 – Facet joints – Ligamentous flavum – Foramina
MRI vs CT • Advantages – Does not require the use of ionizing radiation – Produces excellent sagittal sections – Produces excellent soft tissue detail – Intradural lesions such as tumors, syrinx, and arachnoiditis. – MRI signal is not impeded by bone, which results in better images in the posterior fossa and the base of the brain • Disadvantages – Claustrophobic feeling for the patient. – The scan time is longer for MRI, and a patient in pain may find it difficult, if not impossible, to be still for the time required – Patients with ferromagnetic materials in their body cannot be scanned if the following conditions apply: • Cerebral aneurysm clips will be torqued by the magnet. • Pacemakers will be converted to a fixed rate. • Transcutaneous electrical nerve stimulation units will be drawn into the magnet. • Ocular metallic foreign bodies may be moved and result in damage to vision. • Metallic cardiac valves are at risk
MRI - Indications • Patients with disc rupture who has failed conservative care and is being considered for surgery. • Suspected PIVD • Spinal canal stenosis • Suspected arachnoiditis • Spinal tumors
Nerve conduction test • Evaluate nerve entrapment syndromes • Helps in differential diagnostic problem such as an L5 nerve lesion that could be due to a root lesion (disc rupture) or entrapment neuropathy in the pelvis or around the knee.
Electromyography • Studies intrinsic electrical activity of individual motor units of muscle • Useful in lower motor neuron lesions and is useful for diagnosing neuropathies and myopathies. • Localize the level of lumbar nerve root involvement • In the presence of a nerve root lesion, a series of involuntary electrical discharges can be recorded – Fibrillation potential – Positive wave • Helpful in diagnosing neuropathy (eg: in diabetes)
Diagnostic Approach – Reaching the correct diagnosis 1. Is this a true physical disability or is there a setting and a pattern on history and physical examination to suggest a nonphysical or nonorganic problem? 2. Is this clinical presentation a diagnostic trap? 3. Is this a mechanical low back pain condition, and if so, what is the syndrome? 4. Are there clues to an anatomic level on history and physical examination? 5. After reviewing the results of investigation, what is the structural lesion and does it fit with the clinical syndrome?
Non organic spinal pain - Classification • Psychosomatic spinal pain – Tension syndrome (fibrositis) • Pure psychogenic spinal pain • Situational spinal pain – Litigation reaction – Exaggeration reaction
Non Organic Back Pain • Symptoms – Pain is multifocal in distribution and nonmechanical (present at rest) – Entire extremity is painful, numb, and/or weak – Extremity gives way (as a result, the patient carries a cane) – Multiple crises, multiple hospital admissions/investigations, and multiple visits to doctors • Signs – Tenderness is superficial (skin) or nonanatomic (e.g., over body of sacrum) – Simulated movement tests positive – Distraction tests positive – Whole leg weak or numb
Avoid Diagnostic Trap • Back pain – Peritoneal cavity • GI tumor • Ulcer – Retroperitoneal space • Genitourinary conditions • Abdominal aortic conditions • Primary or secondary tumors of the retroperitoneal space
Differential Diagnosis - Sciatica • Intraspinal causes – Conus and cauda equina lesions (e.g., neurofibroma, ependymoma) – Herniated nucleus pulposus – Stenosis (canal or recess) – Infection: osteomyelitis or discitis (with nerve root pressure) – Inflammation: arachnoiditis – Neoplasm: benign or malignant with nerve root pressure • Extraspinal causes – Pelvis • Peripheral vascular disease (Vascular claudication vs Neurogenic claudication) • Gynecologic conditions • Orthopaedic conditions (e.g., osteoarthritis of hip) • Sacroiliac joint disease • Neoplasms – Peripheral nerve lesions • Neuropathy (diabetic, tumor, alcohol) • Local sciatic nerve conditions (trauma, tumor) • Inflammation (herpes zoster)
Vascular vs Neurogenic claudication Findings Vascular Claudication Neurogenic Claudication Pain Type Sharp, cramping Vague radicular, heaviness, cramping Location Exercised muscles (usually calf and rarely includes buttock, almost always excludes thigh) Either typical radicular or extremely diffuse (usually including buttock) Radiation Rare Common after onset, usually proximal to distal Aggravation Walking, especially uphill Not only aggravated by walking, but also by standing Relief Stopping muscular activity even in the standing position Walking in the forward flexed position more comfortable; Relief comes only with lying or sitting down Time to relief Quick (seconds to minutes) Slow (many minutes) Neurologic symptoms (Paresthesia) Usually not present Commonly present Straight leg raising tests Negative Positive Neurologic examination Negative Positive Vascular examination Absent pulses Pulses present
Hip Pathology • Pain – Groin or hips • Limping • Pain on external rotation of hip • Internal rotation restricted
Neurologic Disorder • If weakness, sensory upset and/or instability the dominant symptom (rather pain) • Weakness as a symptom – A true motor weakness will affect one or both limbs or a muscle group and will originate in the motor unit or the proximal motor pathways in the spinal cord, brainstem, and cortex – Central vs Peripheral – Separate the myopathies (proximal & symmetric) form the neuropathies(distal).
Extremity weakness - Classification • Anatomic Level – Spinal cord – Anterior horn • Motor Neuron Disease (A.L.S.) • Tetanus • Poliomyelitis – Dorsal root ganglion • Herpes zoster (Usu one root, lower thoracic region) – Peripheral nerve (sensory, distal, lower limbs & asymmetrical) • Diabetic • Nutritional • Infectious: Leprosy, GBS • Toxic : Lead, Alcohol – Myoneural junction – Muscle • Polymositis, Polymyalgia rheumatica
Is this a mechanical low back pain, and if so, what is the syndrome? • Mechanical LBP aggravated by activity & relieved with rest • Syndrome – Lumbago (Back pain) – Sciatica (Radicular leg pain) • Unilateral acute • Bilateral acute (Cauda Equina Syndrome) • Referred leg pain – Associated with low back pain – Pain radiating to B/L legs – No neurologic sign & symptoms • Any patient with radiating leg pain, especially unilateral leg pain, has a radicular syndrome until proven otherwise.
Acute Radicular Syndrome • Leg pain (including buttock) is the dominant complaint when compared with back pain • Neurologic symptoms that are specific (Sensory & Motor) • On examination – SLR less than 60 – Bowstring sign – Crossover SLRT – Neurologic sign
Acute Radicular Syndrome in Various Ages Young (<30y) Adult (35-55y) Elderly(>60y) Symptoms Leg pain Usually the only symptom Some BP, but LP dominates Usually BP, but LP still dominates Paresthesia Often absent Usually present Almost always present Signs SLR Positive (++) Positive (+) Occasionally good ability Neurologic signs Absent in at least 50% of patients Sometimes absent Almost always present
Cauda Equina Syndrome • Surgical emergency • Large sequestered disc rupture (acute) at L3- L4, L4-L5, or L5-S1 • Clinical features – Sudden onset of back pain – Bilateral leg pain – Saddle anesthesia – Bilateral lower extremity weakness – Urinary retention and lax rectal tone
Anatomic level – History & Examination
Does structural lesion fit with clinical syndrome? Syndrome Structural lesion Lumbago Degenerative disc disease Facet joint dysfunction Spondylolysis/spondylolisthesis Soft tissue (muscle spasm, strain) Unilateral acute radicular Disc prolapse Lateral recess stenosis Bilateral acute radicular Central disc prolapse (Cauda Equina Syn)
Natural History • Most recover rapidly – 90% of patients seen within 3 days of symptom onset recovered within 2 weeks • Recurrences are common – Most have chronic disease with intermittent exacerbations • Spinal stenosis is the exception  usually gets progressively worse with time
Management of Low Back Pain • General considerations – Primary therapy related to etiology – Patient expectations – Patient education related to pain treatment – Pain treatment cost-effectiveness • Prevention of back pain exacerbations • Prevention of unnecessary surgery and suffering (failed-back-surgery syndrome)
Management of Low Back Pain
• Comprehensive assessment of patients is essential to form the appropriate treatment plan. • In the majority of cases, pharmacologic treatment is the main approach. • Overall, 90% of patients will recover within 2 months without need for any invasive procedure. • The management of acute back pain without sciatica or neurologic deficits calls for a conservative approach with analgesics and no bed rest. Management of Low Back Pain
• With sciatica and no neurologic deficits • Conservative management with analgesics • Bed rest for 2–3 d • Activities as tolerated • Neurologic consultation as needed • With sciatica and positive neurologic deficit • Individualized length of rest • Analgesics • MRI study plus urgent neurologic or emergent neurosurgical evaluation, according to progression of deficits and symptoms Management of Low Back Pain
Management of Low Back Pain
• Who needs Surgery- – Unstable spine – Acute fracture with neurological deficit – Severe stenosis – After failure of aggressive non- operative Rx – Tumour – Progressive neurological deficit Management of Low Back Pain
Management of Low Back Pain
Prevention of Low Back Pain
Management of Low Back Pain