LOW BACK PAIN

Eugene Sherry, MD, MPH, FRACS.

   

  I. A. Back Pain - A common complaint. Standard workup,  

beginning with history taking (most important) and
physical examination. Radiographic and laboratory
studies can help in diagnosis. Some important
considerations in the evaluation of back pain are
presented.

Age - Children may be affected by congenital or, more

commonly, development disorders, infection, or primary
tumours. Younger adults are more likely to suffer from disc
disease, spondylolisthesis, or acute fractures. In older
adults, spinal stenosis, metastatic disease, and
osteopenic compression fractures are more common.
Don’t ignore back pain in children.

Typical posture of LBP Radicular Signs and Symptoms - Often associated with
with sciatic list disc herniation or spinal stenosis. Intraspinal pathology or
other entities associated with cord or root impingement
may be responsible. Herpes zoster is a rare cause of
lumbar radiculopathy with pain preceding the skin
eruption.

Systemic Symptoms - Careful history taking can lead to

the diagnosis of metabolic disease, ankylosing
spondylitis, or infection (confirmed with laboratory studies
patient toxic).

Referred Pain - Back pain can often be viscerogenic,

vascular, or related to other skeletal areas (especially with
hip arthritis). Careful history and physical exam are
essential (palpate abdomen and examine hips).

Psychogenic - Psychological disturbances play an

important role in some patients with chronic low back pain
disorders. Evidence of secondary gain (especially
compensation or litigation) and inappropriate (Wadell)
signs and symptoms can help identify these patients.
 Nevertheless, one must be wary of real pathology, even in
such patients.

Prior History of Back Pain - Perhaps the most important

risk factor for future pain, especially with frequent
disabling episodes and short intervals between episodes.
Compensation work situations, smoking and age > 30
years are also associated with development of persistent
disabling lower back pain. The incidence of disabling pain
actually declines after age 60.

Beware: Children with back pain, night pain, new pain,

patient looks unwell.

Tip: Gently tap spine with closed fist severe localised

tenderness suggests infection/tumour/trauma. Do x-ray.

  Herniated Nucleus Pulposus (HNP).  

Disc degeneration with aging includes loss of water

content, annular tears, and myxomatous changes, nuclear
material. Discs can protrude (bulging nucleus, intact
annulus), extrude (through annulus but confined by
posterior longitudinal ligament [PLL], or be sequestrated

L5/S1 disc prolapse (disc material free in canal) is less likely to herniate in
older populations. Problem of upright posture.

Lumbar Disc Disease - Major cause of increased

morbidity and financial impact in the Western World. Most
involve the L4-L5 disc followed by L5-S1 (posterolateral).
Central prolapse is usually associated with back pain
only; however, acute insults may precipitate a cauda
equina compression syndrome. This is a surgical
emergency that presents with bowel or bladder
dysfunction (usually urinary retention), saddle
anaesthesia, and varying degrees of loss of lower
extremity motor or sensory function.

History and Physical Exam - An acute injury true radicular

pain distal to the knee. Sciatic scoliosis. Tension signs.
Inappropriate signs and symptoms are also important to
note. Inappropriate prolapse symptoms include pain at the
tip of the tailbone; pain, numbness, or giving way of the
whole leg; inappropriate reactions such as moaning, and
emergency admissions. Nonorganic physical signs
include tenderness with light touch in nonanatomic areas,
light axial loading, distraction testing, pain with pelvic
rotation, negative sitting (and positive supine) straight leg
raising test, regional nonanatomic disturbances, and
overreaction.

Diagnostic Tests - Plain radiographs. Myelography, CT,

and MRI studies are effective.

Treatment - Short-term bed rest (3-7 days) with support

beneath the knees and neck, NSAIDs or aspirin, and
progressive ambulation is successful in returning most
patients to their normal function. Over half of patients who
present with low back pain will recover in 1 week and 90%
will recover within 1-3 months.

Complications - Fortunately are rare.

Vascular Injury.

Nerve Root Injury.

Failed Back Syndrome

Dual Tear

Infection

Lumbar Segmental Instability - Present when normal

loads produce abnormal spinal motion. Instability catch
(sudden, painful snapping with extension).

Spinal Stenosis

Spinal stenosis is narrowing of he spinal canal or neural

foramina producting root ischaemia and neurogenic
claudication.
 Symptoms include insidious pain and parenthesis with
ambulation and extension, relieved by lying supine or with
flexion of the spine.

TAKE CARE TO DIFFERENTIATE:

VASCULAR
NEUROGENIC
ACTIVITY CLAUDICATION
CLAUDICATION
(No foot pulse)

Distal - proximal Proximal - distal

Walking
pain, calf pain pain,thigh pain

Symptoms Symptoms develop

Uphill walking
develop sooner later

Relief with Relief - sitting or

Rest
   standing bending  

Symptoms Symptoms do not

Bicycling
develop develop

May exacerbate
Lying flat Relief
symptoms

Rest,
Vascular opinion, decompressive
TREATMENT
vasc. bypass laminectomy =
stabilization.

  

Spondylolysis and Spondylolisthesis

see case 20

Spondylolysis - A defect in the pars interarticularis, and

the most common cause of low back pain in children and
adolescents. The defect fatigue fracture. Oblique
radiographs may show a defect in the neck of the Scottie
dog. (See fig man Sports Medicine).

Spondylolisthesis - Forward slippage of one vertebra on

another.

Adult Degenerative Spondylolisthesis

Other Thoracolumbar Disorders

Destructive Spondyloarathropathy.

Diffuse Idiopathic Skeletal Hyperostosis (DISH).

Ankylosing Spondylitis.

Adult Scoliosis.