LOW BACK PAIN

LOW BACK PAIN

By Dr. KM Liau

Low back pain is extremely common. Almost every person will have at least one episode of low back pain at some time in his or her life. The pain can vary from severe and long term to mild and short lived. It will resolve within a few weeks for most people.

INCIDENCE

Very common problem among working group

90% occurs in patient >45 years old

80% resolves with conservative treatment (in <3 months)

Only 5-10% may require operation

IMPLICATION

1. Work & productivity loss

2. Medical certificate

ANATOMICAL CONSIDERATION

Commonly occur at lumbosacral junction (L4/L5, L5/S1)

REASON:

Junction between the most mobile region of the spine (lumbar) and most rigid region of spine (sacrum) -

Therefore prone to degeneration (wear & tear).

CAUSES

1. Degenerative (most common)

2. Instability(fracture, spondylolisthesis)

3. ORGANIC (TUMOUR , INFECTION)

4. Nerve compression/irritation(PID, root compression)

5. Rule out psychogenic cause (insurance claim, problem with employer ..etc)

NATURE OF PAIN

1.MECHANICAL VS NON-MECHANICAL

2.REFERRED VS RADICULAR

3.CLAUDICATION - VASCULAR VS SPINAL

MECHANICAL PAIN

Pain occurs after specific activities and relieved by rest.

Most of the time responds to conservative treatment.

Non-emergency entity.

Common causes:

1. Muscle strain

2. Ligament sprain

3. Facet joint arthritis

4. Disc-Discogenic pain (NOT PID)

5. Instability - Spondylolysis/spondylolisthesis

NON-MECHANICAL PAIN

Pain occurs at rest, especially at night and often wakes patient up from sleep.

Unrelated to mechanical activities. (It does NOT mean the pain is relieved by activity, BUT, whatever you do the pain is still there)

Note: A non-mechanical pain that progresses to severe mechanical pain that makes the patient to be unable to get up or out of the bed should always make one think of pathological fracture of the spine.

NON-MECHANICAL PAIN

Infection - PYOGENIC VS TB

Always think of TB until proven otherwise because TB is ENDEMIC here.

Tumour - PRIMARY VS SECONDARY

Primary Tumour - BENIGN (usually in children) VS MALIGNANT (in pt>50 years old)

Secondary Tumour - Please make an effort to find the primary source ( In male - always think of prostate ca, in female - must rule out breast ca)

REFERRED PAIN

Characteristics:

1.Distributed over a large area

2.Dull aching ("kebas") to sharp pain

3.NON-Dermatomal (Usually lower back region and/or buttock region and/or posterior thigh region.

4.Always ask for other possible intra-abdominal and intra-pelvic causes.

REFERRED PAIN

1. Abdominal cavity

-gastritis/peptic ulcer
-pancreatitis
-cholecystitis

2. Urinary system

-renal calculi
-UTI

3. Pelvic cavity

-ovarian cyst
-dysmenorrhea

4. Aorta

-Aortic aneurysm

DO NOT MISS THE LIFE THREATHENING CONDITIONS!!!!!

RADICULAR PAIN

Due to true nerve root compression (eg.PID)

Pain distribution over a specific dermatomal region (Very narrow zone of pain).

Pain is very sharp, electric-shock like and excruciating. Some describe it as lancinating pain.

Non-emergency entity (You can safely rule out other more life threathening causes of referred pain - Provided this is really a genuine radicular pain after you have ruled out referred pain)

NOTE: In clinical practice it is very very rare to get a genuine radicular pain - So Always make sure this is not REFERRED pain.

VASCULAR CLAUDICATION

Fixed walking distance

Not related to body posture.

Bicycle paradox - cycling produces pain in vascular claudication but not in spinal claudication.

SPINAL CLAUDICATION

No fixed distance.

Related to body posture - Flexion of spine relieves pain; Extension of spine aggravates it. (Eg. Going upstairs, walking uphill, sitting or cycling will relieve pain; whereas going downstairs, walking downhill or prolonged standing will aggravate pain).

RED FLAGS

1.AGE(>50)

2.IMMUNOCOMPROMISED (DM, Autoimmune, HIV, etc)

3.TB CONTACT

4.KNOWN CANCER

5.NEUROLOGICAL DEFICIT - Motor deficit (NOT sensory), Loss of micturition and bowel control.

6.Constitutional symptoms - LOW, LOA, Fever.

PHYSICAL EXAMINATION

General examination:

Age

Ill-looking?

Local examination:

Deformity
Scoliosis/kyphosis
Step deformity
Local tenderness/paraspinal spasm
Limited ROM

DO NOT MISS A GIBBUS!!!

Full neurological examination

ANAL TONE / PERIANAL SENSATION

DERMATOME & MYOTOME (See the link on ASIA classification)

PLAIN X-RAY

AP VIEW

Always look for:

1.Loss of lumbar lordosis (Paraspinal muscle spasm)

2.Reduced disc space (TB, Degenerative)

3.Osteophytes (Degenerative)

4.Deformity (Degenerative scoliosis/ Spondylolisthesis)

5.Interpedicular distance (increased in Burst Fracture)

6.Pedicle disruption (Primary or secondary tumour)

7.Generalised osteopenia (Osteoporosis)

PROSTATE CANCER METASTASIS

In male patient always think of prostate metastasis whenever you see blastic lesion in the vertebra.

Always do a per rectal examination (or be prepared to get screwed!!!)

BREAST CANCER METASTASIS

In female patients, always think of breast cancer.

They can present either as lytic or blastic lesion.

The picture shows blastic lesion over L1, L2 and L3 vertebrae.

DEGENERATIVE SPINE DISEASE

HEMANGIOMA

The usual plain film of a middle aged adult with back pain. Effectively an incidental finding.

There is a coarsening of the bone texture with relative preservation of vertical trabecula in the body of the third lumbar vertebra.

There is spondylotic change between L4 and L5 with disc narrowing and marginal osteophtyes.

Vertebral alignment is preserved.

Diagnosis : Solitary Vertebral Hemangioma of L3

Note: This condition is not associated with compression fractures.

BACK PAIN IN CHILDREN

Back pain in children is not like back pain in adults.

Compared to an adult, a child with a backache is more likely to have a serious underlying disorder.

This is especially true if the child is 4 years old or younger or if a child of any age has back pain accompanied by:

1. Fever or weight loss
2. Weakness or numbness
3. Trouble walking (LIMP)
4. Pain that radiates down one or both legs
5. Bowel or bladder problems
6. Pain that keeps the child from sleeping

SPONDYLOLYSIS

Spondylolysis, or stress fracture through PARS INTERARTICULARIS (NOT PEDICLE), is a common cause of lower back pain in adolescents.

Stress fractures may occur during adolescent growth spurts or in sports like gymnastics, diving, and football, that repeatedly twist and hyperextend the spine.

Pain is usually mild and may radiate to the buttocks and legs. The pain feels worse with activity and better with rest. A child with spondylolysis may walk with a stiff legged gait and only be able to take short steps.

Girls are more likely to get stress fractures.

Treatment options:

A)Non-pharmacological:

1.Rest from activities that caused the stress fracture

2.Strengthening exercises for back and abdominal muscles to help control symptoms.

3.Bracing for several months and follow-up with X-rays to watch for changes

B)Pharmacological

1.Nonsteroidal anti-inflammatory drugs (NSAIDS)

C)Surgery

1.Surgery to treat painful spondylolysis that does not get better with conservative management

(In a few cases, spondylolysis may lead to slipped vertebrae - spondylolisthesis).

INFECTION

In young children, infection in a disk space (discitis) can lead to back pain.

Discitis typically affects children between the ages of 1 and 5 years, although older children and teenagers can also be affected.

A child with discitis may have the following symptoms:

1.Pain in the lower back or abdomen and stiffness of the spine
2.Walking with a limp, or simply refusing to walk
3.Squatting with a straight spine when reaching for something on the floor, rather than bending from the waist

Treatment:

1.Several days of bed rest and antibiotics

2. In older children - casting or bracing to immobilize the spine if infection narrows the disc space.

Surgical drainage of the infection is rarely needed.

TUMOUR

Most often found in the middle or lower back.

Pain is constant (NON-MECHANICAL) and usually becomes worse over time.

This pain is progressive; unrelated to activity (pain is the same regardless of what he do) and usually happens at night.

Other symptoms vary, and can include any of the following:

1.Muscle spasms or a "tight" back, which may cause the child to lean to one side when bending forward (painful curvature)

2.Pain and/or weakness extending into the legs and causing the child to limp

3.Bowel or bladder problems.

Common tumours: (Mostly in the posterior elements)
1. Osteoid osteoma
2. Osteoblastoma
3. Aneurysmal Bone Cyst

ANEURYSMAL BONE CYST

Note the abscence of pedicle at L4 level.

Expansile lesion arising from the pedicle.

However, no vertebral body destruction noted.

Disc spaces are normal.

OSTEOBLASTOMA

OSTEOBLASTOMA - CT SCAN

Link List

Exercise Therapy

Low back pain exercise therapy

Spondylolysis

Spondylolysis and Spondylolisthesis

Spine Fracture

Fracture of Thoracic and Lumbar Spine

ASIA classification

Standard Neurological Classification of Spinal Cord Injury