Low Back Pain

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 with sciatic list

Radicular Signs and Symptoms - Often associated with 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 ACTIVITY

CLAUDICATION (No foot pulse)

Walking

Uphill walking

  

Rest

Bicycling

Lying flat

NEUROGENIC CLAUDICATION

Distal - proximal

Proximal - distal

pain, calf pain

pain,thigh pain

Symptoms

Symptoms develop

develop sooner

later

Relief with

Relief - sitting or

standing

bending

Symptoms

Symptoms do not

develop

develop

Relief

May exacerbate symptoms Rest,

TREATMENT

Vascular opinion,

decompressive

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.