An approach to the problem ofLow Back Pain

Epidemiology

• Four out of five people will suffer from LBP at some time in their lives

• 80-95% having an acute attack recover within 3 months

• If pain persists beyond 6 months prognosis for recovery is poor

• Important cause for days off work• No clear association with occupation

Pain sensitive structures

Pain sensitive structures

Non-traumatic back pain

LBP

Non-organic

Organic Mechanical

Non-mechanical

Non-mechanical

Outside the spine

Gynae, PU,AAA,Renal,Pancreas, GB

In the spine

inflammatory

neoplastic

benign

malignant

primary

secondary

infective

Non-infective Anky spon, SLE

Specific (TB)

Non-specific

Mechanical

Degenerative

Congenital

DeformityAcquired

Post-trauma

Others – overuse, posture, leg length inequality etc

LBP -diagnosis

• History

• Examination

• Investigations

• Should try to slot the patient into a category

LBP –diagnosis -history

• Age, gender, duration• Aggravating factors, relieving factors• Associated symptoms• Patients perception of the cause• Occupation, lifestyle, sports

LBP –diagnosis -examination

• Inspection – scoliosis, kyphosis, leg length inequality

• Palpate- deformity –gibbus, tenderness• Move – flexion, excursion, extension• SLR –

• Other – neurological, abdomen

LBP examination -SLR

Lift straight leg

LBP examination -SLR

Dorsiflex foot- Increases pain

Lasegue sign

LBP examination -SLR• When knee is flexed, hip can be flexed to 90

degrees. When Knee is extended, pain comes on before leg is straight

• Pressure on lateral side of popliteal fossa increases pain (Bow string)

• Wadell’s sign

• Also remember femoral stretch

LBP –diagnosis - Investigations• Plain X-ray – AP and lateral of LS Spine.

Sometimes do DL Spine• Special views – oblique, tomograms• Myelogram• CT – scan. CT Myelogram• MRI • Bone scan• EMG, NCT• ESR, CRP, WBC/DC, US scan abdo etc. (system

related)

Non-traumatic back pain

LBP

Non-organic

Organic Mechanical

Non-mechanical

Non-organic LBP• Should be a positive diagnosis• Bizarre symptoms – whole body pain,

hemibody pain, • Social problems• Attribution to assault or event at work

• Treat the back pain and the underlying problem

Purely functional

Purely organic

Mechanical or non-mechanical?

• The classic feature of pain of mechanical origin is aggravation by exercise and relief by rest

• Non- mechanical – constant. Night pain (particularly sinister)

Non-mechanical – in the spine or outside?

• Associated features – referable to systems• Dysuria, fever• Related to menstruation• Related to food• Other joints affected• Radiation to groin

Treatment of non-mechanical LBP

• Essentially treatment of the cause

• Referred pain – treat the relevant system

• Pain due to spinal disease – treat the cause. There maybe secondary mechanical effects requiring treatment

Prostate

Breast

Lung

Thyroid

Kidney

Non-traumatic back pain

LBP

Non-organic

OrganicMechanical

Non-mechanical

Types of mechanical LBP

• Acute back strain• LBP with sciatica• Chronic idiopathic back pain• Canal stenosis

Note – acute < 6 weeks

Acute back strain

• Acute onset – e.g.. While lifting

• Treatment is rest• Analgesics – NSAID/COX-2, others• Muscle relaxant• Gradual return to normal activity

LBP with sciatica• Describes sciatica – pain radiates right

down to the foot• SLR+ive (generally)

LBP with sciatica- Treatment options

• Bed rest, analgesics• Epidural steroid injections• Chemolysis, nucleotomy• Discectomy ( after imaging)

Indications for surgery

• Progressive neurological deficit• Non-resolving neurological deficit• No response to non-operative treatment• Acute cauda equina syndrome

Acute cauda equina syndrome

• Bilateral sciatica• Saddle anaesthesia• Impotence• Bladder, bowel disturbances

Chronic idiopathic back pain• No definite cause• Treatment – pain relief• Also – “Back school”

Canal stenosis

• Narrowing of the canal• Causes Neurogenic claudication – feeling of

heaviness, numbness, motor deficit on walking

• Relieved by rest, bending forward• Does not occur when cycling• Causes – spondylolisthesis, ligamentum

hypertrophy,• Treatment – Surgery (laminectomy)

Summary

• Back pain is common. Important to you and to the country

• History, examination and investigations should fit the patient into a category

• Treatment as appropriate• Surgery has little place in the treatment