An approach to the problem of

Low 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
Deformity
Acquired
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)

Wadells 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
Organic
Mechanical
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