Low Back Pain
Dr Liau Kai Ming
Dept. of Orthopaedic

Incidence
 Very common among working group
 90% in pt >45years old
 80% resolves with conservative treatment (in
<3 months)
 Only 5-10% may require operation

Implication
 Work & productivity loss

Anatomical consideration
 Commonly at lumbosacral junction (L4/L5,
L5/S1)
 Why?

 Most mobile region of the spine
 Therefore prone to degeneration (wear &
tear)

Causes of pain
 Degenerative (most common)
 Instability(fracture, spondylolisthesis)
 Organic (Tumour,infection)
 Nerve compression/irritation(PID, root
compression)
 Rule out psychogenic cause (insurance
claim, problem with employer etc)

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

Nature of pain
 MECHANICAL VS NON-MECHANICAL
 REFERRED VS RADICULAR
 CLAUDICATION – VASCULAR VS SPINAL

MECHANICAL PAIN
1. Muscle strain
2. Ligament sprain
3. Facet joint arthritis
4. Disc-Discogenic
5. Instability - Spondylolysis/spondylolisthesis

NON-MECHANICAL PAIN
 Infection – PYOGENIC VS TB
 Tumour – PRIMARY VS SECONDARY
 Primary - BENIGN VS MALIGNANT

Common causes of low back pain
Pathology Age Pain nature Assoc pain Assoc sx
DEGENERA >40y mechanical Distance Active pt
TIVE claudication
Spondylosis
Spondylolisth <20y mechanical extension Hyperextensi
esis >40y on activity
Trauma Any age mechanical - Trauma
Infection Any age non- Rest pain Fever
mechanical
Mets >50y Non- Rest pain Primary +
mechanical LOW
LOA
Osteoporosis >60y mechanical - Trivial trauma

RED FLAGS
 Constitutional symptoms
 LOW, LOA, fever
 AGE(>50)
 IMMUNOCOMPROMISED,
 TB CONTACT
 KNOWN CANCER
 NEUROLOGICAL DEFICIT (CAUDA EQUINA SYN)

Physical findings
 General examination
 Age
 Ill looking
 Local examination – DO NOT MISS A
GIBBUS

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

 Full neurological examination
 ANAL TONE / PERIANAL SENSATION
 DERMATOME & MYOTOME

Investigations

Plain radiograph
 AP
-loss of lumbar lordosis
-reduced disc space
-osteophytes
-deformity
-fracture (increase interpedicular distance)
-osteoporosis
-pedicle disruption

 Lateral
-fracture/wedging
-kyphosis
-spondylolisthesis
 Oblique
-spondylolysis (SCOTTIE DOG)

Plain x-rays

Blood investigations
 FBC
 Anemia, TWC
 ESR
 Liver function test
 ALP
 Renal function test
 Calcium level

CT Scan
 better visualization of bone pathology (eg.
cortical destruction)
 fracture
 tumor

MRI
 -better soft tissue visualization
 -disc
 -ligaments (ALL,PLL)
 -nerves (spinal cord, roots)
 -bone marrow
 -pus collection

MRI

CT myelogram
 role replaced by MRI
 for delineation of neural structures where MRI
is not available/contraindicated

CT Myelogram

Bone scan
 Suspicious of multiple bone mets
 Eg. with history of untreated/treated CA
 Negative in Multiple myeloma

Treatment
 Mainly conservative
-Bed rest/pelvic traction
-physiotherapy
-back exercise
-modification of daily activities
-SWD/ultrasound
-NSAIDs/COX-2 inhibitor
-local injection (epidural steroids, facet joint)

Pelvic traction

Surgery

Indications for surgery
-PAIN - failed conservative treatment (>6 months)
-Evidence of neurological deficit (motor)
-Cauda equina syndrome
-Spinal instability (excessive spinal motion)
-Unacceptable deformity (eg degenerative scoliosis)

Surgery
1. DECOMPRESSION of spinal nerves (BURST
FRACTURE, Spinal stenosis, PID)
2. Fusion & Stabilization (Instrumentation)
3. Correction of deformity

DECOMPRESSION Surgery

FUSION Surgery

THANK YOU