6. Low back pain
LBP can be caused by pain in the muscles,
ligaments, joints, bones, discs, nerves, or
blood vessels.
• In 90% of cases, the specific cause of LBP is
unclear.
• In 10% of cases, a specific cause such as an
infection, fracture, or cancer is identified.
8. Diagnosis
The diagnosis can be classified into three categories:
1. Nonspecific back pain—Pain for less than 6 weeks
(acute), 6 to 12 weeks (subacute), or more than 12
weeks (chronic); negative straight-leg raise test;
absence of red flags.
2. Radicular syndrome—LBP with radiation down leg;
positive straight-leg raise test; absence of red flags.
3. Serious pathology—Further work-up required for
presence of red flags, including age younger than 20 or
older than 55 years; significant trauma; fever;
unexplained weight loss; neurologic signs of cauda
equina; progressive neurologic deficit.
11. Osteoporotic vertebral fracture
Acute onset of pain, typically seen in older
patients or those at risk for osteoporosis,
point tenderness at the level of the fracture,
confirmation by plain radiographs
demonstrating compression or burst fracture
13. Spinal stenosis
Pain worse with extension, presence of
unilateral or bilateral leg symptoms worse
with walking and better with sitting,
confirmation by CT or MRI
15. Herniated disc
Radicular pain that is worse with flexion or
sitting, may be accompanied by numbness or
weakness of foot plantar flexion (L5/S1) or
dorsiflexion (L4/L5), MRI confirms the level
and shows the type of herniation
17. Spinal infection/abscess
•Most commonly seen in patients who use IV
drugs, have diabetes mellitus, have cancer, or
have a transplant; symptoms include fever,
night pain, night sweats, and elevated ESR. MRI
is the study of choice. If neurologic deficit is
present, obtain an urgent MRI to evaluate for
an abscess, which would require hospitalization
and consultation with a spinal surgeon.
19. Ankylosing spondylitis
Pain, most commonly in the low back or
sacroiliac joints, usually begins in late
adolescence or early adulthood. Pain and
stiffness worsen with immobility and improve
with motion. HLA-B27 may be positive.
Radiographic findings confirm the diagnosis,
but occur years after symptoms.
20. Malignancy
Typically seen in an older patient; symptoms of
weight loss and night pain; significant anemia;
history of cancer; nonresponse to therapy.
Often seen on plain radiographs. Bone scan is
the most sensitive test.
21. Abdominal pathology
•such as pancreatitis, pyelonephritis, and
cholecystitis can present as back pain or pain
radiating to the back
23. One of the complications of osteoarthritis of the
vertebral column is the growth of osteophytes,
which commonly encroach on the intervertebral
foramina, causing pain along the distribution of
the segmental nerve. The fifth lumbar spinal
nerve is the largest of the lumbar spinal nerves,
and it exits from the vertebral column through
the smallest intervertebral foramen. For this
reason, it is the most vulnerable
24. Since the fully developed vertebral body is
intersegmental in position, each spinal nerve
leaves the vertebral canal through the
intervertebral foramen and is closely related
to the intervertebra disc. This fact is of great
clinical significance in cases with prolapse of
an intervertebral disc
26. Ankylosing spondylitis causes destruction of
articular cartilage and bony ankylosis
Disease involving the sacroiliac joints and
vertebrae becomes symptomatic in the second
and third decades of life as lower back pain
and spinal immobility
28. The infection breaks through intervertebral discs to
affect multiple vertebrae and extends into the
soft tissues. Destruction of discs and vertebrae
frequently results in permanent compression
fractures that produce scoliosis or kyphosis and
neurologic deficits secondary to spinal cord and
nerve compression. Other complications of
tuberculous osteomyelitis include tuberculous
arthritis, sinus tract formation, psoas abscess,
and amyloidosis.
30. Pyelonephritis is one of the most common
diseases of the kidney and is defined as
inflammation affecting the tubules,
interstitium, and renal pelvis
31. Acute pyelonephritis is generally caused by
bacterial infection and is associated with
urinary tract infection.
Chronic pyelonephritis is a more complex
disorder; bacterial infection plays a dominant
role, but other factors (vesicoureteral reflux,
obstruction) predispose to repeat episodes of
acute pyelonephritis.
32. Acute pyelonephritis
Acute pyelonephritis usually presents with a sudden
onset of pain at the costovertebral angle and systemic
evidence of infection, such as fever and malaise.
There are often indications of bladder and urethral
irritation, such as dysuria, frequency, and urgency.
The urine contains many leukocytes (pyuria) derived
from the inflammatory infiltrate, but pyuria does not
differentiate upper from lower urinary tract infection.
The finding of leukocyte casts, typically rich in
neutrophils (pus casts), indicates renal involvement,
because casts are formed only in tubules. The
diagnosis of infection is established by quantitative
urine culture.
34. Chronic obstructive pyelonephritis may have a
silent onset or present with manifestations of
acute recurrent pyelonephritis, such as back
pain, fever, pyuria, and bacteriuria
36. Chronic pancreatitis is defined as prolonged
inflammation of the pancreas associated with
irreversible destruction of exocrine
parenchyma, fibrosis, and, in the late stages,
the destruction of endocrine parenchyma.
37. Chronic pancreatitis may present in many
different ways. It may follow repeated bouts
of acute pancreatitis. There may be repeated
attacks of mild to moderately severe
abdominal pain, or persistent abdominal and
back pain.
