Low backache


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Low backache

  1. 1. 2. LOW BACKACHEAbout The AuthorDr Manoj R. kandoi is the founder president of “Institute of Arthritis Care & Prevention”an NGO involved in the field of patient education regarding arthritis. Besides providingliterature to patient & conducting symposiums, the institute is also engaged in creatingpatients “Self Help Group” at every district level. The institute also conducts a certificatecourse for healthcare professionals & provide fellowship to experts in the field of arthritis.The author has many publications to his credit in various journals. He has also written a book “ The Basics Of Arthritis” for healthcare professionals.The author can be contacted at:Dr manoj R. kandoiC-202/203 Navare ArcadeShiv Mandir Road, Opposite Dena BankShiv mandir Road, Opposite Dena bankShivaji Chawk, Ambarnath(E) Dist: Thane Pin:421501State: Maharashtra Ph: (0251)2602404 Country: IndiaMembership Application forms of the IACR for patients & healthcare professionalscan be obtained from.Institute of Arthritis Care & PreventionC/o Ashirwad HospitalAlmas mension, SVP Road, New Colony,Ambarnath(W) Pin:421501 Dist: ThaneState: Maharashtra Country: IndiaPh: (0251) 2681457 Fax: (0251)2680020Mobile ;9822031683Email: drkandoi@yahoo.co.inCONTENT2.1 ANATOMY2.2 EPIDEMIOLOGY2.3 CLASSIFICATION OF LOW BACKACHE2.4 CLINICAL EXAMINATION2.5 DIAGNOSTIC STUDIES2.6 EVALUATION OF SYMPTOMS IN PATIENTS WITH LOW BACKACHE2.7 CONSERVATIVE MODALITY OF TREATMENT OF LOW BACKPAIN2.8 CLINICAL APPROACH IN MANAGEMENT OF LOW BACKACHE2.9 COCCYGODYNIA2.10 RADIOGRAPHIC APPROACH TO LOW BACKACHE
  2. 2. 2.1 ANATOMY :In the adult the inter-vertebral disc is composed of the annulus fibrosus and the nucleus pulposus.The annulus fibrosus is composed of numerous concentric rings of fibro-cartilaginous tissue. Therings are thicker anteriorly than posteriorly. The nucleus pulposus, a gelatinous material forms thecenter of the disc. The disc proper is separated from the vertebral body by hyaline cartilage plate.
  3. 3. The intervertebral discs in adults receive nutrition through two routes (a) the bidirectional flow fromvertebral body to disc & from disc to vertebral body, and (a) the diffusion through the annulus fromblood vessels on its surface.Weight is transmitted to the nucleus through the hyaline cartilage plate, Because of this axial loadingthe nucleus pulposus is under considerable pressure & disc tangential load is absorbed by annulusfibrosus.2.2 EPIDEMIOLOGY :Back pain has now appeared as a modern international epidemic. Up to 80% of the population isaffected by this symptom at some point of time.Risk Factors: 1. Cigarette smokers & with greater tobacco consumption 2. Type I personality 3. Patients taller than 181 cm 4. Patients with slightly higher body weight 5. Multiple pregnancies. 6. Jobs requiring heavy and repetitive lifting2.3 CLASSIFICATION OF LOW BACKACHE : 1. Psychogenic back pain (Nonorganic Spinal pain) 2. Viscerogenic back pain 3. Neurogenic back pain 4. Vascular back pain 5. Spondylogenic back pain. 6. Endocrine / metabolic1. Non-organic spinal pain: These groups of disorders include I. Psychosomatic spine pain a. Tension syndrome (fibrositis) II. Psychogenic Spinal pain III. Situational spinal pain a. Litigation reaction b. Exaggeration reaction.Index 2.1 Organic Spinal Pain Non-Organic Spinal Pain Well localized & usually mechanical pain - Multifocal & nonmechanical pain No superficial tenderness - Superficial tenderness SLR reduced in cases of PID - SLR may be normal Lasegue test +ve in PID - Lasegue test +ve Flip test: painful - Flip test: not painful
  4. 4. Flip Test: Normally in a case of prolapsed intervertebral disc, SLR is reduced which can also becheeked with patient in sitting position with knee extended. If true root Lesion were patient, onepatient would “flip” back on sitting SLR testing. A patient with non-organic spinal pain may showreduced SLR in supine position, it that will be normal on Flip test.2. Spondylogenic Back Pain:A. Osseous Lesions: I. Trauma: These can be 1. Compression in an osteoporotic spine 2. Fracture of vertebral appendices 3. Fracture of vertebral body following high-energy trauma.Causes of pain: I. Nonunion of fracture II. Misalignment of spine III. Spinal instability IV. Compression of nerve or spinal cordII. Infection: Infections involving the vertebral column includea. Vertebral osteomyelitis:  Pyogenic  Tuberculous  Miscellaneous.b. Intervertebral disc Infection.c. Intervertebral disc inflammation.The infection is characterized by restriction of range of motion, paraspinal muscle spasm, localizedtenderness, sometimes associated paraspinal mass or abscess. The offending organism can beidentified by blood culture or a vertebral biopsy and culture.III. Neoplasm: - Benign Tumours - Anterior column (Haemangioma & eosinophilic granuloma) - Posterior column (Giant cell tumor, osteod osteoma) - Malignant Tumours - Primary usually involve vertebral body - Secondary metastasis. Lymphoma & LeukemiaThe diagnosis of these tumors is largely dependent on x-rays.IV) Metabolic Bone Diseases: These include osteofibrosis, osteopetrosis, alkcaptonuria , familialhypophosphataemia etc but the metabolic bone problem most commonly presenting with low backpain is osteoporosis.
  5. 5. V) Spondylolisthesis: Spondylolisthesis is due to forward displacement of one vertebra over other. Itmay be because of traumatic, congenital, dysplastic, degenerative etiology. Cause of pain includesmechanical derangement including spinal instability, neuropathy (compression of nerve root)myelopathy (compression of spinal card) & pain arising from defect site at pars interarticularis.VI) Sacroiliac Joint Strain: More common after repeated pregnancies.Clinically characterized by tenderness over lower third of the sacroiliac joint below the posteriorinferior iliac spine and positive pelvic compression test.VII) Ankylosing SpondylitisB) Soft Tissue Lesions: I. Myofascial sprains or strains. II. Fibrositis (Fibromyalgia) and myofascial pain syndrome. III. Disc Degeneration: These pain in general is aggravated by general and specific activities & is relieved, to some extend be recumbency.3. Viscerogenic Back Pain: It is derived from disorders of the kidneys or the pelvic viscera, fromthe lesser sac, & from retroperitoneal tumors. These are usually associated with other symptoms ofvisceral involvement. The pain is not aggravated by activity, nor is it relieved by rest. It includes:A. Pelvic Disorders: a) Pelvic inflammatory disease b) Endometriosis c) Torsion of a mass, cyst or fibroid d) Prostatitis e) Cystitis.B Abdominal Disorders: a) Peptic ulcer b) Pancreatitis.4. Vascular Back Pain: These includeA. Abdominal aortic aneurysm (Atherosclerotic or inflammatory) I. Rupture II. Erosion of surrounding structures III. DissectionB. Epidural HematomaC. Sickle cell diseaseD. Insufficiency of superior gluteal arteryE. Intermittent claudication.Abdominal aneurysm presents as a boring type of deep seated lumbar pain unrelated to activity.Insufficiency of the superior gluteal artery may give rise to buttock pain of a claudicant character,aggravated by walking, relieved by standing still. Intermittent claudication caused by peripheralvascular disease can mimic sciatic pain, but usually can be easily distinguished by the fact, painaggravated by walking is relieved immediately by standing still.Difference between neurological and vascular claudication :Neurological claudication Vascular claudicationVague heaviness, cramping pain. Sharp, cramping pain.It is aggravated by walking and sometimes by Aggravated by walking.standing.
  6. 6. May radiate usually proximal to distal after Rare after onset.onset.Relieved only in flexed position of spine such as Relieved with rest even with standing position.lying down or sitting down.Relief is slow takes many minutes. Relief is faster.Pulses present. Absent pulses and other trophical changes.Neurological symptoms and SLR positive. Absent.5. Neurogenic back pain: Intradural & extradural tumors & cyst may mimic symptoms producedthe day & history of night pain may be there. Diagnosis is mainly on M. R .I.6. Endocrine / Metabolic: a. Osteoporosis b. Paget’s disease c. Diabetes. d. Hypothyroidism e. Hyperthyroidism f. Hyperparthyroidism2.4 CLINICAL EXAMINATION :HistoryAge: Adolescents: - Postural - Traumatic - Infective. Adults: - Ankylosing spondylitis -PID Elderly persons: - Degenerative arthritis - Osteoporosis - Secondary matastasisSex: Back pain is slightly more common in women due to lack of exercise, nutritional osteomalacia,multiple pregnancies.Sex incidence of painful back conditions :Commonly in males Commonly in femalesSpondytoarthropathies OsteoporosisWork related mechanic backache FibromyalgicTuberculosis Polymyalgic rheumaticaNeoplasms HyperparathyroidismPaget’s diseasePeptic ulcerRetroperiteneal fibrosisOccupation: Back pain is common in surgeons, dentists, truck drivers etc.Past History: Past history of trauma, tuberculosis etcPain: Site: Lumbar spine; - P I D - Degenerative spondylosis D L spine - Infection - trauma Onset : - acute, subacute, chronic Progress of pain : - pain of infection & tumor tends to be progressive, pain of arthritis & spondylitis is constant, pain of disc prolapse & trauma may decrease over time.Relieving & Aggravating Factors: Most back pains are worsened by activity relieved by restespecially in arthritis. Pain due to inflammatory spondyloarthropathy is more at rest & may initiallyimprove with activity.
  7. 7. Osteod osteoma is associated with severe pain at night that responds to aspirin. Patient with spinalcanal stenosis will complain of pain on walking & standing relieved by sitting, stooping forwards.Associated Symptoms: 1. Stiffness: It is seen in inflammatory arthropathies. 2. Fever or chills: It suggests possibility of infection 3. Weight loss, chronic cough, change in bowel habits, night pain, other constitutional symptoms may be seen in malignancy. 4. Pain in other joints: e.g. in seronegative spondyloarthropathies or endocrine disorders. 5. Fatigue or sleep disturbances: fibromyalgia should be ruled outDifferential diagnosis of ankylosing spondylitis with other causes of backache : Ankylosing spondylisis Backache due to other causesMorning stiffness >30minutes <15 minutesRest Aggravates pain and stiffness Relieves painPhysical activity Relieves pain Increases painRestriction of joint motion Restricted pain in all directions Only in some directionNeurological Symptoms: Weakness, paraesthesia or numbness in dermatomal distribution points topossible nerve root impingement & the level of impingement. Commonest cause is P I D (in agegroup of 20-50 years) & tuberculosis.L 3-4 disc affects the L 4 nerve root, L 4-5 disc affects L 5 nerve root & L 5-S1 affects the S1 nerveroot.The other cause of neurological symptoms is neoplasm.Presence of bladder / bowel involvement suggest cauda equina syndrome requiring immediateinvestigations & further management.Physical Examination: The patient should be stripped to undergarmentsA. Patient Standing:1. Alignment of spine: normally a person stands erect with the center of occiput in the line with the natal cleft.  Pelvic tilt may suggest paravertebral spasm  Loss of lumbar lordosis suggest spasm or ankylosis  Structural scoliosis.2. Evaluate:  Gait  Station  Posture 3. Range of motion: It is restricted in organic diseases .of the spine.
  8. 8. 4. Swelling: Cold abscess may suggest TB5. Localized tenderness may suggest trauma  Twist Tenderness: On rotating the 2 spinous processes over each other suggest P I D or local infection.  Tenderness at SI jointB. Patient Supine 1. Straight leg raising (SLR): it is indication of nerve root impingement. 2. Neurological examination 3. Peripheral pulse. 4. Adjacent Joints: Hips & SI joint 5. Chest expansion 6. Abdominal, rectal or per vaginal examination if required.C. Patient Prone- Femoral stretch test (extending the hip) may be positive in L4 radiculopathy : This test detectsL234 disc prolapse. The femoral nerve is stretched by extending the hip by 150 with patient in proneposition. Now the knee is slowly flexed to further stretch the femoral nerve. Pain radiating to theanterior thigh is suggestive of radiculopathy. Depending upon the dermatome of pain radiation,exact nerve can be identified.- Palpate bony tenderness & trigger points, nodules.
  9. 9. POSITIVE FEMORAL STRETCH TESTNEUROLOGICAL EXAMINATION :Neurological examination :Nerve tension tests :These tests are for checking nerve root compression of femoral or sciatic nerve. Femoral nerve(formed of L2,3 and L4 nerve roots) runs along the anetomedial aspect of the thigh and sciatic nerve(formed of L4,5 S1,2 and 3 nerve roots) runs along the posterior aspect of thigh.Straight leg rising test : (SLRT)Principle : Normally while doing SLRT during the first 0 to 300 the slack nerve roots become tautbut there is no tension. Between 30 to 700 the sciatic nerve root stretches over the intervertebral disc.Above 700, there is no further deformation of the root and pain may be because of SI joint strain ornerve root compression beyond the spine. The sciatica due to PID is therefore positive between 30 to700. Upto 300 pain maybe due to hamstring tightness, which can be differentiated by Laseque’s test.Method :Position : Patient lies in supine position with the head and the pelvis flat.Procedure : It is a passive test and each leg is tested one by one. With knee in full extension, onelimb is progressively elevated until maximal hip flexion is reached or patient develops radiating pain.The angle formed by the lower limb and the examination cot is noted. The test is considered positiveif there is back pain radiating along the course of sciatic nerve below the knee.Alternative method : Patient sits at the end of the table with spine erect and the legs hanging at theedge from the knees. The affected side leg is extended suddenly with patient supporting himselfwith both hands on the table. In case of sciatic root impingement, patient will develop radiating painand low backache.Laseque test : This test is performed after SLR by lowering the affected leg by few degrees fromthe point of pain and then dorsiflexing ankle. This maneuver again deforms the sciatic nerve.Positive test strengthens the diagnosis of sciatica.Reverse SLR test : It is performed by plantar flexing rather than dorsiflexing the foot, positive testis suggestive of malingering.Crossed SLR test : This is performed on the side opposite that of the sciatica. If this maneuverreproduces or exacerbates the patient’s other side sciatica, the result is considered to be extremelysensitive and specific for herniated L4,5 or L5 S1 disk. This test is usually seen in large discherniation and is also known as well leg raising test of Faserstanzn’s.Lateral flexion test of spine : With the patient in standing or supine position, ask the patient toacutely flex the spine laterally on the affected side. Due to approximation and stretching of root tothe protruded disc from lateral sides, the patient will feel a catching pain. If symptoms are producedon flexing the spine on the opposite side, it is suggestive of pressure on the root from the medial side.Bowstring sign : In this method, SLRT test is performed to reproduce pain. The knee is thenflexed to 900 and digital pressure is applied over the posterior aspect of sciatic nerve. If it reproducesthe pain it is suggestive of sciatica.Cox sign : In this method the patient is asked to raise pelvis from the table rather than hip flexing.This test is suggestive of intervertebral foraminal prolapse of intervertebral disc.Lewing punch test : Here the patient is in standing position, the patient’s buttock on the affectedside is precussed to reproduce pain of sciatica. Positive test is suggestive of a protruded disc.
  10. 10. Valsalva’s maneuver : In this maneuver, patient is asked to bear down as if attempting to have abowel movement, which increases the intrathecal pressure thereby exacerbating pain of nerve rootstretching.Hoover’s test : It is done along with active straight leg rising to determine whether patient ismalingering. When a patient genuinely attempts an active SLR he puts downward pressure oncalcaneus of his opposite leg to gain leverage. It can be confirmed by putting examiners handbetween calcaneum and the examination table.False positive SLRT : False positive SLRT may be found in myogenic pain, ishial bursitis, annulartear and hamstring tightness. These can be differentiated by Lasegue’s test and Bowstring sign,which are positive in prolapsed intervertebral discs.Limitations of SLRT : The straight leg raising stretches the L5 and S1 nerve roots by 2mm to 6mm,but it puts little tension on the more proximal nerve roots. An abnormal straight leg raising test,therefore, suggests a lesion of either L5 or S1 nerve root.3. Motor testing :Lumbar Root Lesions:Root Muscle group weakness Tendon reflex decreasedL2 Hip Flexion / AdductionL3 Hip adduction / Knee extension Knee JerkL4 Knee extension Foot inversion / dorsiflexion Knee JerkL5 Hip extension / abduction Knee Flexion Foot / toe dorsiflexionS1 Knee Flexion Ankle Jerk Foot / Toe planter Flexion Foot eversion.4. Sensory testing :
  11. 11. Special tests :Phalen’s test : This test attempts to reproduce features of leg pain, weakness or numbness byaccentuating spinal stenosis thereby causing neural ischaemia. With the patient upright, bend thepatient into extension for one minute; positive test is associated with the symptoms, which getsrelieved on flexing forward.Squat test : This test is done to rule out joints of lower limb involvement. Patient is asked to squatdown bouncing 2 to 3 times and then returning to the standing position. If patient is able to do sothen hips, knee and ankles are normal.Schober test : It detects limitation of forward flexion of the lumbar spine. Two marks at a distanceof 10 cms are placed, one at the level of posterior superior iliac spine and another above in themidline. With maximal forward spinal flexion with locked knees, the measured distance shouldincrease from 10 cm to at least 15 cms.Chest expansion : Measured at the fourth intercostal space, normal chest expansion isapproximately 5cm.Bulbocavernous reflex : It refers to contraction of anal sphincter in response to tugging of foleycatheter or squeezing of glans penis. This is a spinal cord mediated reflex arch involving S 1,2 & S3nerve roots. In injuries above L1 vertebral levels the reflex is lost during the stage of spinal shock(which usually resolves with 48 hours); at the level of L1 vertebra it may be because of conusmedullaris injury and below L1 vertebra it may be because of cauda equina injury. If thebulbocavernous reflex (stage of spinal shock) returns and there is no sensory or motor recovery thenit is suggestive of complete lesion.Sacral sparing : Sacral sparing is associated with perianal sensation, rectal motor function andgreat toe sluxor activity. Presence of sacral sparing may be the only sign of an incomplete spinallesion. If bulbodavernous reflex returns and there is not even sacral sparing then it is suggestive ofcomplete lesion.
  12. 12. Lesions in a nutshell :L4 root compression :Motor weakness Quadriceps musclesSensory involvement Hypoasthesia at L4 dermatomeReflexes Decreased knee jerkSLRT test NegativeFemoral stretch test Positive L5 root compression :Motor weakness Extensor hallucis longusSensory involvement Hypoesthesia / Hyperaesthesia at L5 dermatome.Reflexes NegativeSLRT test PositivePatient is unable to walk on the heel.S1 root compression :Motor weakness Gastrocnemius and peronei weaknessSensory involvement Hypoesthesia / Hypperaesthesia at S1 dermatomeReflexes Ankle jerk diminishedSLR test PositivePatient is unable to walk on the toes.Signs suggestive of functional backache :Waddell has described five tests to identify functional backache, presence of 3 or more positive testsis suggestive of functional backache.Waddell tests :1. Tenderness to superficial touch.2. Simulation tests : a. Axial loading. b. Spinal rotation in one plane.3. Distraction tests.4. Abnormalities not following neuro-anatomic structures5. Disproportionate symptomatology (overreaction)
  13. 13. 2.5 DIAGNOSTIC STUDIES : 1. X-Rays:  Routinely AP Lateral view should be ordered for low backache  Oblique views may be required if spondylolysis is suspected.  Flexion & Extension view may be ordered if instability suspected.Radiographic Evaluation of Inflammatory Versus Noninflammatory spinal Arthritis Features Non Inflammatory Infection Spondyloarhropathy S. I. Joint Normal Normal / Single joint Erosions + Vertebral bodies Sclerosis - osteoporosis - squaring + - Irregular eroded end - erosions Plates - Osteoporosis Discspace - Decreased -Decreased -may be calcified or convex - Vacuum phenomenon -Usually one space -multiple. Osteophyte Prominent Absent Absent Soft tissues mass - + - Syndesmophyte Absent Absent Present
  14. 14. Degenerative Lumbar Spondylosis Degenerative Spondylolisthesis2. Bone scan: If malignancy or infection is suspected3. CT SCAN / MRI: Especially useful in acute emergencies, unresponsive cases or in those case where surgery is contemplated. 4. EMG -NCV: may be useful in chronic radiculopathy (radiating pain with or withoutneurological deficit) 5. Blood investigation: These include:  CBC ESR: If infection suspected  Mantoux test: To rule out Tuberculosis  Urine( RM) : urinary infection ruled out  Serum Calcium; Phosphorus & alkaline phosphatase: Secondary metastasis is associated with raised alkaline phosphate.  Urine for Bence zones proteins: To rule out multiple myeloma  Serum electrophoresis  HLA B27: If serongative spondylo arthropathy suspected.
  15. 15. 2.6 EVALUATION OF SYMPTOMS IN PATIENTS WITH LOW BACKACHE : Symptoms Possible Etiology Clinical Evaluation Fever or weight loss Infection tumor - CBC ESR - X-rays - Bone Scan - CT / MRI - SOS Biopsy Night Pain - Tumor of bone - X-rays - Spinal cord tumor - Bone Scan - CT / MRI - Hb CBC ESR - Serum Calcium Phosphorus & alkaline phosphatase - Other chemical profile Morning Stiffness - RA - ESR - AS - RA - Psoriatic arthritis - ANA Factor - X-rays including S I Joints Colicky Pain - Kidney - Urine (R&M) - Gall Bladder - sos Urine culture - Acrtic - Amylase - Gastrointestinal - USG abdo - Barium studies - sos CT SCAN - Aortogram2.7 CONSERVATIVE MODALITY OF TREATMENT OF LOW BACKPAIN : 1) Rest:  Absolute bed rest on a hard bed (a mattress if allowed)  Usually up to 2-3 weeks  After 3 week, rest does not have added advantage & gradual mobilization with or without brace is advisable 2) NSAIDS:  To break pain, spasm & pain cycle  Symptomatic relief  To allow mobilization of patient. 3) Muscle Relaxants: In cases with stiff spine, tizanidine or chlorzoxazone may be used. 4) Physical modalities: Such as SWD, hot packs & USG therapy 5) Exercise programme
  16. 16. 6) Traction:  It immobilises the patient  Distracts neural formina there by decompressing nerve root  Relieves muscle spasm7. Brace : Especially useful in trauma, infection & osteoporotic fracture.Education : This includes avoidance of stressful activities, improvement of posture, dietary adviceas related to weight reduction & calcium intake.2.8 CLINICAL APPROACH IN MANAGEMENT OF LOW BACKACHE :A. Acute Backache:Commonest Causes are: I. Prolapsed Intervertebral Disc. II. Trauma:  Soft tissue injury  Bony injury III Infection IV Neoplasm V Referred pain due to viscerogenic or vasculogenic causes. VI Sickle cell crisis, diabetic neuritis.STEP I: Rule out condition, which require urgent intervention.1. Cauda Equina Syndrome:  Saddle Anaesthesia around anus  Bladder / Bowel involvement  Bilateral sensory motor deficit2. Aortic Aneurysm:  Pulsatile Abdominal mass  Absent Dorsalis pedis pulse  Older patient  History of claudication or other circulatory problems  Circulatory instability Acute Low Backache Neurological deficit with NO NO Ruptured aortic aneurysm Bladder / bowel Further Evaluation Yes Yes
  17. 17. Urgent MRI Immediate angiogram Yes Yes Surgical Intervention Resuscitative surgeryB. Chronic Back Pain (Subacute Backache) :Subgroups I. Localized Chronic Back pain II. Low back pain with sciatica III. Anterior thigh pain IV. Chronic Back pain with posterior thigh pain1. Localized Low Backache:Etiology:  Disc Degeneration.  Vertebral instability  Osteoarthritis  Osteoporosis  Spondyloarthropathy  Osteomyelitis  Vertebral neoplasms  Old trauma2. Low Backache With SciaticaSciatica : By definition it is radiation of pain along the distribution of sciatic nerve that is posterioraspect of buttocks, thigh, leg, and foot.Differential diagnosis of sciatica :Intraspinal causes Extraspinal causesAbove the level of disc At the level of pelvisConus lesions and cauda Equina lesions (e.g. Orthopaedic diseases of hip and SI joint.neurofibroma etc.) Neoplasms Gynaecological conditions Cardiovascular conditions (e.g. peripheral vascular diseases)At the level of the disc Below pelvis :PID Nerve lesions
  18. 18. Canal or recess stenosis TraumaticNeoplastic NeoplasticInfection : TB, pyogenic, discitis Herpes zosterArachidonitis Neuropathy due to diabetes or alcohol etc. Causes of SciaticaDiagnostic criteria for sciatica due to disc prolapse :  The leg pain is more than back pain.  Dermadome-wise distribution of tingling and numbness.  Positive SLRT test/Bowsting sign/crossed SLR test  Presence of at least two of the following neurological signs :  Atrophy.  Motor weakness.  Decreased sensation.  Altered reflexes. Therapeutic Approach Low Backache with pain on flexion Low backache with pain on extension Herniated Disc X-rays / CT / MRI Lumbar canal stenosis No significant Neurological Neurological findings deficit –ve deficit + ve Conservative treatment Conservative treatment Conservative CT/ MRI +ve Treatment Epidural steroids - Rest - Heat therapy Surgical decompression - Brace - NSAIDS - Enzyme preparation Orthopaedic management - Low dose steroid
  19. 19. 3. Low Backache With Posterior Thigh PainCauses:  Back strain  Localized spinal stenosis  High herniated discs.Treatment modalities:  Local injection of hydrocortisone at tender spots  NSAIDS  If no relief radiographic evaluation & further management according to the diagnosis4. Low backache With Anterior Thigh PainCauses:  Back Strain  Inguinal Hernia  Hip Etiology  Diabetic Femoral Neuropathy  Abdominal Aneurysm  Renal stone  Retroperitoneal tumor.Therapeutic Approach : Low Backache With Anterior Thigh Pain Clinical Examination Inguinal hernia Anterior hip tenderness/ hip stiffness Negative X-rays PBH Blood Sugar + ve Hip disorders - ve +ve Abdo + pelvic Diabetic neuropathy ultrasound - ve + ve CT Scan with contrast Renal stone or aneunym + ve - ve - Retroperitoneal tumor Conservative therapy
  20. 20. - Retroperitoneal infection2.9 COCCYGODYNIA :This term is used for pain in and around the coccygeal region. ( The term coccyx implies Greekword kokkoux meaning cuckoo since it resembles the shape of a cuckoo’s beak. )Incidence :M : F  1:5 (as coccyx is more prominent and exposed in females)Less than 1% of low back pain incidence.Etiology :Trauma to sarococcygeal joint e.g. due to kick, fall with resultant fracture subluxation or dislocation.Childbirth with concomitant hormonal changes can lead to stretching and inflammation of coccyx.Indiopathic.Pilonodal cyst formation.Piriformis pain.Repetitive strain such as in cycling or rowing.Obesity, which causes excessive pressure on coccyx in sitting.Frictional bursitis at tip of coccyx.Clinical examination :Tenderness on direct palpation of the coccyx.PR and PV examination must be done to rule out masses.Investigations :X-rays lateral view of coccyx : If possible both standing and sitting lateral view should be taken tolook for and abnormal coccygeal mobility. Presence of more than 250 flexion or dynamic x-rayssuggest hypermobility, presence of more than 250 displacement suggests subluxation.MRI may be useful in suspected neoplastic or infective lesionsTreatment :1. Conservative therapy : It includes : a. NSAID. b. Air ring cushion. c. Hot-sitz-type baths. d. Phonophoresis or iontophoresis of local corticosteriod or analgesic combination.2. Local steroid injection.3. Manipulation under GA.4. Surgical Therapy : It includes coccygectomy. The complication of this procedure include infection, rectal injury, local wound dehiscence, scarring etc. Surgery is indicated if conservative therapy fails after an adequate trial of atleast 2 months. Recovery after surgery may take 6 months to 1 year.2.10 RADIOGRAPHIC APPROACH TO LOW BACKACHE : X-rays of spine Changes suggesting of Miscellaneous condition seen Non inflammatory inflammatory arthritis e.g. - Pagets - Metastasis - Myeloma - Fluorosis Age > 50 Age < 50 -Degeneration Ochronosis Arthritis ( Disc space -CPPD calcification)
  21. 21. Sacroiliac joint lesion single disc space infectionSymmetrical Asymmetric UnilateralSyndesmophytes Bilateral- AS syndesmophyte septic- Ulcerative bowel - Reiter’s disease reiter’s disease - psoriasis psoriasisRadiographic Evaluation of Inflammatory Versus Noninflammatory spinal Arthritis Features Non Inflammatory Infection Spondyloarhropathy S. I. Joint Normal Normal / Single joint Erosions + Vertebral bodies Sclerosis - osteoporosis - squaring + - Irregular eroded end - erosions Plates - Osteoporosis Discspace - Decreased -Decreased -may be calcified or convex - Vacuum phenomenon -Usually one space -multiple. Osteophyte Prominent Absent Absent Soft tissues mass - + - Syndesmophyte Absent Absent PresentDifferential diagnosis of lytic lesion of spine :Malignant :osteosarcomachondrosarcomafibrosarcomaEwing’s sarcomamyelomaplasmacytomalymphomaleukemiaBenign :GCTHaemangiomaEosinophilic granulomaABCfibrodysplasiabrown tumorpagets diseaseDifferential diagnosis of ivory vertebra :Pagets disease(bone is expanded)Multiple myelomaLymphomaHaemangioma(coarse marking)metastastasisNeoplastic lesions of vertebral column: Vertebral body :Primary Tumours:Multiple myeloma
  22. 22. ChordomaOsteosarcomaHaemangiomaGCTEosinophilic GranulomaAbout 75%of vertebral body tumors are malignantSecondary TumoursPosterior elements :More commonly benign(65%).These includeABC, Osteoblastoma, Osteod osteoma.Type EtiologyTraction osteophytes Instability.Marginal syndesmophyte As, inflammatory B.D.Nonmarginal syndesmophytes Dish, reiters and pscriasis Steffie plating for spinal pathologies
  23. 23. Lumbar Spondylolysis Severe kyphosis Koch’s SpineThoraco - Lumbar Fracture Spine Giant Cell Tumor of Spine ScoliosisOsteochandroma Dish Syndrome