1. LUMBAR PAIN
Mrinal Joshi
MBBS MD DNB MNAMS GCMskMed
Professor & Head, Dept. of PMR
Rehabilitation Research Center
SMS Medical College & Hospital
Jaipur

2. Low Back Pain
• Most expensive and common cause of
disability
• Maximum number of physician office visit
• Even more at quacks and alternate
practitioners
• Rates of surgery is on rise
• Recurrent symptom but benign prognosis
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3. 3

4. 4

8. Back Problem
• Extremely common medical issue
• Most expensive industrial injury ??
• 25% to 45% have symptom radiating below gluteal
fold
• 5% neurological changes during physical
examination
• 2% indicative of good surgical outcome by
decompression
• Half of the above recovery sufficiently to lose interest
in surgery
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9. Irrational Aspects
• Bleeding legs
• Screening x-rays
• Ageing changes as indication of pathology,
CT/MRI
• Passive treatments
• Huge Owen Thomas
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11. Elements of Pain
• Sinuvertebral nerves are primary innervation of disc
• Travel rostrally 2 levels and caudally 3 levels
• Posterior rami circumflex extends to facet joints
• Potential autonomic input responsible for burning skin,
shocks etc.,
• Sciatica results from both chemical and mechanical
irritation
• Muscular protection reduces with age e.g. leg in cast
• Activity beyond the capacity can result in symptoms
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13. Caveats
• Difficult to predict the outcome of back
problems
• Difficult to pain in those who are extremely
inactive
• Convince that there is nothing dangerous
• Using the back is beneficial and safe
• Managing back pain is like training for
marathon 14

14. Precis of Assessment
• History (sitting)
• Observation (standing)
• Examination
• Active movements (standing)
• Forward flexion
• Extension
• Side flexion (L/R)
• Rotation (L/R)
• Quick test
• Trendelenburg’s and S1 root test
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15. • Passive movements (with care and caution)
• Peripheral joints scan (standing)
• Sacroiliac joints
• Special tests (standing)
• One leg standing lumbar extension test
• H & I test
• Resisted isometric movements (sitting)
• Forward flexion
• Extension
• Side flexion (L/R)
• Rotation (L/R)

16. • Special tests (sitting)
• Slump test
• Sitting root test
• Resisted isometric movements (supine lying)
• Dynamic abdominal endurance
• Double straight leg lowering
• Internal/external abdominal oblique test

17. • Peripheral joint scan (supine lying)
• Hip joint (F/E/Ab/Ad/MR/LR)
• Knee joint (F/E)
• Ankle joint (Df/Pf)
• Foot joints (Sup/Pro)
• Toe joints (F/E)
• Myotomes
• Hip flexion (L2)
• Hip extension (S1)
• Knee extension (L3)
• Knee flexion (S1-S2)
• Ankle dorsiflexion (L4)
• Toe extension (L5)
• Ankle eversion or plantar flexion (S1)

18. • Special tests (supine lying)
• SLR and its variants
• Buttock signs
• Reflexes & cutaneous distribution
• Palpation (supine lying)
• Resisted isometric movements (side lying)
• Horizontal side support
• Special tests (side lying)
• Femoral nerve traction test
• Special torsion tests
• Peripheral joint scan (prone lying)
• Hip joint (Ex/MR/LR)
• Resisted dynamic extension test
• Special test (prone lying)
• Prone knee bending test

19. • Joint play (prone lying)
• Posteroanterior central vertebral pressure
(PACVP)
• Posteroanterior unilateral vertebral pressure
(PAUVP)
• Transverse vertebral pressure (TVP)
• Palpation
• Multifidus test

20. Waddell Embellishment Tests
• Tenderness: subcutaneous (or less) pressure to reproduce
symptoms
• Simulation
• Simulation of loading spine with weight of your hand to reproduce
pain
• Simulation of twisting trunk when rotating the hips and shoulder in
unison to reproduce pain
• Distraction: sitting knee extension and SLR test
• Non-anatomic distribution of pain on pain drawing or giving away on
muscle testing
• Overreaction: grimacing, complaints or suffering displays
inappropriate for situation or manoeuvre21

21. Red Flags
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22. Non-Physical Interference
• Threats to patient’s self-esteem, livelihood,
future, or other loss can significantly influence
patient’s response to caregivers
• Try not to be too judgemental
• Survival behaviour is a common human
response
• Zero to two Waddell’s are normal
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23. Treatment
• Assure that there is nothing to fear
• Comfortable activity tolerance can be achieved only by overcoming or
avoiding the debilitation of inactivity
• Conditioning
• 3-4 weeks of general conditioning
• Speed walk, stationary cycle, jogging
• Specific muscle training at least 4-5 times/week
• Next phase of other core and neck muscles
• Work hardening
• Patient benefit more from our honest help than judgement of legitimacy
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24. Diagnostic Considerations
In
Delayed Recovery
• If back symptoms persist and continue to limit
activity for more than 4 weeks, SEEK CAUSE
• A picture of tissue/bone abutting the dura does
not indicate it to be the cause
• Physiological evidence will tell us whether the
nerve root is compromised
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25. Diagnostic Considerations
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Technique Physiological Evidence Anatomic Evidence
History + +
Circumference measurement + +
Reflexes ++ ++
Straight-leg raise ++ ++
Crossed SLR ++ +
Motor ++ ++
Sensory ++ ++
Lab test (ESR,CBC,UA) ++ 0
Bone Scan +++ +++
EMG +++ +++
X-Ray 0 +
CT 0 ++++
MRI 0 ++++
Myelography 0 ++++
Myelo-CT 0 ++++

26. Disc Findings

28. Reasonable Approach to MRI
• Start with MRI T1 weighted parasagittal lateral view
• For evaluating fat in foramina canal
• Vanishes before root is compressed
• Lateral views are usually left to right
• T2 weighted parasagittal lateral view
• Water content is white like in myelogram
• Contour of canal & indentations
• T2 weighted cross sectional images
• Evaluate convex or flat dural sac
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29. Wheel of Fortune
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32. Epidural Steroid Injection
&
Inflammatory Theory
• Have been used for more than 40 years
• Use of caudal epidural was reported in 1961 with 66%
improvement
• Near level advocacy started in 1972
• Most back pains are due to muscular and ligamentous
strain & spasm
• Mechanical back pain is primarily somatic
• Most studies are anecdotal, retrospective and not
RBCT 33

33. Result of well controlled Lumbar
Epidural Steroid Injections for Acute
Herniated Disc

34. Current Role
• Efficacy of ESI has not been conclusively demonstrated
• Very good short to intermediated-term success in
selected patients
• Presence of nerve root irritation is required to justify use
of ESI
• Less efficacious in patients with neurologic deficits and a
large disc herniations
• Comprehensive management rather than being a needle
jockey
• Fundamentally a safe injection with good efficacy but
should a part of multidisciplinary plan35

36. Surgery in Sciatica
• Only when non-operative treatment fails except some
emergencies
• Nonsurgical management should be attempted for at 4-6
weeks to 6 months depending on condition
• Back pain with leg symptoms of pain, numbness or
weakness after a dermatomal distribution
• Sinuvertebral nerve can get irritated with mechanical or
chemical factors
• Short term relief of symptoms is better with surgery but in
most the long term outcomes are almost similar
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37. Surgery for Herniated Disc
• Tendon reflexes do not usually recover
• One-third are left with some sensory deficit
• Only absolute indication is caudal equina syndrome
• Relative indication
• Gross motor weakness
• Loss of bowel bladder function
• Recurrent incapacitating leg pain
• Persisting leg pain
• Best window 3-6 months
• Not a life saving procedure but improves QOL
• Exclude other causes
• Most have 70% improvement
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38. Herniated Disk
• Back & leg pain with strong physiological
evidence on physical examination or EMG and
corresponding anatomic confirmation on
Imaging are an indication to consider
decompression
• If able to function at less than 3+ EMG and
deferred surgery will eventually recover with
60% recurrence
• With surgery recurrence rate is down to 10%
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39. Appropriate Treatment
• No more than 2-3 days bed rest
• Trial of NSAIDs for 3-4 weeks
• Physical therapy/conditioning
• Nerve root/epidural injection may be attempted
• Lack of scientific data on effect
• Decision usually case-by-case basis
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40. Procedures
• Chemonucleolysis
• Percutaneous discectomy
• Mechanical
• Laser
• Open Surgery
• Posterior Surgery
• Standard laminectomy and discectomy
• Limited approach/microdiscectomy
• Far lateral discectomy
• Anterior approach
• Arthroscopic discectomy
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