Low back pain is one of the most common reasons for seeking medical attention. The majority of episodes are self-limited, but some suffer from chronic or recurrent courses. Almost any structure in the back can cause pain, most commonly the intervertebral discs and facet joints. A thorough history and physical exam are important to determine the likely cause and guide appropriate treatment. Imaging such as X-rays, CT, and MRI may help identify structural abnormalities but often are not needed for typical mechanical low back pain.

1. Approach to Low Back Pain
Dr Sushil Sharma

2. An Important Issue
• One of the most common reasons for seeking
medical attention, second only to respiratory
issues
• 84% of adults will have low back pain at some
point
• Wide variety of approaches for treatment
– Suggests that optimal approach is unsure
• Most episodes are self-limited
• Some suffer from chronic or recurrent courses,
with substantial impact on quality of life

3. Epidemiology
 Almost any structure in the back can cause pain,
including ligaments, joints, periosteum,
musculature, blood vessels, annulus fibrosus and
nerves
 Intervertebral discs and facet joints most commonly
affected
 85% of those with isolated low back pain do not have a
clear localization
 Usually called “strain” or “sprain”  no histopathology, no
anatomical location
 Men and women equally affected
 Age of onset 30-50 years

4. Epidemiology
• Leading cause of work disability in those < 45
years
• Most expensive cause of work disability in
terms of worker’s compensation
• Multiple known risk factors:
– Heavy lifting, twisting, vibration, obesity, poor
conditioning

5. Biomechanics
• Load bearing
– Lateral and posterior shear, axial compression, and flexion : Disc
– Anterior shear and axial torque : Facets
– Facet joint load bearing in lower lumbar spine (20%). It bears
load mostly in extension
• Ligaments
– Have elastic physical property that allows the ligament to
stretch and resist tensile forces.
– Strongest ligaments : Anterior longitudinal ligament and the
facet joint capsules.
– Interspinous-supraspinous ligament complex : Intermediate
strength
– Weakest of all is the posterior longitudinal ligament.

6. Biomechanics
• Abdominal cavity and its surrounding muscles
stabilize the spine for activities such as lifting.
Intradiscal pressure

7. Deyo R and Weinstein J. N Engl J Med 2001;344:363-370
Common Pathoanatomical Conditions of the Lumbar Spine

8. Deyo R and Weinstein J. N Engl J Med 2001;344:363-370
Low Back Pain : Etiology

9. 97%
2% 1%
Low Back Pain
Mechanical
Visceral
Tumor, Infection

10. Low Back Pain….The Patient
History
Physical Exam
Diagnostic Studies

11. History
A doctor who cannot take a good history and a
patient who cannot give one are in danger of giving
and receiving bad treatment
Anonymous

12. History
• Obtain a description of the
pain in meticulous detail
• Ask the patient to
demonstrate the site of pain
• Personality of the patient and
his or her activities
• Correlate the pain to the
disability
– Mild, moderate, severe
• Assess the possible source of
pain.
• Onset, duration, and
progression of the symptoms.
MacNab Sign

13. History
• Ask
– Radiation of pain (to leg)
– Paresthesia
– Morning stiffness
– Bowel & Bladder
symptoms
– Treatment received

14. History
• Red flag sign

15. History
• Mechanical Back Pain
– The sudden onset of pain after provocative
activity with an intermittent course subsequently
is highly suggestive of a mechanical basis for the
symptoms.
– Mechanical back pain is almost always aggravated
by general and specific activities and is relieved by
rest.

16. History
• Prolapse Intervertebral Disc
– Spread of pain to leg suggests nerve root compression
– Pain aggravated by coughing or sneezing
– Referred pain is rarely felt below the knee, whereas pain due to root
irritation may spread to the calf or even into the foot.
– Pain from first and second lumbar root involvement is easily confused
with hip disease because it concentrates around the groin
– Discogenic pain is frequently increased by maintaining one posture
over a period of time: prolonged walking, prolonged sitting, or
prolonged standing.
• With good history there is 80% chance you will know the
diagnosis (you will improve the odds another 10% by doing the
physical examination, and another 5% by ordering fancy,
expensive tests)

18. History
• Any evidence of neurologic compromise?
– Cauda equina syndrome is a medical emergency
• Usually due to tumor or massive herniation
compressing the nerves of the cauda equina
• Urinary retention with overflow, saddle anesthesia,
bilateral sciatica, leg weakness, fecal incontinence
– Sciatica caused by nerve root irritation
• Sharp/burning pain down posterior or lateral leg to foot
or ankle; can be associated with numbness/tingling
• If due to disc herniation often worsens with cough,
sneeze or performing the Valsalva

19. History
• Any evidence of neurologic compromise?
– Spinal stenosis is caused by narrowing of the spinal
canal, nerve root canals, or intervertebral foramina
• Most commonly due to bony hypertrophic changes in facet
joints and thickening of the ligamentum flavum
• Disc bulging or spondylolisthesis may also cause
• Back pain, transient leg tingling, pain in calf and lower
extremity that is triggered by ambulation and improved with
rest
• Can differentiate from vascular claudication through
detection of normal arterial pulses on exam

20. Physical Examination
• The first prerequisite is that the patient must
be undressed.
• Thorough examination
• A cursory examination is worse than no
examination at all, because it may give the
false hope that the lesion is minor.

21. Gait
• Observe gait
– Antalgic gait : Hip or knee
disease
– Shuffling gait : Neurologic
disorder of rigidity or
spasticity
– Walks slightly flexed : Spinal
canal stenosis
• Ask the patient to
– Walk on heels : L5
– Walk on tiptoe : S1

22. Spine Contour
• Look at the patient from
the side and behind
• Sagittal plane
malalignment : Kyphosis
• Coronal plane
malalignment: Scoliosis
• Step off:
Spondylolisthesis

23. Movement
• Forward flexion (90◦)
– Decreased
• PIVD
• Lumbar spondylosis
• Extension (30◦)
• Lateral flexion (30◦)
• Rotation (40◦)
• Rigid spine: Late stage of
AS

24. Movement
• Reversal of normal spinal rhythm : Disc
degeneration associated with a posterior joint
lesion.

25. Neurological examination
• Neurologic examination
– L5: ankle and great toe
dorsiflexion
– S1: plantar flexion, ankle
reflex
• Dermatomal sensory loss
– L5: numbness medial foot
and web space between 1st
and 2nd toes
– S1: lateral foot/ankle

26. Motor Examination
• Tone
• Power
L1,2 Hip flexion
L3,4 Knee extension
L4 Dorsiflexion
L5 Great toe
extension
S1,2 Plantarflexion

27. Motor Examination

28. Motor Examination
Grade Remarks
0 No movement
1 Flicker
2 Movement if gravity eliminated
3 Movement against gravity
4 Movement against resistance but weak
5 Normal strength

29. Sensory Examination
L1 L2 L3
L4
S1
L5

30. Nerve Root Stretching Test
 Straight leg raise: for those with sciatica
or spinal stenosis symptoms
 Patient supine, examiner holds patient’s
leg straight
 Elevation of less than 60 degrees
abnormal and suggests compression or
irritation of nerve roots
 Reproduces sciatica symptoms (NOT just
hamstring)
 Forced dorsiflexion of the ankle
produces pain is highly suggestive of
root tension
 Ipsilateral straight leg raise sensitive but
not specific for herniated disk
 Crossed straight leg raise (symptoms of
sciatica reproduced when opposite leg is
raised) highly specific
 Disc herniation lying in the axilla or medial
to the root

31. Bow String Test
• Most reliable test of root
tension is the bowstring
sign
• Firm pressure with thumbs
in the popliteal fossa.
• Radiation of pain down
the leg or the production
of pain in the back is
pathognomonic of root
tension

32. Femoral nerve stretch test
• Lumbar root tension
(L3,L4)
• Patient prone
• Hip extended & knee
slightly flexed
• pain may be felt in
front of the thigh and
the back
• Done to exclude higher
disc prolapsed (rare)

33. Reflex
• Knee jerk (L3,L4)
• Ankle jerk (S1,S2)
• Babinski reflex
• Clonus

34. Examination
• Hip joint
• Peripheral pulse
• Abdominal examination
• Rectal examination
• Calf girth, Thigh girth
• Chest expansion

36. Investigations
• Laboratory tests are useful as a screening mechanism
 Tests
 Hb, TC,DC,ESR, and CRP
 Serum chemistries, especially calcium, acid and alkaline
phosphatase, and serum protein electrophoresis.
 HLA-B27 antigen
 Indication
 Significant non mechanical component to their pain
 Systemic symptoms such as fever
 Atypical pain pattern or distribution
 Not responding to standard conservative treatment directed at
the mechanical causes of low back pain
 Older patients (age >55 years)

37. Bone Scan
• Technetium-99m-labeled
phosphorus (99mTc) most
commonly used
• Indications
– Localize metastatic bone lesions
– Early detection of bone
infection (67Ga, Indium-111-
Labeled Leukocytes)
– Osteonecrosis
– Study of failed joint prostheses
– Investigation of unexplained
bone pain
– Dating of fracture age

38. Radiograph
• AP and lateral L-spine if no clinical improvement after
4-6 weeks
• Perform x-rays if:
– Significant trauma
– Incapacitating back pain
– Age>50 yrs
– Unexplained weight loss
– Hx of cancer
– Fever
– Neurologic deficits
– Excessively anxious patient
– Clinically apparent spinal deformity
– Hx & Exmn suggestive of A.S. (Ask for sacroiliac joint view)
– Severe pain (despite Rx for more than 2 weeks)

39. Radiograph
• Radiographs have limited function
in diagnosis and treatment.
• The main function of a radiograph
is to exclude serious disease, such
as infections, ankylosing
spondylitis, and neoplasms.
• Reading the X-ray
– Nonskeletal areas
• Retroperitoneal area
• Kidneys and ureters
• Abdominal aorta.
– Skeleteal
• Sacroiliac joints
• Survey the pedicles and vertebral
bodies for erosions
• Structural defects

40. CT and MRI
– Gold standard imaging technique for investigating disc
pathology, tumor and infection.
– Also able to image herniated discs and spinal stenosis,
which cannot be appreciated on plain films
– Beware: herniated/bulging discs often found in
asymptomatic volunteers  may lead to
overdiagnosis/overtreatment (False positive)
– CT scanning, and MRI are part of an operative
procedure; they are not routine radiographs to be
ordered without hesitation
– If a clinician is in trouble with spine differential
diagnosis to the point where frequent myelogram/CT
scans and MRI are part of the practice routine, then a
careful clinical examination is missing.

41. CT vs Myelography

42. MRI
• Gold standard imaging technology for
investigating spine
• Sagittal T1
– Root canals (foramina)
– Facet joints
– Vertebral bodies
– Spinal cord
• Sagittal T2
– CSF
– Internal structure of disc
– Osseous structures are poorly seen on T2-
weighted image.
• Axial T1
– Facet joints
– Ligamentous flavum
– Foramina

43. MRI vs CT
• Advantages
– Does not require the use of ionizing radiation
– Produces excellent sagittal sections
– Produces excellent soft tissue detail
– Intradural lesions such as tumors, syrinx, and arachnoiditis.
– MRI signal is not impeded by bone, which results in better images in the
posterior fossa and the base of the brain
• Disadvantages
– Claustrophobic feeling for the patient.
– The scan time is longer for MRI, and a patient in pain may find it difficult, if
not impossible, to be still for the time required
– Patients with ferromagnetic materials in their body cannot be scanned if
the following conditions apply:
• Cerebral aneurysm clips will be torqued by the magnet.
• Pacemakers will be converted to a fixed rate.
• Transcutaneous electrical nerve stimulation units will be drawn into the magnet.
• Ocular metallic foreign bodies may be moved and result in damage to vision.
• Metallic cardiac valves are at risk

44. MRI - Indications
• Patients with disc rupture who has failed
conservative care and is being considered for
surgery.
• Suspected PIVD
• Spinal canal stenosis
• Suspected arachnoiditis
• Spinal tumors

45. Nerve conduction test
• Evaluate nerve
entrapment syndromes
• Helps in differential
diagnostic problem such
as an L5 nerve lesion that
could be due to a root
lesion (disc rupture) or
entrapment neuropathy
in the pelvis or around
the knee.

46. Electromyography
• Studies intrinsic electrical activity of
individual motor units of muscle
• Useful in lower motor neuron lesions and
is useful for diagnosing neuropathies and
myopathies.
• Localize the level of lumbar nerve root
involvement
• In the presence of a nerve root lesion, a
series of involuntary electrical discharges
can be recorded
– Fibrillation potential
– Positive wave
• Helpful in diagnosing neuropathy (eg: in
diabetes)

47. Diagnostic Approach – Reaching the
correct diagnosis
1. Is this a true physical disability or is there a setting
and a pattern on history and physical examination to
suggest a nonphysical or nonorganic problem?
2. Is this clinical presentation a diagnostic trap?
3. Is this a mechanical low back pain condition, and if so,
what is the syndrome?
4. Are there clues to an anatomic level on history and
physical examination?
5. After reviewing the results of investigation, what is
the structural lesion and does it fit with the clinical
syndrome?

48. Non organic spinal pain - Classification
• Psychosomatic spinal pain
– Tension syndrome (fibrositis)
• Pure psychogenic spinal pain
• Situational spinal pain
– Litigation reaction
– Exaggeration reaction

49. Non Organic Back Pain
• Symptoms
– Pain is multifocal in distribution and nonmechanical (present at
rest)
– Entire extremity is painful, numb, and/or weak
– Extremity gives way (as a result, the patient carries a cane)
– Multiple crises, multiple hospital admissions/investigations, and
multiple visits to doctors
• Signs
– Tenderness is superficial (skin) or nonanatomic (e.g., over body
of sacrum)
– Simulated movement tests positive
– Distraction tests positive
– Whole leg weak or numb

50. Avoid Diagnostic Trap
• Back pain
– Peritoneal cavity
• GI tumor
• Ulcer
– Retroperitoneal space
• Genitourinary conditions
• Abdominal aortic conditions
• Primary or secondary tumors of the retroperitoneal
space

51. Differential Diagnosis - Sciatica
• Intraspinal causes
– Conus and cauda equina lesions (e.g., neurofibroma, ependymoma)
– Herniated nucleus pulposus
– Stenosis (canal or recess)
– Infection: osteomyelitis or discitis (with nerve root pressure)
– Inflammation: arachnoiditis
– Neoplasm: benign or malignant with nerve root pressure
• Extraspinal causes
– Pelvis
• Peripheral vascular disease (Vascular claudication vs Neurogenic claudication)
• Gynecologic conditions
• Orthopaedic conditions (e.g., osteoarthritis of hip)
• Sacroiliac joint disease
• Neoplasms
– Peripheral nerve lesions
• Neuropathy (diabetic, tumor, alcohol)
• Local sciatic nerve conditions (trauma, tumor)
• Inflammation (herpes zoster)

52. Vascular vs Neurogenic claudication
Findings Vascular Claudication Neurogenic Claudication
Pain
Type Sharp, cramping Vague radicular, heaviness, cramping
Location Exercised muscles (usually calf and
rarely includes buttock, almost
always excludes thigh)
Either typical radicular or extremely
diffuse (usually including buttock)
Radiation Rare Common after onset, usually
proximal to distal
Aggravation Walking, especially uphill Not only aggravated by walking, but
also by standing
Relief Stopping muscular activity even in
the standing position
Walking in the forward flexed
position more comfortable; Relief
comes only with lying or sitting
down
Time to relief Quick (seconds to minutes) Slow (many minutes)
Neurologic symptoms (Paresthesia) Usually not present Commonly present
Straight leg raising tests Negative Positive
Neurologic examination Negative Positive
Vascular examination Absent pulses Pulses present

53. Hip Pathology
• Pain
– Groin or hips
• Limping
• Pain on external
rotation of hip
• Internal rotation
restricted

54. Neurologic Disorder
• If weakness, sensory upset and/or instability
the dominant symptom (rather pain)
• Weakness as a symptom
– A true motor weakness will affect one or both
limbs or a muscle group and will originate in the
motor unit or the proximal motor pathways in the
spinal cord, brainstem, and cortex
– Central vs Peripheral
– Separate the myopathies (proximal & symmetric)
form the neuropathies(distal).

55. Extremity weakness - Classification
• Anatomic Level
– Spinal cord
– Anterior horn
• Motor Neuron Disease (A.L.S.)
• Tetanus
• Poliomyelitis
– Dorsal root ganglion
• Herpes zoster (Usu one root, lower thoracic region)
– Peripheral nerve (sensory, distal, lower limbs &
asymmetrical)
• Diabetic
• Nutritional
• Infectious: Leprosy, GBS
• Toxic : Lead, Alcohol
– Myoneural junction
– Muscle
• Polymositis, Polymyalgia rheumatica

56. Is this a mechanical low back pain, and if
so, what is the syndrome?
• Mechanical LBP aggravated by activity & relieved with rest
• Syndrome
– Lumbago (Back pain)
– Sciatica (Radicular leg pain)
• Unilateral acute
• Bilateral acute (Cauda Equina Syndrome)
• Referred leg pain
– Associated with low back pain
– Pain radiating to B/L legs
– No neurologic sign & symptoms
• Any patient with radiating leg pain, especially unilateral leg
pain, has a radicular syndrome until proven otherwise.

57. Acute Radicular Syndrome
• Leg pain (including buttock) is the dominant
complaint when compared with back pain
• Neurologic symptoms that are specific
(Sensory & Motor)
• On examination
– SLR less than 60
– Bowstring sign
– Crossover SLRT
– Neurologic sign

58. Acute Radicular Syndrome in Various Ages
Young (<30y) Adult (35-55y) Elderly(>60y)
Symptoms
Leg pain Usually the only
symptom
Some BP, but LP
dominates
Usually BP, but LP still
dominates
Paresthesia Often absent Usually present Almost always present
Signs
SLR Positive (++) Positive (+) Occasionally good
ability
Neurologic signs Absent in at least 50%
of patients
Sometimes absent Almost always present

59. Cauda Equina Syndrome
• Surgical emergency
• Large sequestered disc rupture (acute) at L3-
L4, L4-L5, or L5-S1
• Clinical features
– Sudden onset of back pain
– Bilateral leg pain
– Saddle anesthesia
– Bilateral lower extremity weakness
– Urinary retention and lax rectal tone

60. Anatomic level – History & Examination

61. Does structural lesion fit with clinical
syndrome?
Syndrome Structural lesion
Lumbago Degenerative disc disease
Facet joint dysfunction
Spondylolysis/spondylolisthesis
Soft tissue (muscle spasm, strain)
Unilateral acute radicular Disc prolapse
Lateral recess stenosis
Bilateral acute radicular Central disc prolapse (Cauda Equina Syn)

63. Natural History
• Most recover rapidly
– 90% of patients seen within 3
days of symptom onset
recovered within 2 weeks
• Recurrences are common
– Most have chronic disease with
intermittent exacerbations
• Spinal stenosis is the exception
 usually gets progressively
worse with time

64. Management of Low Back Pain
• General considerations
– Primary therapy related to etiology
– Patient expectations
– Patient education related to pain treatment
– Pain treatment cost-effectiveness
• Prevention of back pain exacerbations
• Prevention of unnecessary surgery and
suffering (failed-back-surgery syndrome)

65. Management of Low Back Pain

66. • Comprehensive assessment of patients is
essential to form the appropriate treatment plan.
• In the majority of cases, pharmacologic
treatment is the main approach.
• Overall, 90% of patients will recover within 2
months without need for any invasive procedure.
• The management of acute back pain without
sciatica or neurologic deficits calls for a
conservative approach with analgesics and no
bed rest.
Management of Low Back Pain

67. • With sciatica and no neurologic deficits
• Conservative management with analgesics
• Bed rest for 2–3 d
• Activities as tolerated
• Neurologic consultation as needed
• With sciatica and positive neurologic deficit
• Individualized length of rest
• Analgesics
• MRI study plus urgent neurologic or emergent
neurosurgical evaluation, according to progression of
deficits and symptoms
Management of Low Back Pain

68. Management of Low Back Pain

69. • Who needs Surgery-
– Unstable spine
– Acute fracture with neurological
deficit
– Severe stenosis
– After failure of aggressive non-
operative Rx
– Tumour
– Progressive neurological deficit
Management of Low Back Pain

70. Management of Low Back Pain

71. Prevention of Low Back Pain

72. Management of Low Back Pain