A brief overview of back pain and its management strategies.

1. Understand Anatomy
Back Pain

3. Definition
■ Back pain can be defined as pain of any nature
felt in any region ranging from the thoracic
spine to the pelvis.
■ Generally, back pain is classified as mechanical
or non-mechanical and can be subdivided by
regional involvement

4. Causes
■
■
There are numerous causes of back pain.
Generally, pain can be attributed to:
1. Nerve root compression and subsequent
inflammation
2. Mechanical damage to and inflammation of spinal
components
3. Degenerative and bony changes
4. Others eg. psychogenic and referred.
 It should be noted, in a large proportion of
cases back pain is idiopathic.

5. examples
■ Muscle spasms and strains (ligaments, muscles, tendons)
■ Intervertebral disc prolapse
■ Osteoarthritis
■ Osteoporotic compression fractures
■ Traumatic injury
■ Fibromyalgia
■ Ankylosing spondylitis and sacroiliitis.
■ Spinal stenosis (narrowing of spinal canal)
■ Lateral root stenosis (narrowing of root canal)
■ Spondylolysis (deficiency of pars intereticularis of neural
arch)

6. ■ Spondylolisthesis (vertebral body slips forward)
■ Rheumatic disorders eg. RA and polymyalgia rheumatica
■ Paget’s disease
■ Scoliosis – pain from osteoid osteoma of vertebral
pedicle
■ Referred pain eg. from chest, abdomen or pelvis
■ Pregnancy
■ Poor posture
■ Lifestyle eg. smoking

7. Incidence
■ Back pain is one of the most
common health problems in the
developed countries as well as
under develop countries where
laborwork is common.
■
■
It is estimated 50 to 80% of
adults have experienced back
pain at some point.
In the UK, 7% of the adult
population consult their GP
with back pain each year, at a
cost of £500 million and 80
million working days lost.

8. Epidemiology
Age
■ Age of onset is spread relatively evenly from 16 years to the early 40s,
gradually declines thereafter and is uncommon after the mid fifties
Sex
■ No difference in incidence between men and women
Co-morbidity
■ Back pain is commonly associated with other conditions eg. OA
Occupation
■ It is generally thought back pain is more common in those with
manual occupations who undertake heavy lifting
Associations
■ There is a strong association between smoking and back pain,
possibly due to complex interaction of demographic variables

9. Pathology of lowbackpainandsciatica
■ Study by Kuslich et al. operated on
patients undergoing decompression
operations and stimulated various
tissues around the vertebrae using
mechanical force or electrical current.
■
■
■
They found sciatica can only be
produced by direct pressure or
stretch on the inflamed, stretched or
compressed nerve root. This may
occur secondary to disc prolapse
The outer annulus of the
intervertebral disc is the tissue of
origin in most cases of low back
pain.
In spite of what has been previously
suggested, muscle, fascia and bone
were found to be quite insensitive.

10. Clinical Features of aDisc Prolapse
■ Commonest levels to be affected are between L4/5 or
L5/S1
■ Muscular spasms can be profound , leading to a
scoliosis and restricted flexion.
■ Most patients report sharp, burning, stabbing pain
radiating down the leg to the foot ie. sciatica.
■ Pain is intermittent but made worse by activity,
coughing, sneezing and straining.
■ Paraesthesia and motor weakness can also occur – their
distribution may allow the lesion to be localised

11. ■
■
Specific muscles can be assessed
for power to determine location
of the lesion eg.quadriceps are
innervated by L2, L3 and L4
nerve roots. Reflexes should
also be tested.
If straight leg raising on the
■
unaffected side produces
controlateral pain, this is highly
suggestive of a disc prolapse.
Acentral herniated disc may
compress nerve roots of the
cauda equina resulting in
bladder or bowel dysfunction
(difficult urination or
incontinence). This should be
dealt with as an emergency.

12. NaturalHistory
■ Most acute episodes settle within 4-6weeks
without any treatment.
■ It is beneficial to provide symptomatic relief for
■
the first six weeks of symptoms.
Involvement of the bladder, anal canal or any
other severe neurological deficit should be dealt
with as an emergency and treated immediately.

13. Investigations
■ Plain radiographs of the
lumbar spine are of limited
use in the diagnosis of disc
prolapse, but may be used
to exclude other pathology
eg. fracture.
■ The gold standard for
herniated disc imaging is
MRI. This allows
visualizationof disc
damage and should always
be performed if surgery is
contemplated.

14. DifferentialDiagnosis
■ Mechanical back pain:
■ Pain is usually restricted to the buttock and posterior thigh ie.
not sciatic distribution.
■ Pain is exacerbated during standing and twisting movements;
pain from herniated disc is made worse by positions that put
increased pressure on the annular fibres eg. sitting.
■ Any other condition causing compression of lumbar
nerve root
■ Lumbar spinal stenosis
■ Spondylolisthesis
■ Trauma
■ Piriformis syndrome
■ Spinal tumours

15. Treatment
■ Conservative: prevention is the best remedy –lifting
andhandlingmethods,bedrest,physiotherapyand
exercise
■ Medical: analgesia, steroid or local anaesthetic
injections.
■ Surgery is indicated for
■ Acute central disc prolapse with balder involvement
■ Progressive neurological weakness despite bed rest
■ Unremitting pain with abnormal neurological signs despite
bed rest for 2-3 weeks
■ Marked muscle weakness
■ Recurrent episodes of sciatica with only partial relief from
conservative treatment

16. Surgery
■ Involves removal of the protruding material through a
laminotomy or partial laminectomy –maybe combined
with fusion of affected segment.
■ Percutaneousnucleotomy–containeddiscis
decompressed by laser or instrumentation passed into
the disc under X-ray control.
■ Chemonucleolysis–chymopapin is injected into the
disc space to dissolve the disc. High risk of anaphylaxis.

17. Laminotomy

18. Prognosis
■ Most acute episodes settle with bed rest only in 4-6
weeks.
■ 90% of cases don’t require surgery
■ 5% of people do go on to experience chronic severe,
incapacitating lower back pain
■ After successful laminotomy or laminectomy 80-85%
of patients do extremely well and are able to return to
their job in 6weeks.
■ After one disc prolapse there is a statistically significant
increase in risk of afurther prolapse.

19. Summary
■ Back pain is extremely common.
■ There are multiple causes –in most cases no
underlying pathology can be identified.
■ Of the large number of patients presenting with
back pain, the main role of the history and
examination is to identify the small number who
have aserious or specific spinal disorder.