Case 1: A 35-year-old male presented with severe lower back pain after heavy lifting. Exam found tender lumbar spine, reduced flexion, and no neurological symptoms. Diagnosis is acute mechanical lower back pain. Management is pain medication, muscle relaxants, and advice on recovery expectations. Case 2: A 37-year-old male also had lower back pain after heavy lifting, but now the pain radiates down his left leg. Exam found reduced back movement, weak left ankle plantar flexion and big toe flexion, and altered sensation in the left foot. Diagnosis is acute neurogenic lower back pain likely due to herniated disc. Management includes medications and advice, with consideration of imaging and specialist

1. ACUTE LOWER BACK PAIN
DR Ayesha Anwer Ali

2. Case 1
• A 35 years old male presented with severe pain in his lower
back after bending down to pick up a heavy weight.
• No radiation of the pain to the lower limbs
• PH: Nil
• O/E:
– stands with increased lordosis and reduced forward flexion,
walking is painful
– tender over L5 and paravertebral muscles
– No neurological S/S
• What is the diagnosis?
• How would you manage this patient?

3. Case 2
• A 37 years old male presented with severe pain in his lower back
after bending down to pick up a heavy weight.
• The pain is radiating down the back of his left leg as far as the ankle
• PH: Nil
• O/E:
– Walks with pain
– ↓ back movements especially the forward flexion
– The muscle power was difficult to assess because of the pain
– Normal ankle dorsiflexion (bilaterally) but weak left ankle planter flexion
and big toe flexion
– Altered sensation over the lateral side of the left foot
– No other neurological S/S
• What is the diagnosis?
• How would you manage this patient?

4. MOVEMENTS

5. Movement Innervation
Hip flexion L1 L2
Knee extension L3 L4
Knee flexion L5 S1 S2
Hindfoot inversion L4
Great toe dorsiflexion L5
Ankle plantarflexion S1 S2

6. Back pain
• Is the leading cause of occupational
disability in the world.
• 50 - 80%
• With aging population and sedentary live
this situation is unlikely to change.

7. Aim
To provide an evidence based overview of
low back pain to the primary health career.

8. Common causes of low back pain
• Mechanical (80 – 90%)
• Neurogenic (5 – 15%)
• Non-mechanical spinal conditions (1 – 2%)
• Referred visceral pain (1 – 2%)
• Other (2 -4 %)

9. Mechanical causes (80 – 90%)
• Unknown causes
• Degenerative disc or joint disease
• Vertebral fracture
• Congenital deformity
• Spondylolysis
• instability

10. Neurogenic causes (5 – 15%)
• Herniated disc
• Spinal stenosis
• Osteophytic nerve root composition
• Annular fissue with chemical irritation to
the nerve root
• Failed back surgery syndrome
• Infections (e.g. herpes zoster)

11. Non-mechanical spinal conditions
(1 – 2%)
• Neoplastic (primary or secondary)
• Infection (osteomyelitis, discitis or abscess)
• Inflammatory arthritis
• Paget’s disease
• Other (e.g. Sheuermann’s disease, Baastrup’s
disease)

12. Referral visceral pain (1 – 2 %)
• GI diseases
• Renal diseases

13. Other (2 - 4%)
• Fibromyalgia
• Somatoform disorder
• Mallingering

14. Management of acute low back pain in ED
• Rule out the serious causes
• Pain management

15. Red flags
• Cauda equina Syndrome
• Spine fractures
• Malignancy or infection

16. Investigations
• No investigations are required in majority
of cases
• Limited role of X ray in non traumatic low
back pain
• Lab investigations if red flags are present

17. Pharmacological treatment
• Simple analgesia
• NSAID
• Opiates
• Steroids
• Muscle relaxant

18. The real Management
• Discussing expectations
– Likely to have pain for 6/5
– Up to 60% will have pain and decrease
function after one year
• Educate your patient
• Medications