This document provides an overview of low back pain (LBP) by Dr. Varun Singla. It discusses the incidence and sources of LBP, including vertebral bodies, discs, facet joints, spinal nerves, muscles and ligaments. Differential diagnoses covered include lumbar radiculopathy, disc disorders, spinal stenosis, sacroiliac joint dysfunction and myofascial pain. Diagnostic tests and treatment approaches are described for each condition. Imaging findings and pathophysiology of herniated discs are detailed. Facet joint anatomy and causes of facet syndrome are reviewed.

1. DR. VARUN SINGLA
MD (PGI Chandigarh)
PDCC-Pain Management (SGPGI Lucknow)
Fellow FPCI (Mumbai)
Member, Indian Society for Study of Pain
Peer Reviewer, Cochrane PaPaS, UK

2. INTRODUCTION
 Low back pain is the most common source of pain in
modern society
 Incidence of 1st episode – 6.3 – 15.4%
 Incidence of recurrent LBP – 1.5 – 36%*
 Identifying the source of the low back pain is of
paramount importance to a pain physician.
* Best Pract Res Clin Rheumatol, 2010 Dec;24 (6):769 -81

3.  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

4. SOURCES OF LOW BACK PAIN
 Vertebral bodies
 Inter-vertebral discs
 Facet joints
 Spinal nerve roots
 Muscles & ligaments
 Referred pain- abdominal & pelvic viscera
 Sacro–iliac joint

6. DIFFERENTIAL DIAGNOSIS

7. MECHANICAL CAUSES

8. INCIDENCE
 Lumbar radicular syndrome – 12 – 40%
 Sacro iliac joint arthropathy – 15- 30%
 Disc disruption – 25 – 40%
 Herniated lumbar disk – 1- 2 %

9. Other causes of LBP
 Osteoporotic Compression fracture 3-5%
 Fibromyalgia & Myofascial Pain 2-5%
 Spinal canal stenosis 2-3%
 Spondylolisthesis 2-3%
 Tumor <1% / Infection <1% / FBSS <1%

11.  Syn : Lumbar radiculopathy; lumbar radiculitis; sciatica
 Pathology
 Pathologic involvement of the Sensory Spinal Nerve Roots
(SSNR) & Dorsal root ganglia ectopic impulse
generation  pain, numbness, tingling in a dermatomal
fashion
 Signs : Weakness + diminished reflexes + SLR positivity

12. Pathologic processes inv SSNR & DRGs:
 Inter-vertebral disc pathology
 Degenerative spinal disorders
 Neoplastic
 Traumatic – vertebral body fractures
 Infections
 Metabolic
Most common

13. Clinical features
Symptoms
 Radicular pain- sharp, shooting, lancinating pain that
travels along a narrow band.
 Paresthesias & numbness
 Weakness in territory of inv NR
Objective Signs
 Gait disturbances
 Loss of sensation
 Reduced muscle strength
 Diminished reflexes

14. TESTS TO CONFIRM NR IRRITATION
 SLR/ Lasegue test- sensitive, lower NRs.
 SLR & Ankle dorsiflexion of extended lower extremity.
 Crossed SLR/ X-SLR- more specific.
 Tripod test
 Femoral stretch test- L2 & L3 NRs.

17. Differential diagnoses
 Entrapment neuropathy of sciatic nerve
 Piriformis muscle
 Ischial tunnel syndrome
Pain & paresthesia along its distribution, often involving
multiple dermatomes
 Pain from IVD, SI joint and myofascial pain can also be
referred to LL- d/t Interneuronal Convergence within
spinal cord.
 Non dermatomal
 Deep aching
 Lacks objective signs of nerve root irritation

18. DIAGNOSTIC TESTS
 Not recommended for LBP & radicular pain of < 4-6
wks.  because of favorable natural history & often
spontaneous resolution of symptoms.
 Also, common +nce of abnormal diagnostic findings in
asymptomatic individuals.

19. IMAGING STUDIES
 MRI
 CT
 CT-Myelography
 Plain radiography
 Electro-diagnostic studies –
EMG, NCV, SSEP- routine use not recommended

21. Contents of a herniated disc

22. PATHOPHYSIOLOGY
 HD thought to be the mc cause of radicular pain.
 Mechanisms :
- Mechanical compression of the nerve root impairs
nutrition  nerve root ischemia and injury.
- Presence of inflammatory mediators in HD
material.
 Natural history favorable. Spontaneous resolution in
60%. (phagocytic process)
 L4-L5 (59) > L5-S1 (30) > L3-L4 (9).

23. Disc contents
causing nerve
irritation

24. Treatment
 Non surgical
 Systemic corticoteroids
 Bed rest
 Bracing
 Traction
 Behavioral therapy
 Physical therapy – active + passive exercises
Old school

25.  Minimally invasive
 Epidural steroid injections – interlaminar / TF
 Percutaneous disc decompression
- APLD
- IDET (Intradiscal Electrothermal therapy)
- Disc nucleoplasty(RF)
• Operative treatment
 classic diskectomy
 microdiskectomy

27. Lumbar spinal stenosis
 Syndrome : neurogenic claudication or radicular pain
2° to narrowing of spinal / NR canal  compression of
neural elements.
 Classification
ETIOLOGICAL ANATOMICAL
Congenital - achondroplasia Central canal stenosis
Acquired – metabolic,
traumatic, degenerative
Lateral / neural foraminal
stenosis
Combined

28. What happens in LCS
-Loss of disk height
-Disk bulging
-Facet joint hypertrophy
-Thickening of ligamentum flavum
-Osteophyte formation

29. Clinical features
Symptoms
 Neurogenic claudication
 Radicular pain – L5 > L4 > L3  lateral stenosis
 Axial pain - not specific
 Cauda equina syndrome  central stenosis
Signs
 Stooped gait
 Loss of lumbar lordosis
 Negative SLR
 Sensorimotor deficits are less pronounced
chronic,
slow
progress

30. Shopping cart sign

31. CAUDA EQUINA SYNDROME
Symptoms
 B/L Radicular pain
 Isolated back pain – rare
 Weakness U/L or B/L lower limbs
 Gait disturbances
 Abdominal discomfort – urinary retention
Signs
 Motor and sensory deficits
 + SLR & X-SLR
 ↓lower extremity reflexes
 Saddle anaesthesia
 ↓ Sphincter tone
 Urinary retention.

32. Neurogenic
claudication
 Evaluation after walking - ↑
weakness
 Relieved by – bending over,
sitting
 Increases upon – walking
downhill, ↑ lordosis
 Pulses – present
 Shopping cart sign – Present
Vascular
claudication
 Evaluation after walking –
unchanged
 Relieved by – stopping, rest
 Increases upon - Walking
uphill
 Pulses – absent
 Shopping cart sign – absent

33. DIAGNOSIS
 MRI - IOC
 Lumbar CT myelography

34. Treatment
 Non invasive
 Medications – NSAIDs, calcitonin
 Activity modification – avoid aggravating factors
 Bracing – short duration
 Physical therapy – flexion based exercises ↑
microcirculation
 Epidural steroid
 Invasive
 Laminectomy
 Laminotomy, laminoplasty
 Extensive decompression techniques + spinal fusion

36.  Syn : Discogenic pain, internal disk disruption (IDD),
degenerative disk disorder (DDD)
 It is a physiologic consequence of aging
 Factors predisposing to degenerative disk disease
 Diminished blood supply
 Genetic
 Mechanical stress
 End plate injury
 Vascular disease
 Obesity

37. PATHOPHYSIOLOGY
 Normal disc : innervation & vascularity is limited to the
outer 1/3rd of the AF
 Injury  annular tears  vascularised granulation
tissue that extend from the NP to AF (HIZ on MRI)
 Granulation tissue : ↑ pro inflammatory molecules
(substance P)  maintain hyperalgesia  chronic pain

38. Disc innervation

39. Discal tears

41. Clinical Features
Symptoms
 Pain – acute/chronic
 Precipitated by torsion injury
 Pain ↑ axial loading – prolonged sitting, standing
 Referred to lower limb - non dermatomal areas
Signs
 Black disc disease on MRI  dessicated discs (loss of
signal on T2 weighted images)
 Presence of HIZ in posterior annulus on T2

42. Imaging - DDD

43. HIZ

44. Treatment
 Mainly palliative
 IDET
 Disk arthroplasty
 Surgical – Diskectomy + spinal fusion

46. Lumbar facet – anatomy

47. Causes – Facet syndrome
 Inflammatory arthritides – RA, AS
 Degenerative
 Synovial cysts
 Infections
 Microtrauma
 Meniscoid & synovial entrapments
 Joint subluxation

48. Clinical features
Symptoms
 Low back pain – U/L or B/L
 Referral to groin, hip, posterior thigh
 Pain ↑ on twisting, extension, sitting, standing
 Pain ↓ on forward flexion, rest, walking
Signs
 Localized tenderness over facets
 No neurological deficits
 Normal SLR

49. Pain distribution patterns - facet

50. Influence of flexion - extension

51. What clinches diagnosis
Analgesic response to targeted, low volume LA
injections – only accepted standard for diagnosis !!

52. Treatment
Diagnostic facet injections – followed by
 Intra-articular LA + steroid
 Facet denervation – lesioning of the MB at the same
vertebral level & 1 level above

53. Medial branch block
Medial branch of
this facet is
supplied by the
SSNR of the level
above it

55. Sacro – iliac joint anatomy

56. Factors predisposing to SIJD
 Trauma
 Leg length discrepancy
 Spinal deformity
 Surgery
 Lumbar facet syndrome
 Pregnancy
 Inflammatory arthritides – AS
 Infections

57. Clinical features
Symptoms
 Pain – low back – max at the affected site
 Radiation – buttock, groin & posterior thigh
 Hypomobility
Signs
 Tender SI sulcus
 Positive clinical tests – FABER, Yeoman, Gaenslen’s
 Normal lab findings & imaging

58. Treatment
 Diagnostic confirmation – SI injection with LA
 Positive response – 75 – 90% pain relief
 Physical therapy
 Intra-articular steroid
 RF ablation
 Surgical fusion

60.  It is a regional pain syndrome characterised by the
presence of active trigger points in skeletal muscle
 Types of trigger points
 Active
 Latent

61. Diagnostic criteria
Essential Criteria
 Palpable taut band
 Exquisite spot tenderness of nodule in taut band
 Pressure on taut band  recognition of pain (active
TrP)
 Painful limitation of passive range of motion
Confirmatory
 Local twitch response
 Twitch on needling
 Pain on zone of reference
 EMG – spontaneous electrical activity

62. Various trigger points - back

65. Treatment
 Physical interventions
 Cold spray
 Massage of TrP
 Stretching of the muscle
 Needling
 Dry needling
 Wet needling - LA

66. BAASTRUP’S DISEASE
 Hyperlordosis, segmental instability, loss of disc
height  apposition of lumbar spine  degradation of
interspinous ligament  pseudoarthrosis/
pseudobursa
 Midline lumbar pain, radicular or claudicatory pain

67.  X-ray : contact between adjacent spinous processes
with sclerosis, flattening and enlargement
 MRI- edema interspinous ligament with fluid
 SPECT scan Tc : hyperemia

68. BERTOLOTTI’S SYNDROME
 Asso. of transitional LS segments with mechanical
back pain.
 Transitional segment a/w axial pain, related to
- neoarticulation
- C/L facet at level of asymmetric neoarticulation
- IDD in the at-risk disk above.