This document provides an overview of low back pain (LBP), including prevalence, classifications, types, and key points regarding evaluation and management. Some key points: - 60-80% of people experience LBP at some point, though 90% resolves within 6 weeks. Recurrence is common and LBP is a major cause of disability. - LBP can be classified as mechanical, traumatic, infectious, neoplastic, and more. 97% are considered mechanical. - Types include discogenic, radicular, facet joint, sacroiliac joint, muscular/myofascial, and others. Herniated discs can cause radicular symptoms. - Evaluation involves detailed history and exam to identify

1. A Concise Approach to
Low Back Pain
By :
Hieder A`ala
601
MUST UNIVERSITY

2. Prevalence
 60-80% of people will have LBP sometime in their
lives.
 30% are referred to Ortho; 3% admitted; 0.5%
operated.
 90% LBP resolves in 6w, 75% may experience
symptoms & disability one year after initial
consultation.
 The prevalence of LBP has changed little over the
years, but the associated disability has increased
four fold
 In the UK certified incapacity for LBP was 120
milion days in 1996
 14 million consultations annually. Overall cost of
LBP was £6 billion

3. Why take it seriously?
 Acute low back pain is often recurrent,
 Predisposes to chronic pain and disability
 A warning of potential future trouble
 Impacts on the quality of life
 Lost days of productivity
 Huge cost of incapacity payouts
 Enormous burden on healthcare costs when
chronic

4. AETIOLOGY AND CLASSIFICATIONS
 1.congenital:
 2.acquired :
• Mechanical Low Back Pain
• Traumatic
• Infective
• Inflammatory
• Neoplastic
• Degenerative
• Metabolic
• Endocrine
• Idiopathic
• Psychogenic
• Visceral
• Vascular
• Gynaecological

5. 2% visceral 1% tumor,
infection,
inflammatory
arthritis
97%
“mechanical”

6. Types of Back Pain:
 Discogenic back pain
• annulus fibrosus when it is stretched with a
bulging disc
• Outer1/3 has sensory innervation,
• radial fissuring is associated with painful discs
 Radicular back pain
• pain extending to the buttock and/or leg
• disc herniation , spinal stenosis or intraspinal
pathology
 Psychogenic back pain
• must exclude organic pathology

7. Types of Back Pain
 Facet-joint pain
• Studies of provocative intra-articular injection techniques
demonstrated local and referred pain into the lower extremity
from the lumbar facets.
• The fibrous capsule of the facet joint contains encapsulated,
unencapsulated, and free nerve endings.
 Sacroiliac pain
• variable local and referred pain patterns into regions of the
buttock, lower lumbar area, lower extremity, and groin.
 Muscular pain (myofascial pain )
• MP is characterized by muscles that are in a shortened or
contracted state, with increased tone and stiffness, and that
contain trigger points

8. Types of Back Pain
 Viscerogenic Back Pain
• may be derived from disorders of the kidneys or the pelvic
viscera, lesions of the lesser sac, and retroperitoneal tumors
• Backache is rarely the sole symptom of visceral disease.
 Vascular Back Pain
• Abdominal aortic aneurysms or peripheral vascular
disease (PVD) may give rise to backache or symptoms
resembling sciatica
• Intermittent claudication intermittent pain in the
calf”associated with PVD may on occasion mimic sciatic
pain produced by root irritation, but the history of specific
aggravation by walking and relief by standing still will
make the clinician look for signs of peripheral vascular
insufficiency.

9.  Three syndromes are recognized in which spinal disorders cause
both back and neurologic dysfunction. Examples are :
 1. Herniated disc causing a single nerve root compression (leg
pain > back pain).
– Clinical features include positive straight leg-raising test and
radicular pain in the limb disproportionate to pain in the
spine. Loss of strength, reflex, and sensation occurs in the
territory of the compressed root.
 2. Lateral recess syndrome (leg pain ≥back pain). Single or
multiple nerve roots on one or both sides become compressed.
Pain in the limb is usually equal to or greater than that in the
spine. Symptoms are brought on by either walking or standing
and are relieved with sitting. Testing by straight leg raising may
be negative.
 3. Spinal stenosis (leg pain < back pain). Multiple nerve roots
are involved, and the pain in the spine is significantly greater
than that in the limb. Symptoms develop with standing or
walking. Impairment in bowel and bladder dysfunction as well
as sexual dysfunction may occur.

10. History taking….
 Past history of similar symptoms, course of treatment,
and response
 Onset of current episode, mechanism of injury, and
initial location of pain
 Current location and character of pain, associated
symptoms, and influencing factors
 Pain status: improving, deteriorating, or plateaued?
 Red flags (eg, neurologic deficits, bowel or bladder
dysfunction, systemic illness)
 Physical and functional impairment due to pain

11. Identify complexities in management
 Involvement with a disability compensation claim,
 Symptom magnification, drug-seeking behaviour,
past history of chronic pain, and psychosocial
stressors.
 Past medical history, family history, health habits,
exercise habits, social and occupational history
 Dependency, sleeplessness, and emotional distress
resulting from or contributing to the pain.

12. Points to note…..
 Lumbar spine tolerates a higher degree of stenosis
than the cervical or thoracic region
 The discs, facet joints & capsules, ligamentum
flavum are affected by degenerative processes.
 The dimensions of the spinal canal and foramen are
.
influenced by dynamic and postural factors
 The foramina decrease in size while the nerve roots
increase in diameter as you move down the spine.
Thus the lumbar spine is most commonly affected

13. Points to note…..
The objective of a detailed history and
thorough clinical examination are to
avoid missing cauda equina
syndrome…
The MPS case book has highlighted
the following points ( slides 9 -14)

14. What is Cauda Equina Syndrome?
 Cauda Equina Syndrome is a collection of
signs and symptoms resulting from
compression of the bundle of nerve roots
emerging from the end of the spinal cord
below the 1st lumbar vertebra.
 The classic syndrome is characterised by
severe LBP with bilateral sciatica associated
with saddle anaesthesia, urinary retention and
bowel dysfunction.

15. Causes of cauda equina syndrome
 Traumatic injury
 Herniated inter-vertebral disc
 Secondary to surgery, spinal or epidural
anaesthesia, spinal manipulation
 Tumours
 Infections
 Vascular problems
 Spina bifida
 Spinal stenosis
 Late-stage ankylosing spondylitis

16. Cauda equina syndrome - Red flags
 Severe low back pain with bilateral or
unilateral sciatica
 Bladder or bowel dysfunction
 Anaesthesia or paresthesia in perineal
region or buttocks
 Significant lower limb weakness
 Gait disturbances
 Sexual dysfunction

17. Types of onset
The onset can be either acute or chronic….
 Acute onset: of severe back pain, sciatica, urinary
disturbances, motor weakness in the lower extremities
and saddle anaesthesia or hypoesthesia in patient with
no previous history of LBP
 More insidious onset characterised by recurrent episodes
of backache over a few weeks to years followed by
– gradual onset of sciatica and
– motor and sensory loss,
– with bowel and bladder dysfunction developing over a
few days to several weeks.

18. Vital questions for patients with LBP
 ‘Have you noticed any numbness or strange sensations
around your buttocks or between your legs? For
example, does the toilet paper feel normal when you
wipe your bottom?’
‘Has your bladder been working normally? Can you tell
when it’s full? Have you had any loss of control
(accidents), or difficulty passing urine? Or have you felt
that you want to go all the time?’
 ‘Have you experienced any unusual problems with your
bowels lately?’
 ‘Have you noticed any changes in sexual function

19. Physical examination
 The severity depends on the location and the
degree of compression. The levels most often
affected are L4/L5 and L5/S1
 Few patients actually present with a ‘classical’
set of signs and symptoms which should be
specifically elicited
 Neurological examination should include testing
for sensation, motor weakness and diminished
reflexes

20. Spinal Stenosis: Pathophysiology
 Narrowing of the central canal and/or
intervertebral foramina is due to:
– Posterior disc bulging
– bone spur formation
– facet joint enlargement
– hypertrophy of ligamentum flavum
 Natural history
– Symptoms unchanged in 60-70%
– Worse in 15-20%
– Improved in 15-20%

21. Incidence of spinal stenosis on imaging is very
high in the elderly population but only a fraction
manifest the true symptoms
 Central stenosis:
– increased unsteadiness or loss of balance
– they walk stooped forward
– Rarely - urinary incontinence & cauda equina syndrome
– Physical examination can be unimpressive
 Foramenal stenosis:
– Radicular signs from narrowing of the lateral recess or the
neural foramen.

22. Discogenic pain
 Normal discs have sensory nerve endings in the
outer 1/3 of the annulus
 Disc stimulation studies normal discs do not
cause pain
 Disc stimulation is specific for painful discs and
is in particular for radial annular tears
 Reproduction of pain co-relates with the degree
of fissuring of the disc

23. Spondylo-lysis & listhesis
 Caused by a defect in the pars interarticularis
 Usually a fatigue fracture from repetitive
hyperextension stresses (gymnasts)
 most common cause of LBP in adolescents
 plain x-rays demonstrate 80% of lesions
 oblique views - additional 15% picked up -
'Scottie dog' sign (Lachapelle)
 CT - may miss fracture

24. Examination
 Posture – change in lumbar lordosis, scoliosis
 Range of motion – flexion,extension, lateral flexion
 SLR – seated & supine, sciatic nerve stretch test
 Presence of paraspinal muscle spasm, trigger points
 Tender areas –facets, sacro-iliac joints
 Neurological deficit –
– Dermatomal hypo/hyperaesthesia
– Ability to rise from squatting position (L4),walk on
heels(L5), walk on tip-toes (S1)
– Tendon reflexes – knee jerk(L4 root), ankle jerk(S1 root)

25. Evaluation
 Consider the physical & psychological aspects
 Degree of interference with desired & necessary
activity
 Response to past treatments
 Co-existing complaints & medical diseases
 Evaluation of functional capacity – walk, stand, sit,
climb stairs

26. Investigations
 X-rays: bone spurs, decreased disc height and facet
hypertrophy in older patients.
 CT: more accurate and detailed picture of the bony
anatomy
– less accurate than MRI in estimating the degree of
compromise of the soft tissue elements.
– thus can underestimate the degree of stenosis
– spinal canal < 10mm AP diameter = Absolute Stenosis
 MRI: (without gadolinium)
– currently represents the "gold standard" in the evaluation of
central stenosis.
– allows visualization of disc, neural elements, ligamentum
flavum & thecal sac

27. Pitfalls
 Upto 80% of patients cannot be given a definite
diagnosis because of the poor co-relation between
symptoms, clinical findings and imaging results
 High incidence of false negatives on imaging
 No diagnostic lab tests that reveal the cause of LBP
 Outcome of treatment difficult to quantify and
predict

28. Management
 Pharmacological
– NSAIDS – intolerance, cautions, gels, coxibs
– Co-analgesics – TCA, anticonvulsants, ms –relaxants
– Opioids & compound codeine preparations
 Injection Therapy
– Epidural steroids – lumbar, caudal
– Facet joint injection, Sacro-iliac joint injection, coccyx
– Nerve root infiltration
 Physiotherapy
 Acupuncture & TENS
 Pain management – psychological approaches

30. Surgical treatment
Urgent operations
are required in cases like progressive neural deficit, cauda
equine syndrome, lumbar trauma with instability, tumors and
infections (the red flags ) .
The non-urgent operation
operation is for persistent pain that does not respond to proper
conservative measures or mechanical LBP with instability

31. Operative Results
Operative results can be variable as…..
 not all stenotic sites necessarily cause symptoms,
therefore selecting decompression levels can be
difficult
 insufficient decompression
 regrowth of resected tissue & scarring
 Multi-level involvement does not do well due to post-
op instability (should consider fusion, but very
invasive)
Careful attention to patient selection and meticulous operative
planning are important in optimizing surgical outcome.