This document discusses low back pain, which is very common among working adults. It presents in people over 45 years old and is usually caused by degenerative changes or instability in the lumbosacral region of the spine. While 80% of cases resolve with conservative treatment like rest, heat, and over-the-counter medications, 5-10% may require surgery for issues like nerve compression, instability, or deformity. The document outlines approaches to evaluating and diagnosing the cause of low back pain through history, physical exam, imaging studies, and outlines treatment approaches including conservative care, injections, and surgical options.

1. Low Back Pain
Dr Liau Kai Ming
Dept. of Orthopaedic

2. Incidence
 Very common among working group
 90% in pt >45years old
 80% resolves with conservative treatment (in
<3 months)
 Only 5-10% may require operation

3. Implication
 Work & productivity loss

4. Anatomical consideration
 Commonly at lumbosacral junction (L4/L5,
L5/S1)
 Why?

5.  Most mobile region of the spine
 Therefore prone to degeneration (wear &
tear)

6. Causes of pain
 Degenerative (most common)
 Instability(fracture, spondylolisthesis)
 Organic (Tumour,infection)
 Nerve compression/irritation(PID, root
compression)
 Rule out psychogenic cause (insurance
claim, problem with employer etc)

7. Referred pain
1. Abdominal cavity
gastritis/peptic ulcer
pancreatitis
cholecystitis
2. Urinary system
renal calculi
UTI
3. Pelvic cavity
ovarian cyst
dysmenorrhea
4. Aorta
Aortic aneurysm

8. Nature of pain
 MECHANICAL VS NON-MECHANICAL
 REFERRED VS RADICULAR
 CLAUDICATION – VASCULAR VS SPINAL

9. MECHANICAL PAIN
1. Muscle strain
2. Ligament sprain
3. Facet joint arthritis
4. Disc-Discogenic
5. Instability - Spondylolysis/spondylolisthesis

10. NON-MECHANICAL PAIN
 Infection – PYOGENIC VS TB
 Tumour – PRIMARY VS SECONDARY
 Primary - BENIGN VS MALIGNANT

11. Common causes of low back pain
Pathology Age Pain nature Assoc pain Assoc sx
DEGENERA >40y mechanical Distance Active pt
TIVE claudication
Spondylosis
Spondylolisth <20y mechanical extension Hyperextensi
esis >40y on activity
Trauma Any age mechanical - Trauma
Infection Any age non- Rest pain Fever
mechanical
Mets >50y Non- Rest pain Primary +
mechanical LOW
LOA
Osteoporosis >60y mechanical - Trivial trauma

12. RED FLAGS
 Constitutional symptoms
 LOW, LOA, fever
 AGE(>50)
 IMMUNOCOMPROMISED,
 TB CONTACT
 KNOWN CANCER
 NEUROLOGICAL DEFICIT (CAUDA EQUINA SYN)

13. Physical findings
 General examination
 Age
 Ill looking
 Local examination – DO NOT MISS A
GIBBUS

14.  Deformity
 Scoliosis/kyphosis
 Step deformity
 Local tenderness/paraspinal spasm
 Limited ROM

15.  Full neurological examination
 ANAL TONE / PERIANAL SENSATION
 DERMATOME & MYOTOME

16. Investigations

17. Plain radiograph
 AP
-loss of lumbar lordosis
-reduced disc space
-osteophytes
-deformity
-fracture (increase interpedicular distance)
-osteoporosis
-pedicle disruption

25.  Lateral
-fracture/wedging
-kyphosis
-spondylolisthesis
 Oblique
-spondylolysis (SCOTTIE DOG)

28. Plain x-rays

30. Blood investigations
 FBC
 Anemia, TWC
 ESR
 Liver function test
 ALP
 Renal function test
 Calcium level

31. CT Scan
 better visualization of bone pathology (eg.
cortical destruction)
 fracture
 tumor

35. MRI
 -better soft tissue visualization
 -disc
 -ligaments (ALL,PLL)
 -nerves (spinal cord, roots)
 -bone marrow
 -pus collection

36. MRI

38. CT myelogram
 role replaced by MRI
 for delineation of neural structures where MRI
is not available/contraindicated

39. CT Myelogram

40. Bone scan
 Suspicious of multiple bone mets
 Eg. with history of untreated/treated CA
 Negative in Multiple myeloma

41. Treatment
 Mainly conservative
-Bed rest/pelvic traction
-physiotherapy
-back exercise
-modification of daily activities
-SWD/ultrasound
-NSAIDs/COX-2 inhibitor
-local injection (epidural steroids, facet joint)

42. Pelvic traction

43. Surgery

44. Indications for surgery
-PAIN - failed conservative treatment (>6 months)
-Evidence of neurological deficit (motor)
-Cauda equina syndrome
-Spinal instability (excessive spinal motion)
-Unacceptable deformity (eg degenerative scoliosis)

45. Surgery
1. DECOMPRESSION of spinal nerves (BURST
FRACTURE, Spinal stenosis, PID)
2. Fusion & Stabilization (Instrumentation)
3. Correction of deformity

46. DECOMPRESSION Surgery

47. FUSION Surgery

48. THANK YOU