1) This document provides guidance on evaluating and differentiating the causes of low back pain through patient history, physical examination, and imaging. 2) The differential diagnosis depends on characteristics of the pain such as duration, location, radiation, and aggravating/relieving factors. Common etiologies include inflammatory, mechanical, and radicular causes. 3) The physical examination focuses on the spine, hips, and tests to reproduce pain including range of motion and provocative maneuvers. Red flags are identified. 4) Imaging like MRI can identify abnormalities in the discs, vertebrae, nerves and surrounding tissues that provide diagnostic clues. Both regular sequences and enhanced images after contrast are useful.

1. an approach to a patient with
low back pain

3. anatomy

5. Differential Diagnosis of Low Back Pain

6. REVISED LIST
I KNEW
THERE’S
A CATCH

7. PLAN OF ACTION

8. History
Physical examination

9. Site of pain
ISOLATED
LOW BACK
PAIN
BACK PAIN
WITH
LOWER
LIMB PAIN

10. HISTORY
INFLAMMATORY LOW BACK PAIN
(a) onset before age 45,
(b)Insidious onset,
(c) improved by exercise,
(d) associated with
morning stiffness,
(e) at least 3 months duration
(f) may have alternating buttock pain
MECHANICAL LOW BACK PAIN
•worsen with activity, including
prolonged sitting and standing and
bending forward, and improve with
recumbency initially
•Patients with spinal stenosis
typically experience gluteal, thigh,
& calf pain with standing, walking,
and lumbar extension.
•Patients with Deg. causes to their
complaints typically have a variable
severity with some good days and
some bad.

11. Patients with tumors
that involve the
structures of the lumbar
spine may often
experience worsening
pain with recumbency
and nocturnal
exacerbation of pain
Patients with viscerogenic pain
may have symptoms that are
worsened or exacerbated with
meals or bowel movements,
abdominal tenderness,
perimenstrual exacerbation, or
a history of excess alcohol or
nonsteroidal anti-inflammatory
drugs (NSAID) consumption.
Patients may move around with
a forward flexed posture to
avoid tension on the abdominal
muscles, trying to achieve a
comfortable position

12. CHARACTER OF PAIN

13. Attempt to measure pain severity

14. Synovitis Past or present asymmetric arthritis or arthritis predominantly in the
lower limbs
Family history Presence in first-degree or second-degree relatives of any of the
following: (a) ankylosing spondylitis, (b) psoriasis, (c) acute uveitis,
(d) reactive arthritis, (e)inflammatory bowel disease
Psoriasis Past or present psoriasis diagnosed by a doctor
IBD Past or present Crohn disease or ulcerative colitis diagnosed by a
doctor and confirmed by radiographic examination or endoscopy
Alternating buttock pain Past or present pain alternating between the right
and left gluteal regions
Enthesopathy Past or present spontaneous pain or tenderness at examination at
the site of the insertion of the Achilles tendon or plantar fascia
Acute diarrhoea Episode of diarrhoea occurring within 1 month before arthritis
Urethritis/cervicitis Non-gonococcal urethritis or cervicitis occurring within 1 month
before arthritis
History s/o axial
spondyloarthritides

15. If the back pain radiates into the lower extremities, suggesting pseudoclaudication
(neurogenic claudication) secondary to spinal stenosis or sciatica (usually secondary to a
herniated disk). Young adults are more likely to experience disk herniations, and elderly
patients are more likely to have spinal stenosis. Sciatica results from nerve root compression
and produces pain in a dermatomal (radicular) distribution, usually to the level
of the foot or ankle. The pain is lancinating, shooting, and
sharp in quality. It is frequently accompanied by numbness
and tingling and may be accompanied by sensory and motor
deficits. Sciatica due to disk herniation typically increases
with cough, sneezing, or the Valsalva maneuver.
Sciatica should be differentiated from non-neurogenic
sclerotomal pain. This pain can arise from pathology within
the disk, facet joint, or lumbar paraspinal muscles and lig.
Like sciatica, sclerotomal pain is often referred into the
lower extremities, but unlike sciatica, sclerotomal pain is
nondermatomal in distribution, it is dull in quality, and the
pain usually does not radiate below the knee or have associated
paresthesias. Most radiant pain is sclerotomal.
Bowel or bladder dysfunction should suggest the possibility of the
cauda equina syndrome.
RADIATING
PAIN

16. Nerve Root Pain
• Associated w/ Radiculopathy
• Sciatica
-herniated disk
-foramenal or spinal stenosis
-ligamentous hypertrophy
-other space filling lesions: cysts, tumor, abscess
-viral or immune inflammation
-can occur w/ peripheral nerve involvement
• Spinal stenosis
-neurogenic claudication (pseudo claudication)
1 or both legs
-radiation to buttocks, thighs, lower legs
-pain increase with extension (standing, walking)
-pain decrease with flexion (sitting, stooping forward)

17. RED FLAG SIGNS

19. EXAMINATION OF SPINE
• The spine is viewed for curvatures and postural deformities. A list is
present if the first thoracic vertebra is not centered over the sacrum.
• Hyperlordosis or a flattened lumbosacral curve may be
identified, whereas marked kyphosis is noted best from the lateral
position.
• The spinous processes and sacrum can be palpated and percussed
or pressure applied to determine if there is any osseous injury.
• The ischial tuberosity can be palpated to determine if proximal
hamstring tenderness or bursitis is present.
• The paraspinal muscles can be palpated for any areas of spasm, taut
bands, or trigger points.
• In the supine position,
• leg lengths should be measured to document discrepancies

20. Provocative tests for sacroiliac joints
FABERE test/ Patrick test
Sacral thrust & distraction test
Thigh thrust test
Gäenslen’s test

21. Patrick Test
Differentiation of hip pain from sacroiliac joint
pain may be determined by the Patrick or
“FABER” (flexion, abduction, external rotation)
test.
A Patrick maneuver producing low back pain
suggests sacroiliac joint pain but can be non-
specific and seen with spondylolisthesis, spinal
stenosis, facet syndrome, and acute discogenic
pain due to annular tear.
A Patrick maneuver producing groin or anterior
thigh discomfort suggests hip disease.

22. Gaenslen's test is performed with the patient
supine (on the back). The hip joint is maximally
flexed on one side and the opposite hip joint is
extended.

23. YEOMAN’S TEST

24. The patient lies supine with the hip and knee flexed where the
thigh is at 90° to the table and slightly adducted. One of the
examiners hands cups the sacrum and the other arm and hand
wraps around the flexed knee. The pressure applied is directed
dorsally along the line of the vertically oriented femur. The
procedure is carried out on both sides. The presumed action is
posterior shearing force to the SIJ of that side
THIGH THRUST
TEST

25. COMPRESSION &
DISTRACTION
PROVOCATION TESTS

26. HIP

27. • The hip joints should be
examined for any decrease in
range of motion because
hip arthritis, which normally
causes groin pain, may
occasionally present as LBP
• Trochanteric bursitis with
tenderness over the greater
trochanter of the femur can
be confused with LBP.
• The presence of more widespread
tender points, especially in a
female patient, suggests the
possibility that LBP may be secondary
to fibromyalgia.

28. FUNCTIONAL ASSESSMENT

31. FUNCTIONAL
ASSESSMENT BY
INTERMALLEOLAR
DISTANCE

32. • It has been shown that by using a combination of
the distraction, thigh thrust, compression, sacral
thrust, Gaenslen’s, and FABER tests, sacroiliac joint
pathology is the likely pain generator when three
or more of the tests are positive.

33. EXAMINATION FOR PT.s WITH
RADIATING PAIN DOWN THE LIMB

36. ROOT TENSION SIGNS

37. Tension at
dural sheath
starts from 20
deg. Elev.
BRAGGARD
TEST
CROSSED STRAIGHT LEG
RAISING TEST

39. Femoral leg stretch. In the femoral stretch test, the knee is flexed and
lifted superiorly. Sharp pain generated in the anterior thigh is considered to
constitute a positive test.

40. TEST INAPPROPRIATE RESPONSE*
Tenderness Superficial, nonanatomic tenderness to light
touch
Simulation
Axial loading Vertical loading on a standing patient's skull
produces low back pain
Rotation Passive rotation of shoulders and pelvis in
same plane causes low back pain
Distraction Discrepancy between findings on sitting and
supine straight leg raising tests
Regional
disturbances
Weakness “Cogwheel” (give-way) weakness
Sensory Nondermatomal sensory loss
Overreaction Disproportionate facial expression,
verbalization or tremor during examination
WADDELL'S TESTS FOR NONORGANIC PHYSICAL SIGNS
*—Three or more inappropriate responses suggest complicating psychosocial issues in patients with low back pain.

41. •DISTRACTION
•OVERREACTION
•REGIONAL DISTURBANCES
•SIMULATED TESTS
•TENDERNESS WHICH IS SUPERFICIAL ( to be
differentiated from allodynia)

42. • McCombe and colleagues evaluated the reproducibility between three observers
of physical signs used for back pain evaluation. The signs that were
• measurements of lordosis (by tape measure from the maximum kyphosis of the
thoracic spine to that of the sacrum)
• flexion range (Schober test)
• determination of pain location on flexion and lateral bend
• straight-leg-raising test (pendulum goniometer measurement of the angle at
which pain was first experienced and angle of maximum tolerance)
• determination of pain location in the thigh and legs
• sensory changes in the legs
• Nerve root tension signs were reliable if the location of pain was described.
Reproducibility of bone tenderness over the sacroiliac joints, spinous processes,
and iliac crests was greater than that associated with soft tissue structures.
• The diagnostic value of disturbed sensory and motor function was tested
prospectively by Jensen in 52 patients with lumbar disc herniations confirmed at
surgery.The positive predictive value of disturbed sensation in the L5 dermatome
and weakness of foot dorsiflexion was 76% for herniation from the L4/5 lumbar
disc. The positive predictive value of altered sensation in the S1 dermatome was
only 50% adequately reproducible included the following:

43. IMAGING
I THINK U WERE
TRYING TO SAY MRI

45. Without the Scout Image, it is going to be
impossible for the layperson, as well as most
general physicians, to discern which disc is
which when viewing the all-important axial
images (overhead view of the disc). It's like a
roadmap that tells you which slice or current
from the sagittal view (from the side) matches
up with that same view in the axial plane.
For example, the #10 slice in the Scout image
to the left would match up with the #10 axial
view, which in this case happens to run right
through the bottom of the L 4/5 disc.

46. Gray Rami
Communicantes

48. T2 axial mri cut at L4 disc level
demonstrates a T2 weighted
axial of a normal healthy
L4 disc from a 45 year-old
-male. Now, because the
T2 weighted images show
water content, we can see
a distinct nucleus pulp
osus (light-colored center
of the disc) which is surr.
by a darker annulus
fibrosis. we can also
clearly see the nerve roots
within the thecal sac.

50. Sagittal T1 image
This is a T1-weighted sagittal view of the
sacrum. The black L5 disc can be seen b/w be
L5 vertebra and S1 sacral segment

51. T2 weight MRI view of the lumbar spine from the side, or a
Sagittal Image.
First the basic structures: The discs, which are stationed
between the vertebrae, should be a white color (hydration).
Note the 'blackness' (desiccation) of the L5 disc (disc
between L5 and sacrum); this represents
moderate degenerative disc disease. The PLL (tiny blue
arrows) appears as a black vertically orientated line running
down the posterior surface of the vertebral bodies and disc.
The thecal sac (red stars) is the 'super white' structure that
fills the central spinal canal just behind the posterior
vertebral bodies. This sac house the free-floating spinal
nerve roots (cauda equina) and is made up of both motor
and sensory nerve fiber.
The ligamentum Flavum (green star) courses between each
of the vertebrae and adds stability to the spine. This
structure can hypertrophy or thicken in some patients and
help to cause the dreaded central canal stenosis.

53. This is a sagittal T2 waited MRI, which is a far
lateral cut (way off to the edge). This
demonstrates the very important
neuroforamen and the exiting nerve roots (red
arrows) within them.
This is a very important slice and both sides
should be carefully inspected to make sure no
disk herniations have occurred here.
Usually disk herniations do not go into this
area (the neural foramen); however, when
they do, not only can they cause severe
sciatica, they can also be quite difficult to
reach during discectomy.

54. Typical signs of inflamm
atory lesions in ankylosing
spondylitis: (A) T1
pre-gadolinium sequence,
(B) T1 postgadolinium seq.
Thin arrows,
spondylitis anterior (short
arrows) and
posterior (long arrows).
Bold arrow,
spondylitis ant. Surr-
-ounding an
erosion on the lower
edge of the vertebral
body. Circle, inflammation
in the
zygoapophyseal joint

55. spinal fusion (thin arrows
here in the dorsal part of the
thoracic vertebrae)
is depicted better in the T1
pregadolinium MRI sequence,
spinal
inflammation (bold arrows)
are only depicted either
after application of
gadolinium (B) or in the STIR
sequence
(C).

56. . Coronal T1-weighted MR image
Sacral foramen
Sacroiliac joint

57. Definition of sacroiliitis highly suggestive of SpA (‘‘positive MRI‘‘) for application in the new
ASAS classification criteria(Reproduced from Rudwaleit.)
A. Types of findings required for definition of sacroiliitis by MRI
• Active inflammatory lesions of the SI joints
(reflecting active sacroiliitis) are required for the definition of ‘‘sacroiliitis on MRI’’ as one of
the two imaging items in the ASAS classification criteria for axial SpA.
• BME (STIR) or osteitis (T1 post-gadolinium)
highly suggestive of SpA mustbe clearly present and located in
the typical anatomical areas (subchondral or periarticular bone marrow).
• The sole presence of other active inflammatory lesions
such as synovitis,enthesitis or capsulitis without concomitant BME/osteitis is
not sufficient for the definition of sacroiliitis on MRI.
• Structural lesions such as fat deposition, sclerosis, erosions or bony ankylosis are likely to
reflect previous inflammation. At this time, however, the consensus group felt that the sole
presence of structural lesions without concomitant BME/osteitis does not suffice for the
fulfilment of sacroiliitis on MRI in the ASAS classification criteria for axial SpA.
B. Amount of signal required
• If there is only one signal (lesion) per MRI slice suggesting active inflammation, the lesion
should be present on at least two consecutive slices. If there is more than one signal (lesion)
on a single slice, one slice may be sufficient.

62. •Capsulitis is comparable to
synovitis in terms of signal char.
but these changes involve the
anterior and
posterior capsule.
Anteriorly, the joint capsule
gradually continues into the
periosteum of the iliac and
sacral bones and
thus corresponds to an enthesis.
Capsulitis, therefore, may
extend far medially and laterally
into the periosteum. Capsulitis
may be better detectable using
contrast-enhanced T1-weighted
fat-saturated images as
compared to STIR

63. Hyperintense signal on
STIR images and/or on
contrast-enhanced
T1-weighted fat-saturtd
images at sites where
ligaments and tendons
attach to bone, including
the retroarticular space
(interosseous ligaments)
. The signal may extend
to bone marrow and
soft tissue. Enthesitis
may be better detectable
using contrast-enhanced
T1-weighted fat-saturtd
images as compared to
STIR.
A. 1: Enthesitis (white arrow) of interosseous ligaments (contrast-enhanced T1-weighted fat-saturated images; coronal view). Also present: osteitis of
the left iliac bone (black arrow). 2: Enthesitis (white arrows) of interosseous ligaments (contrast-enhanced T1-weighted fat-saturated images;axial
view). Also present: osteitis of the left sacroiliac joint (black arrow).B. 1: Enthesitis (arrow) of interosseous ligaments (short tau inversion recovery
(STIR)). 2: Enthesitis (arrow) of interosseous ligaments (STIR)

65. SURGEONS’
ASSISTANCE

67. GRAY ZONE
• PIRIFORMIS SYNDROME
• LUMBOSACRAL TRANSIENT VERTEBRA
• S.I. JOINT DYSFUNCTION
• BACK MOUSE
• EPIDURAL LIPOMATOSIS
• PREGNANCY

68. THAT’S ALL FOLKS