This document discusses lumbar pain and low back pain. Some key points: - Low back pain is very common, expensive, and a leading cause of disability. - Physical examination and imaging tests can help evaluate the source and severity of back pain. - Treatments may include exercise, medication, injections, and in some cases surgery. However, surgery outcomes are often similar to non-surgical treatments. - Proper diagnosis is important to guide treatment, as many cases of back pain resolve on their own with time and conservative care.

1. LUMBAR PAIN
Mrinal Joshi
MBBS MD DNB MNAMS GCMskMed
Professor & Head, Dept. of PMR
Rehabilitation Research Center
SMS Medical College & Hospital
Jaipur

2. Low Back Pain
• Most expensive and common cause of
disability
• Maximum number of physician office visit
• Even more at quacks and alternate
practitioners
• Rates of surgery is on rise
• Recurrent symptom but benign prognosis
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3. 3

4. 4

8. Back Problem
• Extremely common medical issue
• Most expensive industrial injury ??
• 25% to 45% have symptom radiating below gluteal
fold
• 5% neurological changes during physical
examination
• 2% indicative of good surgical outcome by
decompression
• Half of the above recovery sufficiently to lose interest
in surgery
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9. Irrational Aspects
• Bleeding legs
• Screening x-rays
• Ageing changes as indication of pathology,
CT/MRI
• Passive treatments
• Huge Owen Thomas
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11. Elements of Pain
• Sinuvertebral nerves are primary innervation of disc
• Travel rostrally 2 levels and caudally 3 levels
• Posterior rami circumflex extends to facet joints
• Potential autonomic input responsible for burning skin,
shocks etc.,
• Sciatica results from both chemical and mechanical
irritation
• Muscular protection reduces with age e.g. leg in cast
• Activity beyond the capacity can result in symptoms
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13. Caveats
• Difficult to predict the outcome of back
problems
• Difficult to pain in those who are extremely
inactive
• Convince that there is nothing dangerous
• Using the back is beneficial and safe
• Managing back pain is like training for
marathon 14

14. Precis of Assessment
• History (sitting)
• Observation (standing)
• Examination
• Active movements (standing)
• Forward flexion
• Extension
• Side flexion (L/R)
• Rotation (L/R)
• Quick test
• Trendelenburg’s and S1 root test
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15. • Passive movements (with care and caution)
• Peripheral joints scan (standing)
• Sacroiliac joints
• Special tests (standing)
• One leg standing lumbar extension test
• H & I test
• Resisted isometric movements (sitting)
• Forward flexion
• Extension
• Side flexion (L/R)
• Rotation (L/R)

16. • Special tests (sitting)
• Slump test
• Sitting root test
• Resisted isometric movements (supine lying)
• Dynamic abdominal endurance
• Double straight leg lowering
• Internal/external abdominal oblique test

17. • Peripheral joint scan (supine lying)
• Hip joint (F/E/Ab/Ad/MR/LR)
• Knee joint (F/E)
• Ankle joint (Df/Pf)
• Foot joints (Sup/Pro)
• Toe joints (F/E)
• Myotomes
• Hip flexion (L2)
• Hip extension (S1)
• Knee extension (L3)
• Knee flexion (S1-S2)
• Ankle dorsiflexion (L4)
• Toe extension (L5)
• Ankle eversion or plantar flexion (S1)

18. • Special tests (supine lying)
• SLR and its variants
• Buttock signs
• Reflexes & cutaneous distribution
• Palpation (supine lying)
• Resisted isometric movements (side lying)
• Horizontal side support
• Special tests (side lying)
• Femoral nerve traction test
• Special torsion tests
• Peripheral joint scan (prone lying)
• Hip joint (Ex/MR/LR)
• Resisted dynamic extension test
• Special test (prone lying)
• Prone knee bending test

19. • Joint play (prone lying)
• Posteroanterior central vertebral pressure
(PACVP)
• Posteroanterior unilateral vertebral pressure
(PAUVP)
• Transverse vertebral pressure (TVP)
• Palpation
• Multifidus test

20. Waddell Embellishment Tests
• Tenderness: subcutaneous (or less) pressure to reproduce
symptoms
• Simulation
• Simulation of loading spine with weight of your hand to reproduce
pain
• Simulation of twisting trunk when rotating the hips and shoulder in
unison to reproduce pain
• Distraction: sitting knee extension and SLR test
• Non-anatomic distribution of pain on pain drawing or giving away on
muscle testing
• Overreaction: grimacing, complaints or suffering displays
inappropriate for situation or manoeuvre21

21. Red Flags
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22. Non-Physical Interference
• Threats to patient’s self-esteem, livelihood,
future, or other loss can significantly influence
patient’s response to caregivers
• Try not to be too judgemental
• Survival behaviour is a common human
response
• Zero to two Waddell’s are normal
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23. Treatment
• Assure that there is nothing to fear
• Comfortable activity tolerance can be achieved only by overcoming or
avoiding the debilitation of inactivity
• Conditioning
• 3-4 weeks of general conditioning
• Speed walk, stationary cycle, jogging
• Specific muscle training at least 4-5 times/week
• Next phase of other core and neck muscles
• Work hardening
• Patient benefit more from our honest help than judgement of legitimacy
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24. Diagnostic Considerations
In
Delayed Recovery
• If back symptoms persist and continue to limit
activity for more than 4 weeks, SEEK CAUSE
• A picture of tissue/bone abutting the dura does
not indicate it to be the cause
• Physiological evidence will tell us whether the
nerve root is compromised
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25. Diagnostic Considerations
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Technique Physiological Evidence Anatomic Evidence
History + +
Circumference measurement + +
Reflexes ++ ++
Straight-leg raise ++ ++
Crossed SLR ++ +
Motor ++ ++
Sensory ++ ++
Lab test (ESR,CBC,UA) ++ 0
Bone Scan +++ +++
EMG +++ +++
X-Ray 0 +
CT 0 ++++
MRI 0 ++++
Myelography 0 ++++
Myelo-CT 0 ++++

26. Disc Findings

28. Reasonable Approach to MRI
• Start with MRI T1 weighted parasagittal lateral view
• For evaluating fat in foramina canal
• Vanishes before root is compressed
• Lateral views are usually left to right
• T2 weighted parasagittal lateral view
• Water content is white like in myelogram
• Contour of canal & indentations
• T2 weighted cross sectional images
• Evaluate convex or flat dural sac
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29. Wheel of Fortune
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32. Epidural Steroid Injection
&
Inflammatory Theory
• Have been used for more than 40 years
• Use of caudal epidural was reported in 1961 with 66%
improvement
• Near level advocacy started in 1972
• Most back pains are due to muscular and ligamentous
strain & spasm
• Mechanical back pain is primarily somatic
• Most studies are anecdotal, retrospective and not
RBCT 33

33. Result of well controlled Lumbar
Epidural Steroid Injections for Acute
Herniated Disc

34. Current Role
• Efficacy of ESI has not been conclusively demonstrated
• Very good short to intermediated-term success in
selected patients
• Presence of nerve root irritation is required to justify use
of ESI
• Less efficacious in patients with neurologic deficits and a
large disc herniations
• Comprehensive management rather than being a needle
jockey
• Fundamentally a safe injection with good efficacy but
should a part of multidisciplinary plan35

36. Surgery in Sciatica
• Only when non-operative treatment fails except some
emergencies
• Nonsurgical management should be attempted for at 4-6
weeks to 6 months depending on condition
• Back pain with leg symptoms of pain, numbness or
weakness after a dermatomal distribution
• Sinuvertebral nerve can get irritated with mechanical or
chemical factors
• Short term relief of symptoms is better with surgery but in
most the long term outcomes are almost similar
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37. Surgery for Herniated Disc
• Tendon reflexes do not usually recover
• One-third are left with some sensory deficit
• Only absolute indication is caudal equina syndrome
• Relative indication
• Gross motor weakness
• Loss of bowel bladder function
• Recurrent incapacitating leg pain
• Persisting leg pain
• Best window 3-6 months
• Not a life saving procedure but improves QOL
• Exclude other causes
• Most have 70% improvement
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38. Herniated Disk
• Back & leg pain with strong physiological
evidence on physical examination or EMG and
corresponding anatomic confirmation on
Imaging are an indication to consider
decompression
• If able to function at less than 3+ EMG and
deferred surgery will eventually recover with
60% recurrence
• With surgery recurrence rate is down to 10%
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39. Appropriate Treatment
• No more than 2-3 days bed rest
• Trial of NSAIDs for 3-4 weeks
• Physical therapy/conditioning
• Nerve root/epidural injection may be attempted
• Lack of scientific data on effect
• Decision usually case-by-case basis
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40. Procedures
• Chemonucleolysis
• Percutaneous discectomy
• Mechanical
• Laser
• Open Surgery
• Posterior Surgery
• Standard laminectomy and discectomy
• Limited approach/microdiscectomy
• Far lateral discectomy
• Anterior approach
• Arthroscopic discectomy
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