Low
Back
Pain
Low Back Pain
70% adult at some time
M=F Age=30-50
Mechanical
Inflammatory
Infection
Neoplasm
Metabolic, Visceral Disease
Low Back Pain
Red Flags
50<age<20
Constitutional symptoms: fever, chills, weight loss
History of cancer
Immune suppression: steroid and cytotoxic therapy
,IV drug abuse, AIDS
Recent bacterial infection
Night time pain, failure to improve after 4-6 weeks
Saddle anesthesia, urinary or fecal incontinence,
Severe or progressive neurologic deficit
Low Back Pain
Imaging
Plain radiography: clinical finding
suggestive of systemic disease or
trauma (red flags)
Failure of the pain to improve after
4-6 weeks
CT and MRI : underlying infection,
cancer ,persistent neurologic deficit
Low Back Pain
Mechanical
Lumbar strain / sprain 70%
Degenerative processes 10%
Herniated disk 4%
Spinal stenosis 3%
Osteoporotic compression fracture 4%
Spondylolisthesis 2%
Scoliosis, kyphosis<1%
Low Back Pain
sprain-strain
Age:20-40
Acute, local pain, aggravate with
motion
Increased with standing and bending
Decreased with sitting
Negative SLR
Negative imaging
Treatment
Sprain-strain
Neither bed rest nor exercise in
acute phase, NSAIDs, muscle relaxant
Spinal manipulation and physical
therapy after 3 weeks
The best recommendation: rapid
return to normal activity
Natural history:90% recovery within
2 weeks, recurrence 40% within 6 months
Low Back Pain
Osteoarthritis
Age=over 50
Insidious pain
Increased with standing and
extension
Decreased with sitting and
bending
Negative SLR
Positive imaging
Low Back Pain
Discogenic Pain
Age: 30-50
Acute pain, L5 and S1 root
Increased with sitting and bending
Decreased with standing
Positive SLR
Positive imaging
Low Back Pain
Straight Leg Raising -Lasegue,s test
Positive test if:angle of flexion
is about 20-70
Ipsilateral SLR: sensitive,
not specific
Crossed SLR: insensitive,
highly specific
Reversed SLR: root L3-L4
Low Back Pain
Radicular Symptoms and Signs
Pain distribution Sensory loss Motor Loss Reflex loss
L4:Anterior Medial leg to Anterior tibialis Patellar
thigh to Medial malleolus
medial leg
L5:Lateral leg Lateral leg to Extensor hallucis
to dorsum of Dorsum of foot longus
foot
S1:Lateral foot Lateral foot, Peroneus Achilles
sole Longus and brevis
Low Back pain
Nerve distribution L3-L4
Low Back Pain
Representative Results of MRI Studies in
Asymptomatic Adults
Subjects Anatomical Findings (prevalence%)
Herniated Disk Bulging Disk Degenerative Disk Stenosis Annular Tear
Volunteers <60 yr old 22 54 46 1 NR
Volunteers>60 yr old 36 79 93 21 NR
Volunteers(mean age,42yr) 28 52 NR 7 14
Volunteers(mean age,35yr) 40 24 72 NR 33
Patients referred for head or 33 81 72 NR 56
neck imaging(median age,
42 yr)
NR denotes not reported
Low Back pain
Treatment: Discogenic Pain
NSAIDs ,narcotics,muscle
relaxant,corticosteroides (systemic
or focal injection)
Surgery:Severe stable pain after
one month, cauda equina syndrome,
progressive neurologic deficit
Natural history:only 10% pain after 6
weeks
Low Back Pain
Spinal Stenosis
Age>60, onset: insidious
Increased pain with standing and
extension
Decreased pain with sitting and
bending
SLR(+,-), Imaging (+)
Low Back Pain
Treatment: Spinal Stenosis
Avoidance of alcohol and sedatives
Exercise (bicycle or walking)
NSAIDs,narcotic, corticosteroid(systemic
or focal injection)
Surgery: Progressive or severe neurologic
deficit, severe back and leg pain, disability
Natural history:15% improvement over
4 years, 70% remain stable, 15% deterioration
Low Back Pain
Spondylolisthesis
Age:20-30 Onset:insidious
Increased pain:bending and standing
Decreased pain:sitting
Step off,increased lordosis SLR:negative
Imaging:X-Ray, MRI
Treatment:NSAIDs,flexion strengthening
exercises,orthopedic corsets,surgery
(greater than grade II slippage)
Low Back Pain
Scoliosis
Age=20-40, adolescent girls
Definition:Lateral curvature of
the spine in excess of 10 degree
Onset:insidious, increased with
standing and bending, decreased
with sitting, SLR negative
Imaging: coob’s method
Low back Pain
Scoliosis: Cobb’s Method
Low Back Pain
Treatment: scoliosis
Exercise, braces
Surgery: Progressive scoliosis
(greater than 40 degree),
Harrington rods, fusion
Low Back Pain
Diffuse Idiopathic Skeletal hyperostosis (DISH)
More common in older man, hyperostosis of spine in
anterior longitudinal ligament and peripheral disc
margin ,more in dorsal spine, anterior and right
lateral of disc
Large bony spurs, often in olecranon and calcaneous
Despite extensive anatomic abnormality , minimal
pain, moderate limitation in spinal motility and
prominent stiffness.
DM and impaired GTT in 50% of patients
Low Back Pain
Diffuse Idiopathic Skeletal hyperostosis (DISH)
Resnick criteria for DISH diagnosis
1-Flowing ossification along anterolateral aspect of at
least four contiguous vertebral bodies.
2-Preservation of disc height.
3- Absence of vacuum phenomena or vertebral body
marginal sclerosis.
4- Absence of apophyseal joint ankylosis or sacroiliac
joint erosions, sclerosis, or fusion.
Low Back Pain
Osteoporotic Compression Fracture
• In united state 500000 vertebral fracture annually
• Acute low back pain, progressive kyphosis, often
asymptomatic, decreased height
• Diagnosis often incidental
• Treatment in acute form : analgesic, calcitonin IM or
SC, treatment of osteoporosis
Low Back Pain
Visceral Disease (2%)
Disease of pelvic organs
Prostatitis, Endometriosis, PID
Renal disease
Nephrolithiasis, Pyelonephritis,
Perinephric abscess
Gasterointestinal disease
Pancreatitis, Cholecystitis, Penetrating
ulcer
Low Back Pain
Neoplasia (0.7%)
Multiple myeloma
Metastatic carcinoma
Lymphoma and leukemia
Spinal cord tumors
Retroperitoneal tumors
Primary vertebral tumors
Low Back Pain
Inflammatory Low Back Pain (0.3%)
Ankylosing spondylitis
Reiter’s syndrome
Psoriatic spondylitis
Inflammatory bowel disease
Behcet’s disease
Low Back Pain
Inflammatory Low Back Pain
Onset: Before age 40, insidious
Duration longer than 3 months
Associated with morning stiffness
Decreases with exercise
Nocturnal pain
Sacroiliac joint tenderness and decreased chest
expansion
Low Back Pain
Scheuermann’s Disease (Juvenile kyphosis)
• Osteochondrosis of vertebral bodies in male
adolescent.
• Pain and limitation of movement in dorsal spine,
shoud be differentiated from ankylosing spondylitis.
• In radiography of spine, increased kyphosis,
schmorl’s nodes
• No special treatment.
Low Back Pain
Infection ( 0.01%)
Osteomyelitis
Septic discitis
Paraspinous abscess
Epidural abscess
Shingles
Low Back Pain
Low Back Pain: Tuberculosis
Epidemiology: Age 24-76, endemic region (<20
Year, pott’s disease), 1-5% of mycobacterial
infection, up to 30% have infection in other
organ, tuberculose spondylitis is the most form
of osteoarticular involvement
Manifestation: site (1-thorasic 2-lumbar 3-cervical),
paraspinal abscesses(50-96%),
Skip area between involved vertebae(10%)
Neurologic symptoms(12-50%), 30% no evidence
of extraspinal tuberculosis,positive PPD(95%)
Diagnosis: CT guided or open biopsy, MRI
Low Back Pain
Treatment: Spinal tuberculosis
Medical: 12-18 months treatment, lumbar support
(at least 12 month)
Surgery: Progressive neurologic deficit,
large Abscess, spinal instability, no response
or non compliance with medical therapy,
non diagnostic needle biopsy, spinal
deformity (more than 50% vertebral
collapse or deformity of more than 5 degree
Low Back Pain
Low Back Pain: Brucellosis
Clinical manifestation: very acute, painful lumbar
spinal percussion, fever, splenomegaly, leukopenia,
ESR<50, neurologic deficit rare
Diagnosis: involvement of vertebral body and disk,
barrot shape osteophyte, wright and coomb’s wright,
blood and bone marrow culture
Treatment: Tetracyclin+sterptomycin (8-12 weeks)
WHO recommendation: Rifampicin+Doxycyclin
Low Back Pain
Alkaptonuria (Ochronosis)
Inherited metabolic disease, absence of hemogentisic
acid oxidase, excretion of acid in urine and binding
of metabolic products to connective tissue
Deposition of brown-black pigment in cartilage, skin,
sclera
Degenerative disease in spine, ossification of
numerous intervertebral discs is a characteristic
finding.
