APPROACH TO LOW BACK PAIN

LOW BACK PAINIS A SYMPTOM- NOT A DISEASE

McNab

Cause of the pain may be -

Within the spine

Lesion outside the spine

Within the spine-

Spondylogenic

Neurogenic

Outside the spine

Viscerogenic

Vascular

psychogenic

Spondylogenic

Bony components

Soft tissues of motion segment-disc,lig,muscles

SI joints

Congenital- spina bifida, listhesis, hemivertebra,sacralisation

Traumatic - fractures, lig injuries, LS strain, ruptured disc

Inflammatory-TB, pyogenic, brucellosis, RA, Anks spond

Degenerative- DDD, spondylosis, senile osteoporosis

Neoplastic-primary secondary

NeurogenicTension

Irritation

compression

Discogenic painDisc herniationAnnular tearSinuvertebral nerveDecrease pH within a deg disc –irritate the

nerve root

Arise frfom ventral root and gray rami communicants near DRG

Innervates PLL,ant dura,post annulus,blood vessels

ALL,lat & ant annulus –sympathetics

SP.VIP,CGRP

FACET JOINT PAINInnervated by medial branches of dorsal

primary ramiFacet capsule-contains encapsulated,non

encapsulated & free nerve endingsMechanoreceptors-inflamation sensitizes

these to movements of facet jtNociceptors-unmyelinated & plexiform fibres

sensitizes to chemical or mechanical stimulus

mechanismInjury to articular cartilage as in OADEGEN changes of facet jt-static n dynamic

compression of nerve root-lateral recess stenosis

Blockage of facet by synovial fold

radiculopathyMechanical deformation-intraneural tissue

rreactionsNerve roots –no effective blood nerve barrier

--lack epineuriumInflammation with mechanical compresion

Outside the spineAbdominal – pancreatitis, cholecystitis ,

peptic ulcer

Pelvic – ovaries,tubes,intrapelvic tumours

Vascular- aortic aneurysms,PVD

Psychogenic- Wadells signs

AIMTO LOCALISE THE PAIN GENERATOR IN THE

SPINE-facet,disc…

THE NEUROLOGICAL LOCALISATION-Myelopathy/Radiculopathy(root lesion)

The Aetiological/Pathological localisation –cong/trauamatic/infective/inflammatory/degenerative/neoplastic

APPROACHHISTORY

PHYSICAL EXAMINATION

NEUROLOGICAL EXAMINATION

INVESTIGATION

HISTORYPAIN- Commonest symptom

Site of pain Axial

Radicular involving limbs

combination of both

Onset,Duration,ProgressionAcute onset – fall,lifting weights, sports

injury

Insidious onset with rapid progression-infection, path #, tumours 1* 2*

Referred pain-pancreatitis,aortic aneurysm,pelvic and rectal conditions

duration of painAcute- strains, sprainsChronic- degenerative conditionsa/c on chronic

Radiation of painNature of painAggravating/relieving factors

Nature and intensity of painDiscogenic- focal,aching in nature,increased with

activity causing axial loading,decreased with rest

Facetal pain-pain on extension of spine (Can be of muscle strain)

Degenerative-Pain and stiffness in morning

Inflammatory-prolonged pain with stifness > 1hr

Tumour/infection- Night Pain unrelieved by rest

Neurogenic pain-radicular,claudicatonRadicular

thoracic spine-band like along the rib

Lumbar spine-radiates below knee

L3-4-Anterior thigh

L5- Dorsum of foot, 1 web space

S1-Buttock/posterior thigh

Neurogenic claudicationDiffuse pain n numbness

Progressive loss of walking ability/forward stooping walking

Symptoms produced by activities causing extension of spine, relieved by flexion

To r/o vascular claudication

Neuorgenic vs vascular

Occupational history-return to heavy physical work may not be possible

Family n social history- assess pts resources and support for treatment plan

Other systems assessment-CVS,PULMO,GI ,GU,ENDO

Nonorganic physical signs-The Waddell signsTenderness-superficial,nonanatomical

Simulation- axial loading, rotation

Distraction-SLR

Regional-weakness,sensory

Overreaction-disproportionate verbalization,inappropriate facial expression,tremor,collapsing,sweating

INSPECTIONGaitAntalgic one leg-nerve root

irritation,muscle weaknessSciatica :walk with hip more extended &

knee more flexedHigh stepping : foot drop -to clear the

groundSpastic:drags the foot

Trendelenburgs : L5 - abductor lurch

S1- extensor lurch toe walking not possible

L4-heel walking not possible

Look from front/back &sidesLevel of shouldersiliac crest-pelvic obliquity-LLD,SpineCoronal plane-scoliosisSagittal plane-Kyphosis/lordosisAngular kyphusKnuckle-1 vertebraGibbus-2 vertebraRound kyphus- > 2 vertebraOverall spinal balance

The plumb line

Sciatic list

Shoulder disc Axillary disc

Any swellings-cold abscess.Spina bifida-occulta/manifestaStep signAny scars/sinuses

PalaptionTemp

Tendernessdirect pressureTwistdeep thrust

Step + in > 50% slipParaspinal localised tenderness-facet

arthritis, TP #Cold abscess

movementsFlexionExtensionRotatonSide bending

Schober testExtension catch-

instability,disc pathology

Ext&lat bending-pain n facet pathology

MeasurementsChest expansion-at nipple levelShould be 5 cm,< 2.5cm suggests ASR/o LLD

Neurological examinationMSECNGait-type -Posture Sciatica-walk with hip extended n knee

flexed - to reduce tension on Sciatic N Heel walking-L4Toe walking - S1

motorBulkTonePowerCoordinationAbnormal movementsreflexes

L2

L3

L4

L5

coordinationHeel shin testRombergs sign

Involuntary movements

sensory

Touch-supDeepPain& tempPosterior column-joint sense,vibration

Reflexes- superficial

Plantar reflex

Bulbocavernous reflex

Deep reflexes

Bladder- voluntary control

RetentionDribblingfrequency

BowelControl of

sphinctersconstipation

Nerve root tension signs

SLR LASEGUE/BRAGGARD

BOWSTRING TESTSUDDEN SCIATIC STRETCH TEST

FNST

Well leg raising test-axillary disc

Piriformis syndromeEntrapment of sciatic nerve by the piriformis as

it passes thru the sciatic notchCauses:hypertrophyTraumaExcessive exercisesSpasm n inflammationAnomalies of piriformisPseudo aneurysm of inf gluteal arteryTraumatic myositis ossifcans

Clinical featuresHistory of trauma to SI or gluteal regionExacerbation of symptoms by lifting leg or

stooping/difficulty in walkingTenderness over sciatic notchSausage shaped mass over piriformisFelt by rectal exmn-pathognomonic

Positive SLR,Lasegue signFreiberg sign-pain with forced int rotation

of extended thighPositive sign of Pace and Nagle-pain with

resistance to abduction n ER the thighTibial nerve is less affected than peroneal

TreatmentPhysiotherapyNSAIDStretchingUltrasoundLocal steroid/anaestheticIf no relief-surgical release of piriformis

muscle

TEST FOR SI JT

COMPRESSION TEST DISTRACTION TEST

Axial rotation stress test

Pump handle test Gaenslen’s test

FABER test

Hip joints/other jointsOther systems

investigationsBlood Plain x rayCtMriBonescanInjection studiesBiopsy

Plain Xray APAlignment of vertebral columnLesion of pedicles/ TPSide to side collapseParavertebral soft tissue shadowsscoliosis

Lateral viewShape n size of vertebralbodyAnterior n posterior walls integritySuperior n inferior surfaces of bodyWedgingDisc space Spinal canal-between post end of body n

lamina-space occupied by cord

oblique views-for pars defectsScannograms-to view the entire spinal

columnCt-demonstrates bony lesions betterMri- demonstrates soft tissues betterScrrening of whole spine