Low Back Pain

Dr Herman Gofara, SpOT (K) Spine

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

Implication

 Work & productivity loss

Anatomical consideration

 Commonly at lumbosacral junction (L4/L5,

L5/S1)

 Why?
 Most mobile region of the spine

 Therefore prone to degeneration (wear &

tear)
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)
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
Nature of pain

 MECHANICAL VS NON-MECHANICAL

 REFERRED VS RADICULAR

 CLAUDICATION – VASCULAR VS SPINAL

MECHANICAL PAIN

1. Muscle strain

2. Ligament sprain

3. Facet joint arthritis

4. Disc-Discogenic

5. Instability - Spondylolysis/spondylolisthesis
NON-MECHANICAL PAIN

 Infection – PYOGENIC VS TB

 Tumour – PRIMARY VS SECONDARY

 Primary - BENIGN VS MALIGNANT

 Common causes of low back pain
Pathology Age Pain nature Assoc pain Assoc sx
DEGENERAT >40y mechanical Distance Active pt
IVE 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
RED FLAGS
 Constitutional symptoms
 LOW, LOA, fever

 AGE(>50)

 IMMUNOCOMPROMISED,

 TB CONTACT

 KNOWN CANCER

 NEUROLOGICAL DEFICIT (CAUDA EQUINA SYN)

Physical findings
 General examination
 Age
 Ill looking

 Local examination – DO NOT MISS A

GIBBUS
 Deformity
 Scoliosis/kyphosis
 Step deformity
 Local tenderness/paraspinal spasm

 Limited ROM
 Full neurological examination

 ANAL TONE / PERIANAL SENSATION

 DERMATOME & MYOTOME

Investigations
Plain radiograph
 AP
-loss of lumbar lordosis
-reduced disc space
-osteophytes
-deformity
-fracture (increase interpedicular distance)
-osteoporosis
-pedicle disruption
 Lateral
-fracture/wedging
-kyphosis
-spondylolisthesis

 Oblique
-spondylolysis (SCOTTIE DOG)
Plain x-rays
Blood investigations

 FBC
 Anemia, TWC
 ESR
 Liver function test
 ALP
 Renal function test
 Calcium level
CT Scan

 better visualization of bone pathology (eg.

cortical destruction)
 fracture
 tumor
MRI

 -better soft tissue visualization

 -disc
 -ligaments (ALL,PLL)
 -nerves (spinal cord, roots)
 -bone marrow
 -pus collection
MRI
CT myelogram

 role replaced by MRI

 for delineation of neural structures where MRI
is not available/contraindicated
CT Myelogram
Bone scan

 Suspicious of multiple bone mets

 Eg. with history of untreated/treated CA
 Negative in Multiple myeloma
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)
Pelvic traction
Surgery
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)
Surgery

1. DECOMPRESSION of spinal nerves (BURST

FRACTURE, Spinal stenosis, PID)

2. Fusion & Stabilization (Instrumentation)

3. Correction of deformity
Non Surgery Treatment
THANK YOU