APPROACH TO A PATIENT WITH LOW BACK ACHEDr.Ankur Batra

INTRODUCTION

Low back pain (LBP) is defined as pain localised below the costal margin & above the inferior gluteal folds Non-specific low back pain is defined as low back pain not attributed to any recognizable cause. Acute LBP is defined as the duration12 weeks. Clinically any pain originating in the lumbar and sacral spine is a LBP

ANATOMY OF THE SPINE

The anterior portion of the spine consists of cylindrical vertebral bodies separated by intervertebral disks and held together by the anterior and posterior longitudinal ligaments. The intervertebral disks are composed of a central gelatinous nucleus pulposus surrounded by a tough cartilaginous ring, the annulus fibrosis. Disks are responsible for 25% of spinal column length and allow the bony vertebrae to move easily upon each other

The disks are largest in the cervical and lumbar regions where movements of the spine are greatest. The anterior spine absorbs the shock of body movements and protects the contents of the spinal canal.

The posterior portion of the spine consists of the vertebral arches and processes. The vertebral arch also has two transverse processes laterally, one spinous process posteriorly, plus two superior and two inferior articular facets. The apposition of a superior and inferior facet constitutes a facet joint.

Posterior spine protects the spinal cord and provide an anchor for the attachment of muscles and ligaments. Muscles attached to the spinous and transverse processes work like a system of pulleys and levers that results in flexion, extension, and lateral bending movements of the spine.

Periosteum Dura Facet joints Annulus fibrosus Epidural veins and arteries Post.Long.Ligament

APPROACH TO THE PATIENTDETERMINING THE CAUSE? HOW TO INVESTIGATE ? REFER OR NOT TO REFER ? THE APPROPRIATE TREATMENT MODALITY?

DETERMINING THE CAUSEHISTORYOther than the routine pain questionnaire(onset duration progression location etc.) it is important to evaluate three concerns in taking a history: Is there evidence of systemic disease? Is there evidence of neurologic compromise? Is there social or psychological distress that may contribute to chronic, disabling pain?

RED FLAGS IN THE HISTORY

OTHERS: night pain (also seen with disk disease and neurocompression), pain with recumbency (malignancy),morning stiffness >1 hour (spondyloarthropathy), incontinence, saddle anesthesia, and

TYPES OF BACK PAIN

LOCAL PAIN: injury to pain-sensitive structures irritates sensory nerve endings. The site of the pain is near the affected part of the back. PAIN REFERRED TO THE BACK: arise from abdominal or pelvic viscera. The pain is usually described as primarily abdominal or pelvic but is accompanied by back pain and usually unaffected by posture. PAIN OF SPINE ORIGIN :located in the back or referred to the buttocks or legs. Diseases affecting the upper lumbar spine tend to refer pain to the lumbar region, groin, or anterior thighs. Diseases affecting the lower lumbar spine tend to produce pain referred to the buttocks, posterior thighs, or rarely the calves or feet.

TYPES OF BACK PAIN (cont.)

RADICULAR BACK PAIN: sharp and radiates from the low back to a leg within the territory of a nerve. Coughing, sneezing, or voluntary contraction of abdominal muscles (lifting heavy objects or straining at stool) may elicit the radiating pain. PAIN ASSOCIATED WITH MUSCLE SPASM :commonly associated with many spine disorders and are accompanied by abnormal posture, tense paraspinal muscles, and dull or achy pain in the paraspinal region.

PHYSICAL EXAMINATION

The key to diagnosing the cause of low back ache is a detailed examination of the back which includes starting from the time patient walks into the room. Carefully examining the posture, placement of patients hand during pain and distractibility are some of the things to be noted clearly. Inspection itself can help us distinguish between regional back ache vs non inflammatory vs inflammatory back ache.

Lumbar Spine Examination

There are three important components of a lumbar spine examination: Inspect the presence of deformity Assess the movement of spine Assess the effect of lumbar spinal pathology on spinal cord or nerve roots

EXAMINATION SEQUENCE

With the patient standing , observe the posture from behind , checking that the spine is straight and from the sides to check that there is normal lordosis. Observe the effect of flexion on any abnormal lateral curvature Perform light percussion with fist or hammer to note any tenderness if there. Whilst keeping the legs straight ask the patient to bend backward, then forward and then to each side to note the range of motion

RANGE OF MOTION

The normal ranges of motion of the lumbar spine are 15 degrees of extension, 40 degrees of flexion, 30 degrees of lateral bending, and 40 degrees of lateral rotation to each side. Clinical examination of the ROM is very important as it will identify the lumbar spine pathologies.(SCHOBER TEST)

Schober`s Test

Used to measure the ability of a patient to flex his/her lower back. Mark is made at the level of the posterior superior iliac spine on the vertebral column(L5). The examiner then places one finger 5cm below this mark and another finger at about 10cm above this mark. Patient is instructed to touch his toes. If the increase in distance between the two fingers on the patients spine is less than 5cm then this

Video or photo

Tests for nerve root compression

Most commonly with PIVD. Occurs most frequently at L4-L5 and L5-S1 producing compression of L5 and S1 nerve roots. All the clinical tests used to check the nerve compression causes increased tension in the roots and thus cause pain in already compressed nerve roots.

EXAMINATION SEQUENCE

Straight Leg Raising Test: also called Lasgue's sign or Lazarevi's sign, is a test done to determine whether a patient with low back pain has an underlying herniated disk. With the knee flexed first check that the passive hip flexion is normal With the knee extended raise the leg on the unaffected side by lifting heel and note the range of motion

Repeat this on the affected side and asking the patient to report when he experiences pain or paraesthesia.

If sciatic pain at an angle of between 30 and 70 degrees, then the test is positive and a herniated disc is likely to be the cause of the pain. A meta-analysis reported the accuracy as sensitivity 91% specificity26% CROSS STRAIGHT LEG RAISING: sensitivity 29% specificity 88%

BRAGAARD TEST: When the limit of the patient is reached gently dorsiflex the ankle which causes further more tension and elicits subtle nerve compressions

BOWSTRINGS TEST /CRAMS TEST: Perform the SLRT and limit flex the knee so that the tension on the sciatic nerve root and the hamstrings is reduced. Now flex the hip Extend the knee till the pain is reproduced again. Posterior tibial nerve is now stretched like a bowstring across the popliteal fossa Apply pressure over the popliteal fossa with thumb producing pain in the back

BOWSTRINGS/CRAMS TEST

FEMORAL NERVE STRETCH TEST(L234) Patient lies prone on the table Passively flex the knee and extend the hip asking the patient to report the pain.

FLIP TEST: Ask the patient to sit on the edge of the table with knee and hip in 90 degree flexion and test the knee jerk Then extend the knee and check the ankle jerk. In presence of the nerve root irritation the patient will suddenly flip

OTHER TESTSLOUVEL SIGN :Have the patient cough or perform Valsalva maneuver. An increase in the back pain implies radiculopathy.

PATRICK TEST. With the patient supine, place the patient's ankle on the contralateral knee and then gently press down on the flexed knee, abducting the hip. Pain in hip suggests degenerative joint disease of the hip. Sacroiliitis if radiating pain from the low back down the leg. Pain felt in the lower spine suggests a vertebral

FAJERSZTAJN SIGN:Pain on the contralateral side when the nonpainful side is flexed at the thigh with the leg held in extension.(sciatica) SZABO SIGN: Loss of sensation on the lateral portion of the foot BONNET SIGN: Pain on adduction of the thigh TURYN SIGN : Pain in the buttocks when the great toe is hyperflexed

NEUROLOGICAL ASSESSMENTFollowing physical examination it is essential to assess neuological damage if any. Motor Examination Notice the gait of the patient and any abnormal posture. Instruct the patient to stand and walk on tiptoe and on the heels.This is usually performed to exclude major motor deficiencies.

SENSORY SUPPLYIts divided into band-shaped dermatomes. The most important areas of sensory supply are in order of their clinical significance in nerve-root irritation syndromes:

1.segment S1 that extends in a posterolateral strip from the buttock to the lateral margin of the foot; 2. the region supplied by segment L5 extending slightly inferior to the patella and across the lateral malleolus into the great toe; 3. segment L4 with its dermatome extending from the

SENSORY EXAMINATION PERTAINING THE LOWER BACK

SPECIAL EXAMINATIONPERIANAL REGION(S3S5) Saddle anesthesia(S3S5) usually associated with disturbed micturition, defecation, and sexual function.

Anal tone: Instruct the patient to close it around your palpating finger during rectal

REFLEXES : The two most important intrinsic muscle reflexes in the lower extremities are the patellar reflex (L3L4) and the Achilles tendon reflex (S1S2). Other reflexes: tibialis posterior reflex (L5), elicited by tapping the tibialis posterior tendon superior of the medial malleolus.

If reflex response is weak, the Jendrassik maneuver can be used to emphasize the patellar reflex and facilitate evaluation.

PHYSIOLOGIC SUPERFICIAL REFLEXES are polysynaptic and exhaustibleproprioceptive reflexes

CREMASTERIC REFLEX in which contraction of thecremaster may be elicited by stroking the medial side of the upper thigh (L1L2)

BULBO-CAVERNOSUS REFLEX in whichcontraction of the bulbo-cavernosus is elicited by squeezing glans of the penis(S2-S4)

ANAL REFLEX in which stroking of the perianal region

DETECTING MALINGERINGWADDELL SIGNS

3 out of 5 positives are significant for psychosochial illne

DIFFIRENTIAL DIAGNOSIS

INVESTIGATIONLaboratory Studies CBC ESR-infection URINE ANALYSIS-cancers SERUM AND URINE ELECTROPHORESISmultiple myeloma when other radiographic studies are inconclusive.

IMAGING STUDIES

In the absence of any findings from the neurologic examination and no evidence of infection or cancer, imaging studies are not clinically helpful in the first 4 weeks of symptoms. Quebec Task Force of Spinal Disorders (QTFSD) suggests that early radiographs are necessary only if the patient has neurologic deficits, fever, trauma, age >50 years < 20 years, or signs of neoplasm.

X-RAY PLAIN- AP and lateral views should be used unless spondylolysis is suggested, in which case oblique views are needed Ineffective and obsolete

CT SCANNING: Excellent for bony details and considered excellent for conditions like Lumbar disc herniation & Lumbar spinal stenosis.

CT SCANNING WITH MYELOGRAPH :A myelogram consists of injecting a radiopaque dye into the sac around the nerve roots, which in turn lights up the nerve roots. The CT scan follows and shows how the bone is affecting the nerve roots. This is a very sensitive test for nerve impingement and can pick up even very subtle lesions

MRI: MRI is superior to CT scanning for detection of many conditions because it presents soft tissue detail and multiple planar points of view If infection, disc/annular ligament,cancer, or persistent neurologic deficit is strongly suspected.

ELECTROMYOGRAPHY: An EMG assess the electrical activity of a nerve root. After 3 wks of pressure on a nerve root, the muscle the nerve goes to will begin to spontaneously contract which will also slow electrical conduction along that nerve. The test involves placing small needles into the back muscles Differentiates degenerative conditions vs nerve impingements

DISCOGRAPHY: Determines the anatomical source of lower back pain Most frequently used to determine if degenerative disc disease is the cause of a patients pain.

A needle is inserted in patients back into the center of the disc. Radiographic dye is then injected into the disc, and if injecting the dye recreates the patients normal pain (concordant), it is then inferred that the specific disc is the source of pain for the patient. If the pain is unlike their normal pain (discordant) it can be inferred that even though the disc may look degenerated on an MRI scan, it is in fact not the source of the patients pain.

BONE SCAN: To rule out an inflammatory process (such as a spinal tumor or infection) or an occult fracture. Radioactive marker is injected I.V. and after 3hrs the patient is placed through a scanner and the radioactive marker will be concentrated in any region where there is high bone turnover

Highly sensitive for tumors, infections, or very small fractures. It can also be used to determine if a compression fracture of the vertebral body is old or new, as an old fracture will not light up and a new one will.

DEXA SCAN: A dexa scan is used specifically to assess a patients risk of fracture by detecting osteoporosis of the vertebral bodies A dexa scan takes about ten minutes and is associated with minimal radiation exposure.

WHEN TO REFERPatients should be referred to neurosurgeon, orthopedician, or other specialist if they have Bowel/Bladder weakness with/without ED Progressive neurologic deficits Infections Tumors, or fractures compressing the spinal cord No response to conservative therapy for 4 to 6 weeks for patients with a herniated lumbar disk or 8 to 12 weeks for those with spinal stenosis.

FEW SPECIFIC CONDITIONSSpondylolisthesis: Anterior slippage of the vertebral body, pedicles, and superior articular facets, leaving the posterior elements behind. Associated with spondylolysis, congenital anomalies, degenerative spine disease, or other causes of mechanical weakness (e.g., infection, osteoporosis, tumor, trauma, prior surgery).

The slippage may be asymptomatic or may cause LBP and hamstring tightness, nerve root injury (the L5 root most frequently), symptomatic spinal stenosis, or cauda equina syndrome (CES) in severe cases. Tenderness may be elicited near the segment that has "slipped" forward (most often L4 on L5 or occasionally L5 on S1). The trunk may be shortened and the abdomen protuberant as a result

Surgery is considered for pain symptoms that do not respond to conservative measures (e.g., rest, physical therapy), and in cases with progressive neurologic deficit, postural deformity, slippage >50%, or scoliosis

Lumbar Disk Disease Disk disease is most likely to occur at the L4-L5 or L5-S1 levels Risk is increased in overweight individuals. Genetic factors may play a role in predisposing some patients to disk disease. Most commonly between 35 and 55 yrs of age.

The pain may be located in the low back only or referred to a leg, buttock, or hip. A sneeze, cough, or trivial movement may cause the nucleus pulposus to prolapse, pushing the frayed and weakened annulus posteriorly. With severe disk disease, the nucleus may protrude through the annulus (herniation) or become extruded to lie as a free fragment in the spinal canal.

Nerve root injury (radiculopathy) from disk herniation may be due to compression, inflammation, or both; pathologically, demyelination and axonal loss are usually present Sensory findings > Motor findings Clinical features depend on the root at which the disc has prolapsed. Lumbar spine MRI and CT-Myelogram is diagnostic

Lumbar spinal stenosis (LSS): narrowed lumbar spinal canal. Neurogenic claudication is the usual symptom, consisting of back and buttock or leg pain induced by walking or standing and relieved by sitting. Symptoms in the legs are usually bilateral

Patients with neurogenic claudication can often walk much farther when leaning over a shopping cart and can pedal a stationary bike while sitting with ease. These flexed positions increase the anteroposterior spinal canal diameter resulting in pain relief. Focal weakness, sensory loss, or reflex changes may occur when spinal stenosis is associated with neural foraminal narrowing and radiculopathy(uncommon)

LSS can be acquired (75%), congenital, or due to a combination of these factors. Congenital forms (achondroplasia, idiopathic)short, thick pedicles that produce both spinal canal and lateral recess stenosis. Acquired factors-degenerative diseases (spondylosis, spondylolisthesis, scoliosis), trauma, spine surgery, metabolic or endocrine disorders (epidural lipomatosis, osteoporosis,renal osteodystrophy), and Paget's disease.

ANKYLOSING SPONDYLITIS Insidious onset dull aching pain Males