Low Back pain
Dr Raj Sengupta
Introduction
• Definitive diagnosis difficult – not made in
85%
• Distinguish benign, self limiting disease
(95%) from serious disease (5%)
• When does a patient need further
investigations/ referral to secondary care?
Low Back pain
Sciatica
• sharp radiating pain often
associated with numbness or
paresthesia
• weakness and loss of reflexes
L4: knee jerk
L5: dorsiflexion, medial
sensation
S1: plantarflexion, ankle reflex,
lateral sensation
• aggravated by coughing,
sneezing, Valsalva
• most common cause is
herniated disc
L4/5, L5/S1 most common
Cauda Equina Syndrome
• Compression of cauda equina
– Bilateral leg pain and weakness
– Urinary retention, saddle anaesthesia,
reduced sphincter tone, bilateral sciatica
– Immediate referral for MRI or CT
– Surgical consultation
Compression can be from degenerative changes,
trauma, infection, tumour or haematoma
Spinal stenosis
Disease of older adults
Caused by bone (facets,
osteophytes) or soft tissue
(bulging disc, ligamentum
flavum enlargement)
Neurogenic claudication,
numbness, tingling
Pain improved when seated or
spine is flexed
Ankylosing Spondylitis
Spondyloarthritides
Undifferentiated
SpA
Juvenile chronic
arthritis
Ankylosing
spondylitis
Arthritis /
spondylitis
associated with
IBD
Reactive
arthritis
Psoriatic
arthritis
The SpA are a group of
related disorders that share
distinctive clinical,
radiographic and genetic
features:
• Sacroiliitis and spinal
inflammation
• Peripheral arthritis and enthesitis
• Extra-articular manifestations
• Strong association with Human
Leukocyte Antigen (HLA-B27)
IBD – Inflammatory bowel disease
Linden VD. In: Kelley’s Textbook of Rheumatology. Ankylosing Spondylitis. 8th ed. 2009
Sieper J. Arthritis Res Ther 2009;11:208
Inflammatory Back pain
• Age at onset <40
• Insidious onset
• Improvement with exercise
• No improvement with rest
• Pain at night (with improvement on getting up)
IBP if 4 or out 5 criteria present
Sieper et al. Annals Rheumatic Diseases 2009;68: 784-788
HLA B27 in SpA subtypes
Ankylosing
Spondylitis
Reactive SpA
IBD/ PsSpA
USpA
95%
70-80%
50%
0-70%
Espinoza LR, Cuellar ML. Clinical aspects of the
spondyloarthropathies. In: Lopez-Larrea C, ed. HLA-B27 in the
development of spondyloarthropathies. Austin: Landes, 1996:1–16.
Role of MRI
Axial Spondyloarthritis
Case presentation
Ms NH
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22 years old from Milton Keynes
4 year history of back symptoms
EMS 1 hour
Symptoms better with activity
Sleep disturbed
Night sweats
Father has AS
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Saw GP – NSAIDs
NSAIDS effective – ongoing symptoms
Referral to orthopaedics 2008
MRI requested 2008– normal
Returned to orthopaedics several times
MRI requested 2009 – normal
Discharged – ongoing back symptoms
RS clinic
• IBP symptoms
• MRI reviewed
• Correct MRI requested – Diagnosis made
• Patient frustrated and delay in diagnosis
GP Inflammatory Back Pain Pathway
Back pain
Inflammatory back pain
Xray pelvis
Sacroiliitis on xray
Normal
Refer to me
HLA B27 positive
Summary
• Most patients with back pain have self
limiting disease
• Some causes of mechanical back pain
need further urgent investigations eg
cauda equina
• Important to distinguish inflammatory
spinal disease