LOW BACK PAİN
Prof. Dr. Hidayet SARI
KEY POINTS
• Low back pain (LBP) is the second most
comman condition seen primary care
practice, and the most common problem
seen by musculosceletal specialists. It is
essential that physicians be comfortable
with the nuances of diagnosis and
teratment of LBP.
KEY POINTS
• Less common causes of LBP such as
infection (fever and focal pain) and cancer
(weight loss, unexplained pain,and
oncologic risk factors) must be overlooked.
If the pain persists and is unexplained,
then the case must be investigated further.
KEY POINTS
• Magnetic resonance imaging (MRI)
images have a 30% false-positive rate,
and therefore must be used in a
discrminating manner. Remember that
most patients with acute LBP and without
neurologic signs and symptoms will
respond to conservative therapy, and need
no diagnostic tests.
KEY POINTS
• Prolonged bed rest is harmful. An
extended period of inactivity is a risk factor
for converting acute LBP into chronic LBP.
Start an appropriate regimen of exercise
as soon as possible to preserve strength
and flexibility in the muscles that support
the lumbar spine.
KEY POINTS
• Sensitization of peripheral or central pain
processing systems will explain some
cases of chronic LBP that persist despite
the correction of the anatomical factors.
Therefore, the first 3 to 6 months of
assessment and treatment of patients with
LBP are critical with regard to preserving
and optimizing function of the lumbar
spine.
INTRODUCTİON
• LBP can affect up to 80% of the
population at some point in their lives,
making it second only to the common cold
as an illness affecting the general
population, and the fourth or fifth most
comman reason for a visit to the
physician’s office in the United States.
INTRODUCTİON
• Acute LBP usually resolves
spontaneously, but up to 10% progress to
chronic LBP resulting in temporary or
permanent disability. This results in a loss
of more than 1,000 work days per 1,000
workers each year, costing more than $20
billion annually and disabling several
million individuals in the United States
alone at any on time.
INTRODUCTİON
• Risk factors for the development of LBP
include heavy manual work, poor job
satisfaction, exposure to vibration, cigarette
smoking and pregnancy. A sedentary lifestyle is
also probably a cause.
• Most patients with acute and chronic LBP
have “idiopathic“ LBP, meanng that despite
testing, no clear cause can be found for their
pain.
INTRODUCTİON
• Most patients who present with acute
LBP in the absence of significant
neurologic physical findings need no
diagnostic tests and will respond to
conservative management.
• Patients who do not respond to a
conservative regimen may need imaging
studies, and rarely surgery
ETIOPATHOGENESİS
• Any of the components of the lumbosacral spine when
combined with related conditions listed in the subsequent text may
be responsible for LBP.
I- VERTEBRAL BODY (fracture,osteoporosis, metastatic disease,
sickle cell disease and infection)
II- INTERVERTEBRAL DİSC (herniation and infection)
III-JOINTS (osteoarthritis and ankylosing spondylitis)
A- Apophyseal joints
B- Sacroiliac joints
ETIOPATHOGENESİS
IV- LİGAMENTS (strain and rupture)
A- Anterior and posterior longitudinal ligaments)
B- Interspinous ans supraspinous ligaments
C- Iliolumbar ligaments
D- Apophyseal ligaments.
V- NERVE ROOTS (herniated nucleus pulposus and spinal stenosis)
VI- PARASPİNAL MUSCULATURE (strain and spasms)
IV- LİGAMENTS (strain and
rupture)
A- Anterior and posterior
longitudinal ligaments)
B- Interspinous ans
supraspinous ligaments
C- Iliolumbar ligaments
D- Apophyseal ligaments.
V- NERVE ROOTS (herniated
nucleus pulposus and spinal
stenosis)
VI- PARASPİNAL
MUSCULATURE (strain and
spasms)
VII- PAIN FROM ADJACENT
STRUCTURES (referred pain)
A- Kidney (pyelonephritis and
peripheric abscess).
B- Pelvic strucures (pelvic
inflammatory disease, ectopic
pregnancy, endometriosis and
prostate disease)
C- Vascular (aortic aneurysm and
mesenteric thrombosis)
D- Intestinal (diverticulitis)
VIII- Pain amplification syndromes
where there is no identifiable
abnormality of the peripheral
tissue, but there is localized or
widespread hyperalgesia (e.g.,
myofascial pain and regional
forms of fibromyalgia).
PREVALENCE
• Prevalence of LBP ranges from 38 to 39
per 1,000 population, with female sex,
white ancestry, and increasing age being
independent risk factors for increased
incidence.
CLINICAL MANIFESTATIONS
I. Clinical history of the patients is of great
importance in obtaining information
regarding associated symptoms and
establishing a pattern of pain. A thorough
review of symptoms that would suggest a
nonmechanical cause for LBP is required.
CLINICAL MANIFESTATIONS
• I. Clinical history
A- Fever or chills would raise the possibility of an
infectious process.
B- Weight loss, chronic cough, change in bowel
habits, or night pain may suggest malignancy
C- Similar pain or morning stiffness in different
areas of the body would increase the suspicion
of a more generalized rheumatic condition such
as ankylosing spondylitis, psoriatic arthritis, or
reactive arthritis (ReA9
CLINICAL MANIFESTATIONS
• I. Clinical history
D- If fatigue or sleep disturbance is present, in the
setting of a diffus pain syndrome, the diagnosis
of fibromyalgia should be considered.
E- Morning stiffness or back pain that improves
with exercise should prompt consideration of a
spondyloarthropathy such as ankylosing
spondylitis.
CLINICAL MANIFESTATIONS
II- PAIN The quality of pain, its distribution,
and modulating factors are helpful in
determining etiology.
CLINICAL MANIFESTATIONS
• II- PAIN
A- Onset of pain
1. Sudden onset especially following trauma suggests injury.
2. Indolent onset suggests a nonmechanical cause.
3. Episodic or colicky pain suggests an intra-abdominal or pelvic
source.
B- Localization of pain
1. Localized pain provides a focus for the diagnostic workup.
2. Radicular pain, suggesting nerve root impingement.
3. Pain thatn is not easily localized, migratory, or multifocal suggests
fibromyalgia.
CLINICAL MANIFESTATIONS
• II- PAIN
C- Modulating factors
1. Exercise-induced pain, especially on walking,
suggests osteoarthritis or spinal stenosis, whereas
pain that improves with exercise especially following
morning stiffness suggests an inflammatory
process, for example, a spondylarthropathy.
2. Valsalva maneuvers such as coughing, sneezing,
or bowel movements that worsen pain suggest nerve
root impingement.
CLINICAL MANIFESTATIONS
III- NEUROLOGİC SYMPTOMS.
The presence of neurologic symptoms
should be spesifically sought in patiets
with LBP. Their presence can not only help
to delineate the site of the abnormality but
also can prompt more rapid intervention.
CLINICAL MANIFESTATIONS
• III- NEUROLOGİC SYMPTOMS.
A- Weakness, numbness, or paresthesias in a
dermatomal distribution suggests nerve root
impingement.
1. The most common cause of nerve root
impingement in individuals between the ages of
20 and 50 years is a herniated nucleus
pulposus.
2. Radicular symptoms in individuals older than
60 are more likely to be secondary to spinal
stenosis resulting from osteoarthritis.
PHYSICAL EXAMINATION
• Spesific abnormalities and provacative
maneuvers designed to elicit pain
associated with certain synrromes should
be tested for in patients with LBP.
CLINICAL MANIFESTATIONS
• III- NEUROLOGİC SYMPTOMS.
B- Bowel or bladder dysfunction suggests
the presence of cauda equina syndrome
and should prompt emergent investigation.
C- LBP in the presence of fever and
neurologic symptoms should trigger the
mind to the possibility of an epidural
abscess.
PHYSICAL EXAMINATION
1- PATIENT IN STANDING POSITION
A. Note the alignment of the spine looking for a
pelvic tilt may indicate a paravertebral spasm ,
for loss of normal lumbar lordosis that could
indicate either spasm or ankylosis, and for
evidence of structural scoliosis.
B. Evaluate gait, station, and posture.
C. Evaluate the patient’s ability to flex,
hyperextend, rotate, and tilt the spine.
PHYSICAL EXAMINATION
2- PATIENT IN SUPINE POSITION
A. Straight leg raising (SLR).Flex each leg at the
hip with knee extended and record the angle at
which pain occurs and whether it radiates below
knee. A true positive SLR test is defined as
radicular pain radiating belox the knee, is a
sensitive indicator of nerve root impingement,
and should be confirmed by extending the knee
while the patient is sitting, to eliminate
malingering.
2- PATIENT IN SUPINE POSITION
B. A crossed SLR test (radicular pain
contralateral to the leg being
raised) is highly predicitive of
nerve root compromise.
C. Evaluate hip and knee range of
motion to eliminate these areas as
a source of pain.
D. Carry out thorough neurologic
examination and symptoms define
a “root signature,” allowing the
physician to localize the source of
the problem and potentially
correlate it with the results of the
imaging test.
3- PATIENT IN PRONE POSITION
A. Look for evidence of sciatic notch
tenderness, sometimes
seen in sciatica.
B. Results of the femoral stretch test
(extending the hip)
may be positive in L4 radiculopathy.
C. Palpate bony structures, especially
the vertebral
structures, for localized tenderness,
and examine for the
resence of trigger points, not only in
the low back but also
in other areas of the body.
DIAGNOSTIC INVESTIGATIONS
I- Laboratory tests should be performed as indicated by the history
and
physical examination, age of the patient, and duration of symptoms.
A. The erytrocyte sedimentation rate (ESR) and C-reactive protein,
reflect acute phase reactants and will usually be elevated in infection,
inflammatory joint disease, and metastatic malignancies.
B. Determinations of calcium, phosphorus, and alkaline phosphatase
levels screen for metabolic bone diseases.
C. Serum and urine protein immunoelectrophoresis should be
performed if
multipl myeloma is suspected because of the coexistence of back
pain,
elevated ESR, and anemia.
IMAGING STUDIES
A- Imaging studies are not performed until the
patients fails a trial of conservative therapy or
unless neurologic or constitutional symptoms
are
present.
IMAGING STUDIES
1- Plain films should be taken as an initial study
in the evaluation of LBP.
a. Anteroposterior, lateral end cone-down views of
the lower two interspaces are standard
procedure.
b. Oblique views will identify subtle spondylosis
and help to visualize the neural foramina, but
are not routinely necessary.
c. Fleksion extension views may be obtained to
document instability and range of motion.
IMAGING STUDIES
2- Bone scintigraphy is useful as a
screening study when malignancy (other
than multipl myeloma), infection, or occult
fracture, which are not visualized on plain
films, are suspected.
IMAGING STUDIES
3- Magnetic resonance imaging (MRI) has revolutionized
the imaging of the lumbosacral spine and can visualize
both bony and soft tissue structures well. MRI is now the
imaging modality of choice for imaging intraspinal
pathology. The principal problem with MRI is the high
rate of false-positive results. Up to 30% of asymptomatic
individuals will be shown to have significant
abnormalities on MRI. Therefore, MRI-defined
abnormalities need to ve viewed in the context of the
findings based on history and physical examination.
IMAGING STUDIES
4- Computed tomography (CT) scan. When
used without intradural contrast, CT scan is the
modality of choice for delineating the bony
structures of the spine (e.g., to detect spinal
stenosis). With the addition of intrathecal
metrizamid, the sensitivity for detecting neural
involvement is enhanced.. CT scan dopes not
detect intraspinal pathology as well as MRI
does, and false-positive results may also be
present as in MRI.
IMAGING STUDIES
5- Myelography outlines the dural theca and its
contents after injection of a contrast media into
the dural sac. This is a good study to delineate
neural compression. It remains the study of
choice when metal hardware is present or when
arachnoiditis is suspected. Myelography is
slowly falling from favor because of its
invasiveness, side effects, and because of the
improvement in imaging techniques with MRI
and CT scan.
IMAGING STUDIES
6- Diskography is performed by injecting
dye into the disk space. If symptoms are
reproduced during the procedure, iı may
be particularly helpful, especially if other
imaging studies have been nondiagnostic.
IMAGING STUDIES
1- Degenerative disk disease. Radigraphic
abnormalities correlate poorly with symptoms
and they must be correlated with the patient’s
history and physical examination findings.
a. Narrowing of the intervertebral disc.
b. Vacuum phenomenon defined as radiolucency
in the disc space.
c. Traction osteophytes defined as anterior
osteophytes on the lumbosacral spine indicative
of spinal instability.
IMAGING STUDIES
2- Osteoarthritis
a. Osteophytes formation
b. Facet joint arthritis.
c. Spinal stenosis
d. Acquired spondylolisthesis
IMAGING STUDIES
3- Congenital and developmental defects
a. Spondylosis refers to the dissolution or failure of the develoment of
the neural arch, typically noted as a lucency in the “neck” of the
“Scotty dog” noted on oblique spine radiographs (the “eye” of the
Scotty dog is the pedicle, the “ear” is the superior articulation of
that vertebral body, and the “neck” is the pars interarticularis).
Failure of the pars can lead to slippage (usually anteriorly) of one
vertebral body over the other.
b. Spondylolisthesis is slippage of one vertebral body on another. It
can be a consequence of spondylolysis or an acquired condition.
c. Transitional vertebrae, with lumbarization of S1 or sacralization of
L5.
d. Schmorl’s nodes are defects in the vertebral end plates that allow
vertikal disk herniation.
e. Scoliosis or kyphosis.
IMAGING STUDIES
4- Spondyloarthropathies (ankylosing
spondylitis, ReA, psoriatic arthritis, and arthritis
associated with inflammatory bowel disease).
a. Erosions or sclerosis of the sacroiliac joints
are best seen in a Ferguson (sacroiliac) view
of the pelvis, a special view that allows better
visualization of the joint.
b. Syndesmophytes Calcification of the
ligamentous structures leads to a bridging of
the adjacent vertebral bodies.
IMAGING STUDIES
5- Neoplasm
a. Typically leads to destruction of the vertebral
body.
b. Loss of the outline of the pedicle on the
anteroposterior films.
c. Pathologic fracture.
6- Infection should be suspected when
destruction of adjacent vertebral end plates is
present or bony destruction is accompanied by
constitutional symptoms.
IMAGING STUDIES
7- Miscellaneous
a. Osteoporosis. Loss inmineralization,
compression fractures with characteristic
anterior wedging, “fish mouth” appearanca to
the intervertebral spaces.
b. Metabolic bone disease (i.e., osteomalacia,
Paget’s disease, or hyperparathyroidism)
c. Sickle cell disease.
DIFFERENTIAL DIAGNOSİS
I- VERTEBRAL BODY DISEASE
A. Fracture
B. Multiple myeloma
C. Metastatic cancer
D. Infection
II- INTERVERTEBRAL DISC DISEASE
A- Herniation
B- Infection
DIFFERENTIAL DIAGNOSİS
III- JOINT DISEASE
A- Apophyseal joint disease due to osteoarthritis
B- Sacroiliac joints
IV- LIGAMENTOUS DISEASE
A- Anterior and posterior long ligaments.
B- Interspinous and supraspinous ligaments.
C- Iliolumbar ligaments
D- Apophyseal ligaments.
DIFFERENTIAL DIAGNOSİS
V- NERVE ROOT IMPINGEMENT
A- Herniated nucleus pulposus.
B- Spinal stenosis.
C- Neoplasm.
VI- PARASPINAL MUSCULATURE
A- Fibromyalgia
B- Myofascial (localized pain).
VII- REFERRED PAIN
A- Renal
B- Pelvic
C- Vascular
D- Gastrointestinal.
TREATMENT
I- Because more than 90% of cases of
LBP are self-limiting and resolve
spontaneously, any treatment algorithm
must account for this and should avoid
immediate laboratory or imaging studies
unless constitutional symptoms,
weakness, or neurologic dysfunction
suggests that there is an urgent problem.
TREATMENT
II- ACUTE TREATMENT
A- Rest versus activity. Many longitudinal studies
suggest that prolonged rest, and/or “fear” on the
part of patients that activity will worsen their
pain, are associated with a higher likelihood of
the acute LBP becoming chronic. Patients
should avoid extended periods of inactivity.
B- Spinal traction has no direct benefit, but may
help enforce bed rest if this is desirable for a
very short period of time.
TREATMENT
II- ACUTE TREATMENT
C- Pharmacologic treatment
1.
Pain control. This is often brought about with the use of single or
combination drug therapy with nonsteroidal anti-inflammatory
drugs (NSAIDs), other classes of analgesics, and topical pain
patches. (i.e., Lİdoderm 5%)
2.
Muscle relaxants. The mechanism of action of these drugs is not
entirely clear, but they are helpful in some patients with acute
LBP. Examples include cyclobenzaprine 5 to 10 mg either as a
single nighttime dose or up to a maximum of every 6 hours
methocarbamol 750 to 1500 mg up to every 6 hours, and
chlorzoxazone 500 to 750 mg up to every 6 hours.
Benzodiazepines such as diazepam may also be used for a
limited period of time.
TREATMENT
II- ACUTE TREATMENT
D- Physical measures
1. Moist heat. Heating pads, hot tubes,
steam, and sauna baths.
2. Massage, ultrasound.
3. Bracing for any extended period of time
may lead to muscle weakness.
TREATMENT
III- Failure of conservative treatment as outlined
at the end of 4 to 6 weeks is considered an
indication to initiate a diagnostic workup and
consider surgical intervention. The
workupshould include plain radigraphs of the
lumbosacral spine, and usually an MRI of the
lumbosacral spine, as well as any other
laboratory studies deemed necessary based on
the patient’s history and physical exam.
TREATMENT
IV- OTHER TREATMENT MODALITIES
A. Injection of myofascial trigger points with lidocaine
alone or combined with corticosteroids if the patient
exhibits only a few spesific areas of tenderness.
B. Facet or nerve block procedures can be both
diagnostic and therapeutic, but require spesific skills
and experience.
C. Transcutaneous electrical nerve stimulator(TENS).
D. Physical therapy.
TREATMENT
V- Invasive intervention should be
considered if there is a failure of
conservative therapy and when there is a
radiographically demonstrable anatomic
lesion that could explain the pain, or when
malignancy or infection cannot be
excluded with noninvasive techniques.
TREATMENT
V- Invasive intervention
A- Surgery should rarely be performed
before 2 months of conservative therapy,
except in circumstances that require urgent
intervention such as worsening neurologic
deficit. However, a delay of more than 6
months may also be unwise becauseof a
higher risk of the development of chronic
pain.
TREATMENT
V- Invasive intervention
B- Types of surgical intervention. These
operations usually are performed after
conservative therapy has failed and interactable
pain, other sensory findings, or motor weakness
are present. Depending on the skill and
experience of the surgeon, disease, artificial disc
replacements are being developed and hold
promise for less invasive surgery that does nor
disrupt the normal bony structures.
TREATMENT
V- Invasive intervention
B- Types of surgical intervention.
1- Laminectomy or hemilaminectomy. Removal
of all or part of the lamina while preserving the
apophyseal joints or in the case of spinal
stenosis trimmingthe joints to decompress the
neural tissues.
2- Laminotomy or hemilaminotomy An opening
is created in the lamina without it being totally
removed.
TREATMENT
V- Invasive intervention
B- Types of surgical intervention.
3- Discectomy. Removal of the nucleus pulposus
by standard surgical approach or fiberoptic
approach.
4- Microdiscectomy. Removal of a portion of the
herniated nucleus pulposus under microscopic
guidance with a fiberoptic scope.
5- Spinal fusion. The preciseindications for this
surgery are controversial; this is usually
performed in combination with one of the above
operation.
TREATMENT
VI- Chronic pain may arise from a failure of
conservative or more aggressive
therapies, and these patients renmain
difficult to treat even in specialized setting.
A subset of this group has fibromyalgia.
TREATMENT
VII- REHABILITATION AND EXERCISE
Flexibility and strengthening exercise is
frequently recommended for patients with
LBP. Basic principles regarding
rehabilitation in these patients should be
followed, and physical therapists are very
helpful in instructing patients in these
programs.
TREATMENT
VII- REHABILITATION AND EXERCISE
A- Postsurgical patients
1. Ambulation is encouraged early and prolonged sitting is
avoided.
B- Nonsurgical patients. “Exercises” for LBP probably
should not be initiated until the acute phase of recovery
has been completed and the patient can move freely
without pain, whereas resumption of normal “activities”
should be encouraged as early as possible. In the
beginning of an exercise program, patients should be
instructed to begin with only three to five repetitions of
each exercise and proceed slowly to increase the
repetitions.
TREATMENT
VII- REHABILITATION AND EXERCISE
B- Nonsurgical patients.
1- Pelvic tilt. Buttocks are tightened, and the lumbar spine is flattened
isometrically.
2- Modified sit-ups. With the patients supine, knees bent, and arms at
the side, the head and shoulders are lifted off the ground for 5
seconds.
3- Knee-chest stretch. With the patients supine, knees bent, and arms
at the side, each knee is brought top the chest one at a time and
held with the arms for 5 seconds. Then the knee is extended and
that leg is lowered to the ground slowly.
4- Wall exercise. The patients leans againist the wall with the feet
approximately 1 foot from the wall, depending on the height of the
patients. Knees are then bent to approximately 45 degrees or until
the lumbar spine feels flat againist the wall for a few seconds. The
patient then returns to the upright position.
TREATMENT
VII- REHABILITATION AND EXERCISE
C- Other suggestions
1- Weight reduction
2- Increase aerobic fitness with walking, swimming, or
other low impact activities. Do stretching activities as a
workup before aerobics.
3- Lifestyle modifications such as proper lifting techniques
(while lifting, the knees should be flexed and the back
straight, and twisting while lifting should be avoided); use
of a firm mattress to sleep on; and vocational training
that may be of help.
PROGNOSIS
I- In long-term follow-up, most patients with LBP
without a seious underlying disorder such as
malignancy, herniated nucleus pulposus with
spinal cord or nerve root compression, or
significant spinal stenosis will do well with a
short period of rest, a conservative exercise
program (in some cases, supervised by physical
therapist) that emphasizes flexion and extension
exercises, stretcing regimens, and gradual
aerobic conditioning and weight loss.
PROGNOSIS
II- Factors associated with a poor
prognosis include malignancy, fracture,
multiple level spinal stenosis, or herniated
nucleus pulposus, or other conditions with
spinal cord or nerve root impingement taht
is not corrected surgically in a timely
manner.
PROGNOSIS
III- Patient characteristics that usually indicate the need
for surgery are sphincter and sexual dysfunction due to
the compression of the conus medullaris or cauda
equina and persistenet radicular symptoms especially if
associated with neurologicmotor deficits that progress.
The surgical procedure chosen is determined by the
anatomic lesion that needs correction, and the training
and skill of the surgeon called upon to do the surgery.
Choosing a surgeon with extensive experience and good
outcomes is an important role tahat mediacal consultatns
can fulfill on behalf of the patients with LBP
PROGNOSIS
IV- Serious intraoperative or
perioperative complications can occur
during low back surgery if important
neorologic structures are comromised due
to surgical erro, infection or bleeding that
causes pressure and subsequent damage
to the spinal cord or nerve roots.
PROGNOSIS
V- Patients with LBP who have uncorrected
pain for more than 3 to 6 months may have
difficulty being totally free of pain even after the
anatomic cause of their original pain is
corrected. This may occur because of behavioral
(e.g., fear of movement leading to inactivity and
isolation) or neurobiologic (e.g., “sensitization” of
peripheral or central pain processing systems)
reasons, or misdiagnosis (e.g., pain coming from
a different cause than that originally treated), or
may be due to multiple causes.