/STRU^NI RAD
UDK 616.711-009.7-079.4-036-085
Low back pain – differential diagnosis, prognosis and
treatment
........
.................................
rezime
V. Lalo{evi}, Z. Poleksi}, Z. Blagojevi}, S. Tomi},
S. Mili~kovi}
Institute for Orthopedic Surgery "Banjica", Belgrade, Serbia
From January 2002 to February 2003, 137 patients complaining of low back pain were treated at
the Institute for Orthopedic Surgery "Banjica",
Belgrade, Serbia. There were 89 male and 48 female patients aged 13 to 77, mean age 42.2. Their
condition was diagnosed through use of radiography, CT, MRI, EMNG, standard battery of neurological tests, and laboratory analyses (urine and
blood analysis). Surgical treatment was performed on
39 patients; all other patients received some form of
non-surgical care (physical therapy, medication or corset). Treatment efficacy was evaluated by use of the
visual analog scales (VAS) and the Oswestry index, before and after treatment. The use Wilcoxon’s pair test
revealed statistically significant difference between before and after treatment data on VAS and Oswestry
index for all patients.
Key words: lumbal spine, low back pain, Oswestry
index, visual analog scale(VAS)
INTRODUCTION
L
ow back pain is a very common medical condition of
modern women and men due to their upright posture
and many hours spent sitting. It is hard to diagnose and
even harder to treat medically resulting in an enormous
socio-economic cost. In addition, discrepancy in low back pain diagnosis - even among spinal surgeons working
in the same medical institution and sharing most of their
medical training and education - does not make things any
better. Thus, differential diagnosis of lumbar spine is still
a very challenging area of medical science.
Traditionally, medical diagnosis of diseases and injuries
is based on documented changes in the anatomy, changes
in chemical content of bodily fluids and tissues, and changes in physiology. Concordances of independent medical observations, or group of observations, are usually recognized as a clinical entities or syndromes. Lumbar diseases are characterized by their specific causes: physical
traumas and infectious agents (staphylococcus or tuberculosis). This diagnosis is further detailed with respect to time (acute – less than 2 weeks; sub acute – 2-7 weeks; and
chronic), physical capacity (blocked, moveable), psychological reaction and adaptive changes in behavior.
Primary objective of this paper was to systematize causes and treatments of low back pain and to propose best
treatment modalities for hospitalized patients. Questionnaires (Oswestry index and VAS) were used to assess treatment outcomes in accordance to the newest North American Spinal Society (NASS) classification of lower back
pain:
1. Trauma ( skin, ligament, muscle, bone, nerve injuries).
2. Disorders of Specific Sites or Tissues (stenosis, disc,
congenital abnormalities).
3. Neurologic Disorders (brain, cord, root, nerve, autonomic).
4. Alignment and Stability (scoliosis, kyphosis, lordosis,
olisthesis, hypermobility)
5. Post-treatment (status, complications, pain).
6.Infection and Inflamatory (infections, arthropathy, enthesopathy).
7. Metabolic and Hematologic (osteopenias, metabolic,
hematologic ).
8. Tumors and Tumorous Conditions.
9. Nonspecific and Miscellaneous (pain, psychosocial,
lab, syndromes).
MATERIAL AND METHODS
From January 2002 to February 2003, 137 patients complaining of the low back pain were treated at the Institute
for Orthopedic Surgery "Banjica", Belgrade, Serbia. There were 89 male and 48 female patients aged 13 to 77,
mean age 42.2. Their condition was diagnosed through
use of radiography, CT, MRI, EMNG, skeleton scintigraphy standard battery of neurological tests, and laboratory
analyses ( urine and blood analysis). (Table 1)
50
V. Lalo{evi} i sar.
According to the criteria used in the NASS classification, there were 22 patients in the first group (trauma), 48
patients in the second group (diseases of specific loci and
tissues: stenosis, discus hernia), 1 patient in the third group (neurological diseases), 17 patients in the fourth group
(alignment and stability), 4 patients in the fourth group
(post surgical), 15 patients in the sixth group (infections),
7 patients in the seventh group (metabolic and hematological), 19 patients in the eighth group (tumors and tumor
like conditions). Four patients were classified in the ninth
group (non-specific and miscellaneous). Standard neurological examination was performed on all patients and reported 43 patients with no noticeable deficits. Also, there
were 94 patients with neurological deficits. In specific, 15
patients with paraparesis, 4 patients with paraplegia, 2 patients with Syndrom conus medullaris, 2 patients with neurological claudication and 71 patients with radiculopathy
most frequently affecting either the root L5 (24 patients)
or the root S1(20 patients).
Before being admitted to the hospital 46 patients were
treated with NSAID therapy, 17 patients with physical
therapy, 33 patients with a combination of NSAID and
physical therapy, 4 patients with a plaster corset, 8 with
orthosis, 2 patients with a combination of surgery, chemotherapy and radiotherapy. Ten patients had no prior history of medical treatment and 17 patients were admitted to
the hospital as urgent.
Among 39 patients that received surgical treatment in
the hospital, 13 patients were subjected to discektomy, 12
patients to biopsy, 7 patients to anterior surgery with stabilisation and spondylodesis, 1 patient to spondylodesis
intertransversalis, 2 patients to reposition and fixation
with Harrington rod, 4 patients to transpedicular fixation
(Miami Moss).
Both surgically and non-surgically treated patients received initial polyvalent physical therapy. All surgically treated patients and all patients that were clinically assessed
as lacking mobility were treated with adequate doses of
Fraxarin for tromboembolic protection.
All patients receiving hospital treatment were administered Owestry index and VAS in order to assess their everyday functioning and intensity of pain. In addition, lumbal lordosis was assessed before and after hospital treatment. Degree of discus degeneration (Modik) was determined in all 62 patients subjected to MRI. Individual scores obtained on Oswestry indexa and VAS, before and after medical treatment were statistically analyzed by Wilcoxon’s pair test.
ACI Vol. LIII
14
12
Discektomy
10
13
8
Biopsy
12
Anterior surgery
6
4
7
Transpedicular
fixation
7
2
0
FIGURE 1
INCIDENCE OF LOW BACK PAIN SURGERY
TABLE 1
NASS CLASSIFICATION OF LOW BACK PAIN
Group 1
22
Group 2
48
Group 3
1
Group 4
17
Group 5
4
Group 6
15
Group 7
2
Group 8
24
Group 9
4
16%
32%
18%
Fractures
Tumors
Discus hernia
Spondylodiscitis
RESULTS
More male (64%) than female (36%) were hospitalized
because of the low back pain. Most prevalent pathology
was discus hernia (31 patients), fracture of lumbal spine
(17 patients), spondylodiscitis (15 patients) and spondylolisthesis (7 patients). Other types of spinal pathology
were sporadic. (Table 2)
Pathology-wise, average patient age was 32.5 for discus
hernia, 47.8 for fractures, 43.6 for spondylodiscitis, 53.76
for tumors, and 45.69 for the other. (Table 3)
Other
11%
23%
TABLE 2
RELATIVE PROPORTION OF LOW BACK PAIN PATHOLOGIES
Br. 4
Low back pain - differential diganosis, prognosis and
treatment
51
TABLE 3
AVERAGE PATIENT AGE BY PATHOLOGY OF LOW BACK PAIN
Diagnostis
Dscus hernia
Fracture
Spondylodiscitistumors
Tumors
Other
Average age
32.5
47.8
43.6
53.75
45.69
Neurological deficit was most pronounced in trauma
(13) and tumor patients (6) but was not observed in one
third of the patients. Less severe neurological deficit was
observed mostly in patients diagnosed with degenerative
spinal disease. Thus, 38 patients had radiculopathy of
L5 - S1 spinal root.
Before being admitted to the hospital 79 patients were
subjected to physical therapy and analgesic medication,
but with no apparent success. Average sick leave before
hospitalization was 100 days, most likely due to improper
diagnosis and consequent inadequate treatment. Spondylodicitis and degenerative conditions were hardest to diagnose properly. The average follow-up of hospitalized patients was 14.27 months.
Thirty-nine of 137 hospitalized patients were subjected
to surgery. (Figure 1)
A total of 8 post-treatment complications was observed:
5 among surgically and 5 among non-surgically treated
patients. Among surgically treated patients there were: 1
superfitial infection, 1 deep infection, 1 lesion of the L4
spinal root, 1 breckage of the rod due to pseudoarthrosis,
and 1 perforation of dura. Among the non-surgically treated there were: 1 , 1 infection of urinary tract (due to catheterization), and 1 decubital ulcer .
Average Oswestry index score was 67% and 44%, before and after surgery, respectively. Statistical analysis revealed significant difference between Oswestry index scores before and after treatment for all treated patients
(W=1653, p<0.001), surgically (W=703, p<0.001), and
non-surgically treated patients ((W=210, p<0.001).
Average VAS score was 6.3 and 3.8, before and after
surgery, respectively. Statistical analysis of VAS scores
revealed significant difference between VAS scores before and after treatment for all treated patients (W=1596 ,
p<0.001 ), surgically (W=703, p<0.001) and non-surgically treated patients (W=190, p <0.001).
Before treatment, Oswestry index scores were significantly higher in patients that were later subjected to surgery relative to Oswestry index scores in patients that
were later treated non-surgically, as evidenced by MannWhitney rank sum test (t =314.5, p< 0.001).
Before treatment, VAS scores were significantly higher
in patients that were later subjected to surgery relative to
VAS scores of patients that were later treated non-surgically, as evidenced by Mann- Whitney rank sum test (t =
333, p <0.001).
Lumbar lordosis values among hospitalized patients
were significantly lower than in normal population. Comparing lumbar lordosis of our patients (mean = 17.58, standard deviation = 8.17) with average values of lumbar
lordosis in normal population revealed statistically significant difference (t = 8.28, p<0.001). However, there was
no statistically significant correlation between lumbar lordosis scores and VAS scores (r = -0,164, p> 0,05) before
treatment.
DISCUSSION
Differential diagnosis of low back pain is complex and
difficult to establish. Many conditions and diseases of adjacent organs can imitate and irradiate lower part of the
back. Different diseases affecting kidneys, bladder, colon,
abdominal aorta and female reproductive organs can present low back pain symptoms. Therefore, a whole set of
procedures should be involved in the diagnosis including:
abdominal and minor pelvis ultrasound, clinical and neurological observation, RTG, CT and MRI, skeleton scintigraphy and the complete blood and urine laboratory.
These analyses help as to clearly differentiate specific diagnoses (patients that were treated in the hospital) and
non-specific and borderline cases, such as:
1. Instability, that can be caused by progression of adult
scoliosis or by progression of degenerative spondylolisthesis. About 20 % of verified RTG instability does not
cause any symptoms.
2. Sciatic condition causing pain alongside sciatic
nerve. This pain can originate from extra spinal compression (inflammation, circulatory disorder) affecting neural
fibers through anatomic projection of sciatic nerve.
3. Strains, sprains, tendinitis and enthesopaties ,bursitis
and sindroma m.piriformis, further complicate clinical diagnosis of low back pain.
4. Fibromyositis or fibromyalgia is associated with trigger points situated at back muscles and extremely pain
sensitive to palpation. It was reported by McCain GA that
fibromyalgia can be caused by medical treatment with tricyclic antidepressant and /or exercise regimens .
5. Internal Disc Disruptive Syndrome. This condition is
often caused by axial trauma associated with persistent
lumbar pain and normal RTG scan. However, pathological changes are detectable trough discogram and MRI Modik l.
6. Facet Syndrome. Causes of are facet syndrome impinged synovial folds,synovial inflammation,chondromakacia, meniscoid entrapment, cartilage splits and capsular tears
7. Sacroiliac Syndrome, caused by pathological changes
in the joint (infections, arthropathie, arthrosis).
Surgical treatment of low back pain of known etiology
should nevertheless be rather restrictive due to often observed recidivism, infections, missed level and site and
chronic post-perative ailments. Absolute indications for
surgical treatment of discal pathologie,spondylodiscitis,
trauma and tumor are: neurological deficit, instability and
chronic pain. There are also relative indications for op-
52
V. Lalo{evi} i sar.
erative treatment, especially applicable for spondylodiscitis and tumors, when diagnostic methods failed to reveal
their true etiology.
This study has confirmed that low back pain is a common population ailment calling for exhaustive approach to
etiology, careful approach to surgical treatment, and effective and resolute physical rehabilitation. Timely diagnosis and adequate medical treatment will have beneficial
effects on duration of sick leaves and the overall cost reduction.
CONCLUSION
Low back pain is a very common condition among ambulatory and hospitalized patients. It is more prevalent in
men, older than 30. Etiology is of low back pain is diverse
and speckled and hard to diagnose correctly. The use of
surgical therapy should be minimized and limited only to
cases with absolute indications.
REZIME
U Institutu za ortopedsko hirur{ke bolesti Banjica, u periodu od januara 2002. do februara 2003. godine, le~eno je
137 bolesnika zbog bola u donjem delu ledja. Distribucija
po polu, mu{karaca 89,enskih 48, uzrasta od 13 do 77
godina, u proseku 42,2 godine. Hirur{ki je le~eno 39
bolesnika a ostali su le~eni neoperativno (procedure fizikalne terapije,mider i medikamentozno). U dijagnostici
osim standardnih radiografija, koristili smo i CT, MRI,
EMNG, neurolo{ki nalaz i laboratorijske analize. U analizi rezultata koristili smo Oswestry index i VAS (Visual
Aanaloge Scale) kako pre tako i posle le~enja. Statisti~kom analizom pomo}u Wilcoxonovog testa ekvivalentnih parova, obradjeni su Oswestry index i VAS, na osnovu koje analize je dokazana zna~ajna razlika u vrednostima Oswestry indexa i VAS-a, pre i posle le~enja,
kako za ukupan broj bolesnika tako i u grupama operativno i neoperativno le~enih.
Klju~ne re~i: lumbalna ki~ma, low back pain,
Oswestry index, VAS
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