An up-to-date and comprehensive yet complete presentation on backache, especially due to disc prolapse and spinal stenosis.

1. Backache
Disc Prolapse
Spinal Stenosis
Dr M. Tahir Karim
PGR
Orthopaedic Surgery Unit-I
JHL

2. Mechanics of the Back
 Vertebral column is pillar like structure supported in all directions by
musculature;
 Anteriorly, the recti and the abdominal muscles
 Posteriorly, erector spinae and quadratus
 If any of these supports give away, vertebral column will move to the other
side, and most of the times its anterior musculature that gives away.
 Since lumbar vertebrae (L1-L5) supports much of the weight of the upper
body, pain mostly occurs in the lower back.

3. Lower Back Pain (LBP)
 Pain and discomfort between the costal margin and inferior
gluteal folds with or without leg pain
 An estimated 80% of the normal population will experience
lower back pain in their lifetime

4. Based on duration
Acute < 6 weeks
Subacute 6-12 weeks
Chronic >12 weeks

5. Causes of Backache
 Mechanical (80%)
 Muscular strains or from ligamentous
injury
 Degenerative disc disease
 Facet joint disease
 Spondylolysis
 Osteoporotic compression fractures
 Sacroiliac joint pathology
 Neurogenic (15%)
 Herniated disc
 Spinal stenosis
 Foraminal stenosis
 Disc annular tear and neuritis
 Non-Mechanical back pain (1-2%)
 Infections
 Neoplasms
 Inflammatory conditions
 Referred pain (1-2%)
 Gastrointestinal disease
 Renal disease
 Aortic aneurysm
 Other (2-4%)
 Somatization disorder
 Fibromyalgia
 Malingering

7. Risk Factors
 Age (4th – 5th decade)
 Gender (Men:Women = 3:1)
 Obesity
 Smoking (1.5-2.5 more risk)
 Alcohol and drug abuse
 Heavy lifting
 Strenuous physical activity
 Occupational driving
 Poor posture
 Previous back injury
 Psychosocial and social factors
 Family history

8. Clinical Features
 Mechanical:
 dull, aching pain which doesn’t radiate down the leg
 aggravated with movement and relieved on rest
 usually not possible to clinically distinguish the source of pain
 Discogenic:
 pain on flexion
 Facetogenic:
 pain on hyperextension
 Neurogenic:
 pain radiating down to the buttocks and posterior thigh
 poor walking distance

9. Red Flags
(Indicate conditions in addition to back pain and warrant
investigations to exclude serious pathology)
 Age on onset < 20 yrs or > 55 yrs
 Recent history of trauma
 Constant progressive, non mechanical pain
 Thoracic pain
 Past history of malignant tumour
 Prolonged use of corticosteroids
 Drug abuse, immunosuppression, HIV
 Systemically unwell
 Unexplained weight loss
 Widespread neurological symptoms
 Structural deformity
 Fever

10. Yellow Flags
(Indicate psychosocial factors that increase the risk of
chronicity and disability from back pain)
 Belief that back pain is harmful or potentially severely disabling
 Fear and avoidance of activity or movement
 Tendency to low mood and withdrawal from social interaction
 Expectation of passive treatment(s) rather than a belief that active
participation will help

11. Examination
 Inspection
 Contour of the spine (kyphosis, lordosis or scoliosis)
 Restriction of back movements
 Palpation
 Tenderness over spine or para-spinal muscles
 Provocative tests
 Straight leg raise sign (L4-S1)
 Femoral stretch test (L2-L4)
 Slump test
 Neurological examination
 Motor (Knee extension-L4, Dorsiflexion of foot and big toe-L5, Plantar flexion of foot-S1)
 Sensory
 Reflexes (Patellar tendon reflex-L4, Medial hamstring reflex-L5, Ankle reflex-S1)
 Hips are examined to exclude hip joint pathology
 Sacroiliac joints are routinely assessed by FABER/Patrick’s test

12. Straight leg raise test
If the patient experiences
sciatic pain, and more
specifically pain radiating
down the leg
(radiculopathy), when the
straight leg is at an angle of
between 30 and 70
then the test is positive and
a herniated disk is a
cause of the pain.

13. Femoral nerve stretch test,
also known as Mackiewicz
sign is a test for disc
protrusion
and femoral nerve injury.
The patient lies prone, the
knee is passively flexed to
the thigh and the hip is
passively extended.
The test is positive if the
patient experiences anterior
thigh pain.

14. Slump test
Positive sign is any kind of
sciatic pain (radiating, sharp,
shooting pain) or
reproduction of other
neurological symptoms.
This indicates impingement
of the sciatic nerve, dural
lining, spinal cord, or nerve
roots

15. The examiner lowers
the test leg toward the
examining table while
compressing the
opposite anterior
superior iliac spine.
A positive result
occurs when
the test leg remains
above the opposite leg,
usually with pain and
may indicate hip
disease, iliopsoas
spasm, or sacroiliac
disease.

16. Investigations
 X-rays
 May be normal
 Flattening of the disc space and marginal osteophytes (Intervertebral disc
degeneration)
 Slight displacement of one vertebra upon another, either forward
(Spondylolisthesis) or backward (retrolisthesis)
 Blood Tests
 FBC and ESR (screen for non-mechanical causes
 In elderly, serum protein electrophoresis and prostate specific antigen should
be part of the workup

17. Investigations
 CT & MRI
 May reveal disc degeneration
 Early features of OA in facet joints
 Bone scan & SPECT scan
 Active inflammatory conditions will show increased uptake in the facets and
sacroiliac joints.
 Vertebral fractures and metastatic neoplasms can also be appreciated.

18. Diagnosis
 Goal is to categorize the pain into three categories:
1. Serious spinal pathology
2. Neural pain
3. Non-specific back pain
 History and examination are first directed at distinguishing between any
serious pathology and musculoskeletal back pain
 Then, decide if there is a neural element of pain (spinal stenosis or
radiculopathy). If the neural pain source is absent from clinical findings,
the problem can be characterized as non-specific lower back pain
 This assessment should be supported by X-rays, FBC and ESR.
 Where there are “red flags” and/or abnormal specific findings, further
imaging (CT, MRI, Bone scan) may be required

19. Treatment
 Conservative treatment
 Reassurance
 Medication (Paracetamol, NSAIDS, Short course of opioids or non-
benzodiazepine muscle relaxants for acute, TCAs for chronic and
Gabapentin for radiculopathy)
 Activity modification
 Physical therapy
 Spinal support
 Psychological support
 Injection therapy (Nerve blocks in chronic radiculopathy, Epidural
steroids in spinal stenosis)

20. Treatment
 Surgery
 Very strict guidelines should be followed to avoid ‘failed back surgery’
1. Repeated examinations should ensure no other treatable pathology
2. At least some response to conservative treatment
3. Unequivocal evidence of pathology at specific level
4. Patient should be emotionally stable and should not exaggerate his/her symptoms
5. Patients expectations should be in line with the surgeons expectations
6. Surgery is effective in pain relief and deformity in infections, tumours and fractures.
Surgery is also cost effective and superior in degenerative conditions with neural
pain
7. Surgery for non-specific back pain is far less effective.

21. Disc Prolapse

22. Intervertebral Disc
 An intervertebral disc lies between adjacent vertebrae in the
vertebral column. Each disc forms a fibrocartilaginous joint to allow
slight movement of the vertebrae, to act as a ligament to hold the
vertebrae together, and to function as a shock absorber for the
spine.
 From C2-C3 to L5-S1
 Nucleus pulposus + Annulus fibrosus
 L4-L5 disc, largest avascular structure in the body

23. Intervertebral Disc Prolapse
 Intervertebral disc prolapse or herniation is a protrusion of the
nucleus of the disc into the annulus with subsequent nerve
compression.
 Most common at L4-L5 and L5-S1 disc levels.

25. Risk Factors
 Aging (Degeneration)
 Trauma
 Congenital predisposition
 Twisting and repetitive motions in occupational setting
 Sedentary lifestyle
 Obesity
 Smoking

26. Pathophysiology
 The cause of a herniated lumbar disc is usually a flexion injury, but many
patients don’t recall experiencing a traumatic event
 The herniation compresses the spinal nerve root usually restricted to one
side. With further degeneration of the disk, may eventually produce
pressure on the spinal cord.
 This sequence may take months to years, producing acute and chronic
symptoms.

27. Clinical Features
 Disc may herniate without causing any symptoms
 Symptoms depend on location, size, rate of development and
effect of surrounding structures
 Symptomatic disc herniation may results in
 pain
 sensory changes
 loss of reflexes
 muscle weakness

28. Cervical Manifestations
 Pain and stiffness in neck, shoulders and region of scapula
 Pain in upper extremities and head
 Paraesthesia and numbness in upper extremities
 Weakness of upper extremities

29. Lumbar Manifestations
 Lower back pain with varying degree of sensory and motor
dysfunction
 Pain radiating to the buttocks and down the leg (Sciatica)
 A stiff or unnatural posture
 Some combination of paraesthesia, weakness and reflux
impairment.

30. On Examination
 Patient will be tilted to his side (ipsilateral side in medial herniation and
contralateral side in lateral herniation) and will feel pain on straightening
the body or tilting to other side
 Sometimes the knee on the affected side is held slightly flexed to relax the
tension on the sciatic nerve
 Straight leg raise test may be positive, a crossed leg raise test-if present- is
highly specific for a disc prolapse
 Femoral stretch test may be positive in high or mid-lumbar disc prolapse

32. Investigations
 CT and MRI usually confirms the diagnosis
 Electromyography (can reveal nerve dysfunction, muscle
dysfunction or problems with nerve-to-muscle signal
transmission)
 Myelogram (A special dye is injected in the spinal canal and
image is recorded by X-ray or CT fluoroscope. Myelogram can
show conditions effecting the spinal cord and nerves within
the spinal canal.

33. MRI
lumbosacral
spine showing
a huge L4-L5
herniated disc

34. Myelogram

35. Treatment
The goals of treatment are
To rest and immobilize the spine to give the soft tissues
time to heal
To reduce inflammation in the supporting tissues and the
affected nerve roots in the spine

36. Non Interventional Treatment
 Bed rest, heat, ice
 Massage, spinal manipulation, spinal traction, acupuncture,
advice to stay active
 Cervical collar or traction are widely used in case of cervical
disc prolapse
 Physical exercise therapy

37. Medical Treatment
 Anti inflammatory drugs such as ibuprofen or prednisone
 Muscle relaxants such as diazepam or cyclobenzaprine
 Analgesics, opioids may be necessary for several days acute
phase

38. Interventional Treatment
 Following modalities are available
Epidural corticosteroids
Automated percutaneous discectomy
Laser discectomy
Percutaneous disc decompression
Chemonucleolysis dissolution of the nucleus pulposus by
percutaneous injection of a proteolytic enzyme (chymopapain)

39. Surgical Treatment
 Indications for surgery include neurological deterioration, persistent pain
and failed conservative treatment.
 The presence of prolapsed disc and its level must be confirmed by
imaging and anatomical location of disc prolapse must correlate with the
symptoms.
 Different surgical techniques used are
 Laminectomy
 Laminotomy
 Discectomy
 Foraminotomy

40. Laminectomy

41. Complications
 Permanent neurologic dysfunction (weakness & numbness)
 Chronic pain
 Cauda equina syndrome: a rare disorder that is a surgical
emergency and an absolute indication for surgery. It occurs when
the bundle of nerves below the end of spinal cord is compressed or
damaged. Signs and symptoms include low back pain that radiates
down the leg, perineal numbness, and loss of bowel or bladder
control
 Recurrent prolapse with sciatica (5-11%)

42. Spinal Stenosis

43. Spinal Stenosis
 Refers to narrowing of the spinal canal, nerve root canals or
intervertebral foramina due to spondylolysis and degenerative
disc disease
 Usually occurs in cervical or lumbar spine
 More common in females

44. Etiology
 Is part of aging process, it is not possible to predict who will be affected.
 No clear correlation exists between the symptoms of stenosis and race,
occupation, gender or body type.
 2 forms:
 Primary: Congenital, uncommon, younger patients, occurs with achondroplasia
or hypochondroplasia
 Acquired: Mostly a degenerative condition, but may also occur with
spondylolysis and spondylolisthesis, iatrogenic, post-traumatic, local infection
and metabolic stenosis.

46. Anatomically, stenosis can be
Central Lateral Foraminal
 Involves the area
between the facet
joints
 Contains dural sac
and nerve roots
 Lateral border of
dura to the medial
border of pedicle
defines the lateral
recess
 Contains traversing
nerve roots
 Situated under the
pars
 Contains exiting
nerve roots

47. Pathophysiology
 Degenerative disease is the most common
 Involves changes in disc and facet joints
 Synovitic changes, cartilage thinning and capsular laxity of facet joints allow increased
segmental motion and accelerated disc degeneration
 This leads to loss of disc height and bulging or prolapse into the canal
 Vertebral end-plate osteophytes also contribute to the stenosis and the normally oval
canal becomes trefoil-shaped.
 Increasing canal narrowing, neural compression, vascular compromise and neural
demyelination cumulate in symptoms of spinal stenosis.
 Spondylolysis, spondylolisthesis, foraminal disc herniation and a facet joint cyst
may result in stenosis

48. Clinical Features
 Symptoms include aching, heaviness, numbness and paraesthesia in the
thighs and legs
 Pain occurs after standing upright or walking for 5-10 mins and is relieved
by sitting, squatting or leaning against a wall to flex the spine (hence the
term ‘spinal claudication’)
 Patients prefer walking uphill than downhill

49. Examination
 Often the neurological examination is normal
 Intact pedal pulses and absence of trophic skin changes will confirm the
claudication to be spinal
 Pain is relieved on flexion of the spine, hence Shopping cart sign is present
 Imperative to exclude vascular claudication, hip pathology and peripheral
neuropathy

51. Investigations
 X-rays
 Not the most sensitive imaging study
 Useful in excluding fracture, spondylolysis or neoplasm
 Flexion extension views are useful to show spine instability
 MRI
 Investigation of choice
 Non-invasive, safe, can differentiate different types
 Disc degeneration, prolapse and facet arthrosis can be appreciated
 CT myelogram
 Indicated when MRI contraindicated
 May better demonstrate canal narrowing with dynamic stenosis or scoliosis

53. Treatment
 Signs and symptoms of myelopathy or cauda equina
syndrome warrant urgent surgical decompression of the
spinal cord or nerve roots
 Significant muscle weakness due to nerve root impingement
is also a strong indication for surgery
 For the patients with LSS who do not have fixed or
progressive neurologic deficits, conservative treatment is the
first choice

54. Conservative Treatment
Reassurance and education
Analgesics and NSAIDS
Non-impact exercise programme, aerobic fitness, activity
modification
Epidural and nerve root steroid injections

55. Surgical Treatment
 Posterior decompression is the mainstay of surgical treatment
 Central stenosis: Laminectomy
 Lateral recess stenosis: Undercutting facetectomies and removal of ligamentum
flavum
 Foraminal stenosis: Fusion to decompress and maintain foramen patency
 Spinal stenosis with spondylolysis, spondylolisthesis, scoliosis and kyphosis are
indications for fusion with decompression
 SPORT (Spine Patient Outcomes Research Trial) confirmed the cost effectiveness of
surgery over non-operative treatment over a 4 year period for spinal stenosis

56. Thank you….