A brief approach to low back ache : etiologies, diagnosis and management

1. Alankar Tiwari
MD Internal Medicine
Approach
to Low
Back Ache

2. Epidemiology
• Low back pain (LBP) is a very common symptom which
can affect about 70% of the population at least once in
lifetime.
• Maximum incidence between 35-55 years age group.
• Each year, 15–20% of the population will have back pain. It
is the second most common symptom seen in general
practitioners’ clinic.
• Males and females are equally affected.
• It is usually a self-limiting condition (90% resolve in 6
weeks) but can go into chronicity in about 10% of the
individuals. It is the most common cause of disability for
people less than 45 years of age.

3. • 85% patients are never given precise
pathoanatomical diagnosis.
• No. 1 cause and no. 1 cost of work
related disability.
• Second most common cause of missed
work days
• Number one impairment in
occupational injuries
• Low backache which is acute and has
red flag signs should be evaluated
urgently to look for emergency.

4. Figure 1 : Oblique (A) and
axial (B) views of the spine
showing anatomical
relationships between
neural and bone elements.

5. Figure 2: Anatomy of
the lumbosacral plexus

6. Figure 3 : Lumbrosacral Dermatomes

7. Low Back
Ache
Neural Mechanical
Non-neural,
non-
mechanical

8. Classification of Lower Back and Lower Limb Pain

9. • Causes of lower back pain without leg pain:
Ligamentous strain
Muscle pain
Facet pain
Bony destruction
Inflammation
• Causes of lower back plus lower limb pain:
Radiculopathy
Plexopathy

10. Common Etiologies of Low Back Ache
Cont...

12. Basics of Low Back Ache
• Clinical abnormalities confined to one nerve root
distribution usually are caused by intervertebral disk
disease or lumbosacral spondylosis producing
radiculopathy.
• Clinical abnormalities that involve several nerve
distributions usually are caused by plexus lesions, with
cauda equina lesions being the alternative diagnosis.
• Bilateral lesions suggest proximal damage in the spinal
canal affecting the roots of the cauda equina.
• Impairment of bladder control indicates either a cauda
equina lesion or, less commonly, a bilateral sacral
plexopathy.

13. Important Questions for Evaluation
 Is systemic disease the cause?
 Is there social or psychological distress that
prolongs or amplifies symptoms?
 Is there neurologic compromise that
requires surgical intervention?

14. To Answer These Important
Questions
Careful history and physical examination.
Imaging and Lab investigations when
indicated.

16. Clinical History
• Mode of onset:
Acute onset lower back pain radiating down the leg s/o
lumbosacral radiculopathy.
Onset with exertion suggests a disk prolapse as a cause of
radiculopathy.
Progressive symptom development can be from any expanding
lesion like tumor or expanding disk extrusion.
• Character
• Distribution
• Associated motor and sensory symptoms
• Bladder and bowel involvement
• Exacerbating and relieving factors
• H/O predisposing factors

17. Examination
• Muscle groups to be tested :
Hip Girdle Muscles
Knee muscles
Ankle and Foot muscles
• Sensory examination should include the important nerve
roots and peripheral nerve distributions: the femoral,
peroneal, tibial, and lateral femoral cutaneous, lumbar
roots L2-L5, and sacral root S1.
• Reflexes to be studied include the Achilles, patellar, and
plantar reflexes.
• Straight leg raising augments pain in a lumbosacral
radiculopathy.

18. Straight Leg Raise Test
The straight leg raise
test is positive if pain in
the sciatic distribution
is reproduced between
30° and 70° passive
flexion of the straight
leg. Dorsiflexion of the
foot exacerbates the
pain . Sensitivity 91%,
specificity 26%.

19. Waddell signs for Non-organic pain
• Superficial non-anatomic tenderness.
• Pain from maneuvers that should not elicit pain.
• Distraction maneuvers that should elicit pain but don’t.
• Disturbances not consistent with known patterns of pain.
• Over-reacting during the exam.
• Not definitive to rule out organic disease.

20. Differential diagnosis of lower back and leg pain

21. Differential diagnosis of isolated lower back pain

22. Diagnostic Studies: Imaging and
Electrophysiological
• Radiography:
• Plain radiographs are obtained in patients with acute
skeletal trauma and in almost all patients with isolated
lower back pain.
• Among the potential findings are degenerative joint
disease, vertebral body collapse, bony erosion, subluxation,
and fracture.
• Radiographs of the pelvis and long bones also are obtained
and may show fractures and destructive lesions.

23. • CT Scan:
• Shows bone (e.g., fractures) very well.
• Good in acute situations (trauma).
• Soft tissues (discs, spinal cord) are poorly visualized
• CT-myelogram adds contrast in the CSF and shows the
spinal cord and nerves contour better.

24. • MRI:
• Commonly performed to assess the lumbosacral spine and
the lumbosacral plexus.
• It also can be used to evaluate the peripheral nerves in the
pelvis and lower limbs.
• Shows tumors and soft tissues (e.g., herniated discs) much
better than CT scan.
• Almost never an emergency
(Exception: Cauda equina syndrome)

25. X-Ray Lumbosacral spine showing lumbar osteophytes in lumbar
spondylosis

26. X-ray of sacroiliac (SI) joint showing bilateral sclerosis in SI joint

27. MRI spine suggestive of destruction of the vertebral bodies and intervertebral disk
suggestive of infective etiology most likely tuberculosis on T1-weighted images
with post-contrast enhancement

28. CT Scan Lumbar spine showing disc prolapse

29. Myelography

31. Cont...

32. Clinical Syndromes
1) Low back ache alone:
1.1 Mechanical Lower Back Pain:
• Combination of bone, muscular, and connective tissue pain
• Strain of paraspinal muscles and ligaments, with local
inflammation.
• Pain in the lower back without radicular symptoms and show
no motor, sensory, or reflex abnormalities on examination.
• Diagnosis is based on the clinical features and exclusion of
other causes.
• Usually is treated by an initial period of rest of approximately
2 days, followed by an increase in activity.

33. • Muscle relaxants can help reduce the tightness of the
muscles.
• Patients who do not respond to conservative management
may benefit from epidural blocks.
• Surgery for “bulging disks” occasionally is performed in
patients who have clinically apparent mechanical back
pain, but the likelihood of response is not high.

34. 1.2 Facet Joint Pain Syndrome :
• Pain results from long-term degenerative changes in the facet
joints, usually caused by strain. Repetitive strenuous activity,
excessive weight, and abnormal posture may predispose
affected persons to the development of facet pain.
• Usually lateral to the spine and exacerbated by extending the
spine or bending toward the affected side.
• Patients present with pain without motor, sensory, or reflex
deficit unless radiculopathy or spinal stenosis also is present.
• Usually is treated with anti-inflammatory agents and physical
therapy.

35. 1.3 Lumbar Spine Osteomyelitis :
• Most common in the lumbar region and may develop as a
sequela of trauma, urinary tract infection, respiratory infection,
and other causes of sepsis.
• Limitation of the motion of the spine and tightness of the
paraspinal muscles are additional features. Local lumbar spine
pain with tenderness to percussion is characteristic.
• Systemic signs of infection—fever, elevated CRP concentration,
and elevated white blood cell count.
• Radiographs show degeneration of the disk margin of the
vertebral body and disk space narrowing.
• Treatment is with antibiotics and bed rest. Surgical debridement
is needed in patients who do not respond to antibiotics.

36. 1.4 Lumbar Spine Compression:
• Occurs in the setting of acute trauma, osteoporosis, infection, or
tumor.
• Patients present with severe lower back pain, usually without
radicular symptoms.
• If the collapse results in compression of the nerve roots by bone,
radicular pain may develop in addition to the lower back pain.
With compression of the cauda equina, diffuse weakness of the
legs with sphincter disturbance can develop.
• Lower back ache that is exacerbated by movement, jarring, or
certain postures such as bending or twisting.
• Treatment consists of immobilization of the fracture site. Pure
analgesics often are needed, especially at night. Corticosteroids
should be avoided if the cause is osteoporotic but can be very
helpful for malignant vertebral collapse. Malignant collapse
usually is treated by radiation therapy.

37. 1.5 Lumbar Diskitis :
• Inflammatory process affecting the intervertebral disks of any
level, often occurring in the lumbar spine.
• In adults, Staphylococcus aureus and Mycobacteria are important
causes. Source: skin infection, urinary tract infection, or
intestinal infection.
• Lower back pain with marked restriction of flexion of the spine.
• Severe lower back pain without a radicular component, with
tenderness and spasm of the paravertebral muscles, associated
with willingness of the patient to flex the hips but not the spine.
ESR and CRP concentration usually are increased.
• Diagnosis confirmed by MRI.
• Treatment usually consists of bed rest and antibiotics.

38. 2) Low back ache with lower limb pain:
• 2.1 Lumbar Canal Stenosis:
• Affects mainly late-middle-aged and older adults. The cause is
multifactorial, with disk disease, bony hypertrophy, and
thickening of the ligamentum flavum being the most important.
• Symptoms caused by direct pressure of these tissues on the
cauda equina and exiting nerve roots, but a major contributor
appears to be compression of the vascular supply of the nerve
roots.
• Compression of the vascular supply creates nerve root ischemia,
which can produce severe pain and weakness with exertion.
• Leg pain that is exacerbated by standing and walking and
relieved promptly by sitting. Lying down, especially in the prone
position, may exacerbate the low back pain, again through
lumbar extension, a feature that helps to differentiate lumbar
spine stenosis from lumbar radiculopathy.

39. • Treatment can be conservative in the absence of neurological
deficits. Physical therapy and medications can help, but surgical
decompression often is required. Weakness of the legs or
sphincter disturbance indicates a need for decompression .
2.1 Lumbosacral Radiculopathy :
• Usually caused by infringement on the neural foramen by either
herniated disk material or osteophytes. Herniated disk is more
common in young patients; osteophyte formation is more
common in older patients.
• Patients present with back pain radiating down the leg in a
distribution appropriate to the involved nerve root. The most
common lumbosacral radiculopathy is of the S1 nerve root,
produced by a lesion at the L5-S1 interspace.

40. • Motor, sensory, and reflex deficits are
not always present, so the diagnosis is
suspected on the basis of symptoms
without objective signs.
• Confirmation of the diagnosis is by
MRI, which can show disk protrusion
or osteophyte encroachment with
nerve root compression.
• NCS findings usually are normal,
although F-waves may be delayed in
the affected root. The EMG can reveal
evidence of denervation in a nerve
root distribution and usually can
differentiate peripheral neuropathic
processes from radiculopathy.

42. MRI Lumbosacral spine showing disc prolapse

43. • Management :
Conservative :
Moderate bed rest; Spinal manipulation
Physical therapy; Medications: NSAIDS, muscle relaxants,
rarely narcotics.
Surgical :
• Microdiscectomy
• Less than half of an inch incision
• Go home the same or next day
• Good results in up to 90% of cases

44. 2.3 Plexopathy:
• Neoplastic lumbosacral plexopathy
• Plexus injury from retroperitoneal abscess
• Plexus injury from retroperitoneal hematoma.

45. Algorithmic approach for low back ache

46. Some Practical Tips in Treatment of
Patients with LBP
• All patients should be instructed regarding proper posture
and lifestyle modification:
• Weight reduction: It helps by decreasing the weight
burden on the spine. Hence, watch what you eat.
• Regular exercises to stay fit and stay active. Majority of the
patients of LBP should be mobilized as early as possible.

47. • Lift the things correctly.
• Maintain a correct posture while sitting and standing. Use
proper back supporting chairs or pillows.
• Avoid unwanted and sudden jerky movements which can
trigger somatic dysfunction in the muscles.
• Use firm mattresses while sleeping
• Stress management techniques. Stress increases muscle
tension and aggravates more pain.
• Thus, not only coming to a diagnosis of LBA can be
challenging, but keeping the patient pain free is a
Herculean task! It has multiple causes and involves various
disciplines of medical specialties to treat patients.

49. References
• Bradley’s Neurology in Clinical Practice. 6th Edition
• Harrison’s Principles of Internal Medicine. 19th Edition
• Veeravalli Sarath CM, Wagh S. Low back pain and neck pain. In: Wagh S
(Ed). Rheumatology in Primary Care, 1st edition. KYA Foundation;
2012.pp.47-59.
• Mogren IM, Pohjanen AI. Low back pain and pelvic pain during
pregnancy: prevalence and risk factors. Spine (Phila Pa 1976).
2005;30(8):983-91.
• Licciardone JC, Gatchel RJ, Kearns CM, et al. Depression, Somatization
and Somatic Dysfunction in Patients with nonspecific Chronic Low
Back Pain: Results from the Osteopathic Trial. J Am Osteopath Assoc.
2012;112(12):783-91.

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