2. Common cause of low back pain
• Myofascial lower back pain
HNP of lumber spine
Spinal canal stenosis
Lumber spondylolysis
Spondylolisthesis
Facet Syndrome
Adult kyphosis and scoliosis
Infective pathology of spine eg. TB & osteomyelitis
Primary neoplasm of the neural tissue and MM
Metastatic disease of spine
Rheumatic conditions eg. Ankylosing spondylitis and fibromyalgia
Metabolic causes of back pain
FBSS
Ref. Handbook of pain medicine / G. Dureja / 2nd
ed
3. PAIN CLINIC ,BSMMU
10 years old boy comes with low back pain
26 years old boy comes with low back pain
65 years old female comes with the low back
pain
4. COMMON CAUSES OF BACK PAIN IN VARIOUS AGE
GROUPS
CHILDREN
ADOLESCENTS
YOUNG ADULTS
• scoliosis
• Spondylolisthesis
• Pyogenic or tuberculous infections
• Calve’s disease
• Scheuermann’s disease
• Scoliosis(idiopathic and postural)
• Mechanical baack pain
• Adolescent intervertebral disc syndrome
• Pyogenic or tuberculous infection
• Prolapsed intervertebral disc
• Spondylolidthesis
• Spinal fracture
• Ankylosing apondylitid
• Coccydynia
• Pyogenic or tuberculous infection
• Spinal stenosis
5. MIDDLE – AGED
ELDERLY
• Mechanical back pain
• Prolapsed intervertebral disc
• Scheuermann’s disease and old fracture
• Spondylolisthesis
• Rheumatoid arthritis
• Spinal stenosis
• Paget’s disease
• Cocccydynia
• Spinal metastases
• Pyogenic osteitis of spine
• Osteoarthritis(primary or secondary)
• True senile kyphosis
• Osteoporosis(with or without fracture)
• Osteomalacia(with or without fracture)
• Spinal metastases.
6. • Site and nature of pain : localized of diffuse
persistent or intermittent
• Onset of pain :
When did the symptoms commence?
pattern of onset: slow and insidious
rapid or sudden ( strongly suggestive of mechanical
factor)
history of an injury
( a sudden twist or strain or sneeze occurring when the
patient was in a flexed position :a common history for
intervertebral disc prolapse )
7. • Character of pain
Usually described by adjectives like
sharp, dull, burning, tingling, boring , stabing
Directly relevant previous history :
Is there any history of previous similar attack?
or any previous trouble with the spine ?
• Radiation of the pain :
does the pain radiates to the legs ?
how far down does the pain go & what are the area involved ?
commonly affaected nerve root L 4,L 5 &S1
•
8. Associated any paresthesia
N.B. Pain radiates into legs is not necessarily due to nerve root compression. It seems that irritation of facet joints
, ligaments and muscles may produce dull aching pain in the buttock and back of the thighs.
Pain arising from nerve root is usually sharp and knief like
Back with without radiation Back pain with radicular lower extremity pain or weakness
Musculoskeletal lower back pain
Spondylosis
Facet syndrome
Adult scoliosis
Adult kyphosis
Spondylolisthesis
Infection
Fracture
Dislocation
Arthritis
Rheumatological condition
Reffered pain from visera
HNP
Spinal stenosis
Fracture
Dislocation
Cauda equina syndrome
Ref. Handbook of pain medicine / G. Dureja/ 2nd
ed
9.
10. •
Timing of pain
Constant: back ache with spinal pathology ( tumour , infection or inflammation
constant night pain , distinct short lived pain when turning in bed) > Sleep disturbance
Episodic
In particular day or part of whole day
Any changes in severity as day progress
Morning pain associated with stiffness
Exacerbating and relieving factor
Mechanical back pain bending or sudden movement may make the pain worse
,whereas lying flat , particularly on a hard surface or applying local heat or even sitting, may
relieve pain.
During rest pain increase or decrease?
11. • Motor involvement
any weakness in the lower limbs or any muscle wasting or fibrillation?
Any disturbance of gait or balance , any tendency to giving way of the
legs , any sign of foot drop?
• Any constitutional symptoms : malaise , fever ,
weight loss
involvement of other joints
associated GIT problems
associated genitourinary symptoms
respiratory difficulty
major neurological disturbance
12. COMMON CAUSES OF LOW BACK
PAIN
PATHOLOGY AGE PAIN NATURE ASSOCIATED
PAIN
ASSOCIATED
SYMPTOMS
Degenerative
spondylosis
> 40 years Mechanical Distance
claudication
Active patient
Spondylolisthesis <20 years
>40 years
Mechanical Extension Hyperextension on
activity
Trauma Any age Mechanical _ Trauma
Infection Any age Non- mechanical Rest pain Fever
Mets >50 years Non-mechanical Rest pain Primary+
LOW
LOA
Osteoporosis >60 years Mechanical _ Trivial injury
13. Findings PID Lateral stenosis Central stenosis
Average age 43 41 65
Duration of symptoms Shortest
Pain at rest, at night
and on coughing
+ Equal +
SLR +++ Sometimes Hardlyever
Motor disturbance Commonest specially
knee jerk
Sensory changes Commonest
DIFFERENCE BETWEEN DISC PROLAPSE AND SPINAL STENOSIS
14. RED FLAG FEATURES
•Histosry
• Age <20 years or >55 years
• Recent significant trauma
• Pain- thorasic (dissecting aneurysm)
• non-mechanical
(infection/tumour/pathological fracture)
• Fever(infection)
• Difficulty in micturition
• Faecal incontinence
• Motor weakness
• Sensory changes in the perineum( saddle
anesthesia)
• Sexual dysfunction( erectile/ejaculatory
failure)
• Gait change ( cauda equine syndrome)
• Bilateral sciatica
16. YELOOW FLAG FEAturEs
These are psychosocial factors associated with greater likelihood of long term
chronicity and disability
•A history of anxiety, depression chronic pain irritable bowel syndrome, chronic
fatigue, social withdrawal.
•A belief that the diagnosis is severe such as cancer, faulty beliefs can lead to
‘catastrophisation’ and avoidance of activity.
•Lack of belief that the patient can improve leads to an expectation that only
passive, rather than active, treatment will be active.
•Ongoing litigation or compensation claims such as work , road traffic accident.
18. Family History
In a young man with gradual-onset chronic back pain, a positive
family history for reactive arthritis, psoriasis or inflammatory
bowel disease, and the presence of peripheral joint involvement
or anterior uveitis all suggest a diagnosis of ankylosing
spondylitis.
