LOW BACK PAIN

Nurul Miftah & Che Nurul Ain

Mechanical
Causes
Lumbar Strain
Degenerative
disease
Discs (spondylosis)
Facet joints
Spondylolisthesis
Herniated/Prolasp
ed disc
Spinal stenosis
Osteoporosis
Fractures
Congenital
disease
Severe kyphosis
Severe scoliosis

Nonmechanical
spine disease
Neoplasia
Multiple myeloma
Metastatic
carcinoma
Lymphoma and
leukemia
Spinal cord tumors
Retroperitoneal
tumors
Infection
Osteomyelitis
Septic discitis
TB
Inflammatory
arthritis (often
HLA-B27 associated)
Ankylosing
spondylitis
Psoriatic
spondylitis
Reiter's syndrome

Visceral
disease/
Referred Pain
Pelvic Organs
Prostatitis
Endometriosis
Chronic pelvic
inflammatory
disease
Renal disease
Nephrolithiasis
Pyelonephritis
Perinephric
abscess
Aortic aneurysm
Gastrointestinal
disease
Pancreatitis
Cholecystitis
Penetrating ulcer

Causes in relation to age

15-30 years old
Prolapsed disc
Trauma
Fracture
Ankylosing
spondylitis
Spondylolisthesis

30-50 years old

> 50 years old

Prolapsed disc
Degenerative spinal
disease
Bone infection or
tumour(pyogenic
osteomyelitis, spinal
TB, spinal
metastases)

Degenerative spinal
disease,
osteoporotic
vertebral
collapse,
malignancy(primary
or secondary from
lung, breast,
prostate,
thyroid, or kidney
Ca),
Multiple myeloma,
spinal stenosis, TB
spine

Red Flags!

Disc degenerate -fissures and

cracks occur in the annulus,
and herniations of nucleus
Disc cell
proliferate and
collect into
clusters then die
at an increased
age

Root canal
stenosis, spinal
stenosis

PATHOPHYSIOLOGY OF
DISC DEGENERATION
Glycosaminogl
ycan
diminished>poor water
retention>drying out

Secondary
changes :
segmental
instability
( displacemnet
of facet joints)

Osteophytes
formation

Lumbar Spondylosis (Degenerative

osteoarthritis)
Degenerative joint disease affecting
lumbar vertebrae and intervertebral disc
Pain and stiffness
Sciatic radiation due to nerve root
pressure by associated protruding disc or
osteophytes

Clinical features
Hx of acute disc ruptured -> recurrent attacks of pain
over several years
Intermittent backache
Hard physical work, standing or walking a lot or sitting in
one position during a long journey
Relieve by laying down

Pain referred to buttock and down the leg (like

sciatic)
Tenderness at back and buttocks
Lumbar movement limited & painful at extreme
Difficult in straightening up from forward bend
position

X-rays
Radiographic
features of
intervertebral disc
degeneration
Flattening of disc
space
Marginal bony spur
(osteophytes)
OA of facet joints

Management
Asymptomatic dont need treatment
Conservative treatment
Modified activities
Exercise aerobic, stretching and muscle
strengthening
Wearing of a lumbar corset
Small doses of anti-inflammatory drug

Pain control fail

Spinal fusion : immobilize the degenerated
vertebrae -> relieve pain

Spinal Metastasis
If > 50 y.o., think bone mets > primary
malignancy of bone
Commonest sources : Ca of breast, prostate,
kidney, lung, thyroid, bladder and GIT.
Commonest site : vertebrae, pelvis, the
proximal half of the femur and the humerus.
Spread : hematogenous or direct
Metastases are usually osteoclastic and
pathological fractures are common.
Osteoblastic tumours are uncommon,
usually occur in prostatic carcinoma.

Clinical Features

Previous history of cancer

Age 50-70
Bone/back pain
Sudden collapse of vertebrae body
Symptoms of hypercalcaemia
Anorexia, nausea, thirst, polyuria,
abdominal pain, general weakness and
depression

Lytic = black hole in

the bone

Blastic =
abnormal
white area

discrete rounded sclerotic lesions

in right ilium
"ivory vertebra" involving
L4 and S1.

Bone Scan

A nuclear medicine bone scan

would show bone mets as dark
areas

CT
Determining integrity of vertebral
column (if surgery indicated)

Management
Curative - Radical treatment (surgery +
radiotherapy) for both primary and secondary tumor
if possible
Prognosis for survival = almost hopeless
Focuses on relieving and preventing the suffering of
patients
Pain management- analgesia or radiotherapy
Fix fractures intramedullary nailing
Prophylactic fixation
Spinal stabilisation- fitted braces or operative stabilization
Hypercalcaemia hydration, reduce Ca intake,
biphosphanates

Cervical spondylosis

Cervical myelopathy

Defini
tion

Chronic intervertebral disc

degeneration

Cervical cord compression

due to a narrow cervical
canal
-mainly due to cervical
spondylosis.

Clinic
al
featur
es

-aged > 40
-neck pain and stiffness
-Gradual onset and worse
after waking up.
-Radiates to occiput, back of
shoulders or one or both
upper limbs.
-numbness, weakness and
clumsiness of hands

-neck pain and brachialgia

-discomfort varies from
aching to sharp pain
-gait disturbances, clumsy
hand, spasticity, sphincter
disturbances, motor
weaknes, hypereflexia.

X ray
-Narrowing of one or more
Findin intervertebral disc.
gs
-Bony spur formation at the
anterior or posterior of disc.
-Osteophytes encroaching on
the intervertebral foramina.

-narrow vertebral canal

( <11 mm )

Treat

-analgesics, collar, isometric

-analgesics, collar,

OSTEOPOROSIS
-Abnormally LOW BONE MASS
-imbalance between bone resorption and
bone formation activity
-NORMAL mineralization
-high risk for FRACTURE!

Generalised

Primary/age
related
postmenouposa
l osteoporosis
>acute back
pain d/ t
vertebral
compression
Repeated minor
fractureprogressive
kyphosis

Localised
-due to
disuse/nearby
inflammation

Secondary
1-nutritional-scurvy
2-endocrine
disorders- high PTH,
cushings
3-malignancymultiple myeloma,
leukemia
4-non-malignantRA, AS, TB, CKD
5-ALCOHOL ABUSE!

DIAGNOSIS
Primary-Usually
obvious-need to
exclude secondary
causes
Dexa scan T score
<-2.5
X-ray