LOW BACK PAIN

Susanto, dr, Sp.S

RSUD Kelas B Cianjur
June 9, 2015

PAIN
An unpleasant sensory and
emotional experience associated
with actual or potential tissue
damage, or described in terms of
such damage.

International Association for the Study of Pain

(Merskey, 1979)

PAIN

Pain is always subjective.

The patients self-report of pain is

the single most reliable indicator
of pain.

The clinician must accept the

patients self report of pain.

Types of Pain
DIFFERENT TYPES OF PAIN

Acute pain is defined as short-term pain or pain with an easily

identifiable cause

Chronic pain is medically defined as pain that has lasted 6 months

or longer

Cutaneous pain is caused by injury to the skin or superficial tissues

Somatic pain originates from ligaments, tendons, bones, blood

vessels, and even nerves themselves

Visceral pain originates from body organs

Phantom limb pain is the sensation of pain from a limb that one no
longer has

Neuropathic pain can occur as a result of injury or disease to the

nerve tissue itself

University of Pcs, Department of Neurology

Types of Pain
Nociceptive Pain
Nociceptors = pain fiber sensitive to
noxious stimuli
Somatic injury to tissues, well
localized
Visceral injury to organs (stretch
receptors), poorly localized
Referred afferent visceral fibers +
somatic to same spinothalamic
pathway

Types of Pain
Neuropathic pain

Abnormal neural activity secondary to disease, injury,

or dysfunction
Persists without ongoing injury (trigeminal neuralgia,
DM neuropathy)
Types:

Sympathetic from peripheral nerve injury with

autonomic changes

New term Complex Regional Pain Syndrome (CRPS)

Peripheral autonomic pain

Type I = RSD
Type II = causalgia

Same but without autonomic change (PHN)

Central Pain (spinal cord injury)

Low Back Pain

Definition :
Pain that occurs in an area
with boundaries between the
lowest rib and the crease of
the buttocks

 Back pain is one of the most

common ailments of mankind.
An estimated 80 % of people
experience back pain at some
point in their lives, and slightly
more men suffer from it than
women
Potent cause of absence from
work

The prevalence rates for low back pain in the general

population by age

Low Back Pain - Disorders

Mechanical (>80%)

Referred

Rheumatologic

Hematologic

Infectious

Neurologic

Neoplastic

Psychiatric

Endocrinologic

Miscellaneous

(N > 60)

_______________________________
Borenstein D, Wiesel S, Boden S: Low Back Pain: Medical Diagnosis and Comprehensive Management. 1995

Vertebra

ANATOMY

Body, anteriorly

Functions to
support weight

Vertebral arch,
posteriorly

Formed by two
pedicles and two
laminae

Functions to
protect neural
structures

S. Matin MD

ANATOMY

Causes of back pain

LBP: Risk Factors

Heavy lifting and
twisting
Obesity
Poor physical
fitness/conditioning
History of low back
trauma
Psychiatric
history(chronic LBP)
S. Matin MD

Differential Diagnosis for all

back pain

Etiologic

1. Mechanical Spinal Condition (97%)

2. Non-mechanical Spinal Condition (1%)
3. Non-spinal/Visceral Disease (2%)
Temporal
Acute < 6 week duration
Chronic > 6 week duration

Differential: Mechanical LBP

Lumbar Strain or Sprain (70%)

Degenerative processes of disc and
facets (10%)
Herniated disc (4%)
Osteoporotic Compression Fracture
(4%)
Spinal Stenosis (3%)
Spondylolisthesis (2%)
Traumatic Fractures (<1%)
Congenital disease (<1%)
Spondylolysis*
Internal Disc Disruption/Discogenic
Back Pain
Presumed Instability

(About 2%)

Nonmechanical spinal conditions

(1% OF ALL LOW BACK PAIN)

Neoplasia: multiple myeloma, metastatic

Ca, lymphoma, leukemia, spinal cord
tumors, retroperitoneal tumors, primary
vertebral tumors (0.7%)
Infection: osteomyelitis, septic diskitis,
paraspinous abscess, epidural abscess,
shingles (0.01%)
Inflammatory arthritis: Ankylosing
spondylitis, psoriatic spondylitis, Reiters
syndrome (0.3%)
Scheuermann Disease (osteochondrosis)
Paget Disease

Visceral Disease
(2% OF ALL BACK PAIN)

1. Disease of pelvic organs:

prostatitis, endometriosis, chronic
PID
2. Renal Disease: nephrolithiasis,
pyelonephritis, perinephric abscess
3. Aortic aneurysm
4. GI disease: pancreatitis,
cholecystitis, penetrating ulcer

Used terminology in back pain

Spondylosis
Spondylolysis
Spondylolisthesis
Spinal stenosis
Radiculopathy
Sciatica
Cauda Equina Syndrome
Lordosis, Kyphosis, Scoliosis
Piriformis Syndrome

04/19/16

Mechanical LBP Differential Diagnosis

Clinical Features

Herniated disk

Usually occurs in adults aged 30 to 55 years

Sciatica, often associated with leg numbness or

paresthesias, is a

highly sensitive (95%) and specific (88%) finding

for herniated disk

Exacerbation of pain may occur with

coughing, sneezing, Valsalva maneuvers

Spinal Stenosis

usually occurs in older adults

characterized by neurogenic claudication

radiating back pain and lower extremity numbness

exacerbated by walking and spinal extension

improved by sitting

Causes of Low Back Pain

Lumbar strain or sprain 70%
Degenerative changes 10%
Herniated disk 4%
Osteoporosis compression
fractures 4%
Spinal stenosis 3%
Spondylolisthesis 2%
Steven Stoltz, M.D.

Causes of Low Back Pain

Spondylolysis, diskogenic low
back pain or other instability 2%
Traumatic fracture - <1%
Congenital disease - <1%
Cancer 0.7%
Inflammatory arthritis 0.3%
Infections 0.01%
Steven Stoltz, M.D.

3 Most Common LBP

other than Radiculopathy
Sacroiliac Disorder
Trochanteric Bursitis
Pyriformis Syndrome

Piriformis syndrome
Pain from piriformis
muscle irritation of
sciatic nerve passing
deep or through it
Pain on resisted abduction /
external rotation of leg

PATIENT HISTORY
Onset
Palliative/Provocative factors
Quality
Radiation
Severity/Setting in which it occurs
Timing of pain during day
Understanding - how it affects the
patient

Onset
Acute - Lift/twist,
fall
Subacute inactivity,
occupational
(sitting, driving,
flying)
Pain effect on:

work/occupation
sport/activity (during or
after)
ADLs

Pain Character

Sharp
Burning
Dull ache

Pain with
Prone position

Facet, Lat HNP, systemic

dz

Sitting

Paramedian HNP,
annular tear

Standing

Lateral HNP, spinal

stenosis, facet syndrome

Walking

Spinal stenosis

Radiation

Up back
To sacrum
To buttocks
Down leg

Referred pain
Pleuritic pain
Upper UTI / renal calculus
Abdominal aortic aneurysm
Uterine pathology (fibroids)
Irritable bowel (SI pain)
Hip pathology

Other Symptoms

Cough/valsalva exacerbation
Distal neuro sx weakness/paresthesia
Perianal paresthesia
Bowel/bladder sx

Other History
Prior treatments and
response
Prior h/o back pain
Exercise habits
Occupation/recreational
activities

Yellow Flags
Factors prolonging back pain
Internal factors-Opioid dependency
External controller patient-type;
learned helplessness; factitious disorder
Mental health- depression or anxiety
Interpersonal factors "Sick role
Stressors in relationships
Environmental / societal factorsDisability payments / Litigation /
Malingering

Red Flags

Age > 70
Fevers, chills, recent UTI/skin infection, penetrating wound near
spine
Recent significant trauma or milder trauma age > 50
Unrelenting night pain or pain at rest
Progressive motor or sensory deficit
Saddle anesthesia, bilateral sciatica or leg weakness, difficulty
urinating, fecal incontinence
Unexplained weight loss
History of cancer or strong suspicion of cancer
History of osteoporosis
Immunosuppression
Chronic oral steroid use
IV drug use, substance abuse
Failure to improve after 6 weeks of conservative therapy
Point tenderness

Physical Examination

Observation of walking
Inspection of back and posture
Palpation of the spine and soft tissue
Range of motion
Strength testing
Straight leg raising (for patients with leg symp)
Neurologic assessment of L4, L5, S1 roots (for
patients with leg symptoms)
Special tests

Evaluation for malignancy (breast, prostate, LN exam)

Peripheral pulses in older patients with exerciseinduced calf pain.

Inspection (cont.)
Posture
Shoulders and pelvis should be level
Bony and soft-tissue structures
should appear symmetrical

Normal lumbar lordosis

Exaggerated lumbar lordosis is
common characteristic of weakened
abdominal wall

Bone Palpation
Palpate L4/L5 junction (level of iliac
crests)
Palpate spinous processes superiorly
and inferiorly
S2 spinous process at level of posterior
superior iliac spine

Absence of any sacral and/or lumbar

processes suggests spina bifida
Visible or palpable step-off
indicative of spondylolisthesis

Soft Tissue Palpation

4 clinical zones
Midline raphe
Paraspinal muscles
Gluteal muscles
Sciatic area
Anterior abdominal wall and inguinal
area

Strength Testing
test hip flexion, hip extension, knee
flexion, knee extension, ankle
dorsiflexion, and ankle plantar
flexion.
Additional testing if the weakness
is in the distribution of a specific
nerve or nerve root

Special Tests

Tests to stretch spinal cord or sciatic nerve

Straight Leg Raise, Cross Leg SLR, Kernig Test

Tests to increase intrathecal pressure

Valsalva Maneuver : Reproduction of pain
suggestive of lesion pressing on thecal sac

Tests to stress the sacroiliac joint FABER

Test (Patricks Test), Gaenslen sign

Pelvic Compression Test

Fabere test

Neurologic Examinaion

Includes an exam of entire

lower extremity, as LS
spine pathology is
frequently manifested in
extremity as altered
reflexes, sensation and
muscle strength

Describes the clinical

relationship between
various muscles, reflexes,
and sensory areas in the
lower extremity and their
particular cord levels

Nerve Root Syndromes

Nonorganic Physical Signs

Psychological distress may amplify low
back symptoms
Superficial tenderness
Distracted SLR
Patient overreaction during the
physical examination

No RED FLAGS ?
-After a history and exam eliminates the
possibility of a dangerous back
condition, we can move on to
treatment. Most people will fall into
this category. No radiographs or labs
will be necessary.

-One can reassure patients that 90 % of

cases resolve in one month with only
conservative treatment.

Approach to LBP
History & physical exam
Classify into 1 of 4:
BAD: LBP from other serious causes

Cancer, infection, cauda equina, fracture

LBP from radiculopathy or spinal stenosis

Non-specific LBP
Non-back LBP

Workup or treatment

BAD low back pain (examples)

Radiculopathy, Spinal Stenosis

Suspected Radiculopathy or
Spinal Stenosis
Refer to Neurology, Physical
Therapy
Follow in 2-4 weeks for progress
If no improvement by 6-12 weeks
Plain films, MRI, +/- EMG/NCV
Refer for interventions

Some Causes of Non-specific LBP

Acute lumbar strain

Facet pain

Discogenic pain

Ligamentous pain

Spondylosis
(Osteoarthritis of
facet/disk)

Spondylolysis/listhesis

Non-specific Low Back Pain

Educate patient about expected good
prognosis
Advise to remain active as tolerated
Provide analgesics and self-care
directions
FU in 2-4 weeks; adjust tx as needed
Dont do xrays unless it becomes
chronic
WU if no improvement

Outside the Back

Non-back LBP

Retroperitoneal dz
(Pancreatic, Renal,
Duodenal, Gyn,
Prostate)

Gynecological dz

AAA

Zoster

Diabetic
radiculopathy

SI joint
Rheumatologic
disorders

Reiters

Ankylosing Spondylitis

Labs

Labs are generally not necessary, but may be helpful

if cancer or infection or visceral disease is suspected.

The following laboratory studies should be considered

if there is concern for cancer or infection
1. CBC
2. ESR/CRP
3. PSA
4. Alkaline phosphatase
5 Serum immunoelectrophoresis
6. Urine testing for light chains

Diagnostic Studies
Radiographs

Early if RED FLAGS

Symptoms present
> 6 weeks despite
tx

Further studies

CT and MRI should be considered when:

1. If a serious problem is suspected
(cancer/infection) and is not visualized on
plain film
2. Suspicion of cauda equina or spinal
stenosis
3. If there is a plan for surgery or other
intervention
4. To diagnose visceral disease, if indicated

Lumbar Spine Imaging Studies

36% of CT scans abnormal in
asymptomatic persons
24% of myelograms abnormal in
asymptomatic persons
37% positive discograms in
asymptomatic persons

PAIN TREATMENT CONTINUUM

Diagnosis
Oral Medications
PT, Exercise, Rehabilitation
Behavioral Medicine
Corrective Surgery
Therapeutic Nerve Blocks
Oral Opiates
Implantable Pain Management Devices
Neurostimulation
Intrathecal Pumps
Neuroablation

Pain modulating therapy

Tricyclic antidepressants
(Amitryptiline, Nortryptiline)
Dose titration

(SSRIs)
Possibly SNRIs
Muscle relaxants
Anti-seizure medication
Gabapentin, Pregabalin, etc.

Chronic opioid therapy

Indicated in patients if not operative

candidates

Limited RCT evidence shows analgesia but

not improved functional status

Requires clear understanding of duration and

conditions of renewal

Longer duration analgesics preferred

MS Contin

Methadone, etc.

Multi-Disciplinary Pain Program Models

Pain Consultation Team
Multidisciplinary Programs
Multidisciplinary Outpatient Programs
Multidisciplinary Inpatient Programs

Pain Service

Pain Consultation Team

Pain Management Team
Multidisciplinary

Anesthesiology
Neurology
Physical Medicine and Rehabilitation
Psychology
Orthopaedic / Neurosurgery

Pain Medications
Second most commonly prescribed drug
class
Does not eliminate pain
Long term Opiates

(32% reduction)

Anti-Convulsive / Depressants

(1:3 will have 50% reduction)

Rarely below 4 (0-10 rating)

Turk (2002), CJP

Interventional Treatment Options

Neural blockade

selective nerve root blocks

facet joint blocks, medial branch blocks

Neurolytic techniques

radiofrequency neurotomies

pulse radio frequency

Stimulatory techniques

spinal cord stimulation

peripheral nerve stimulation

Intrathecal medication pumps

delivery into spinal cord and brain via CSF

Referral for surgery

Sciatica and probable herniated
discs
Cauda equina syndrome
Progressive or severe neurological
deficit
Persistent neuromotor deficit after 46 weeks conservative treatment
Persistent sciatica with consistent
neurologic and clinical findings

Referral for surgery

Spinal Stenosis
Progressive or severe neurological deficit
Persistent back and leg pain improving
with flexion and associated with spinal
stenosis on imaging

Spondylolisthesis
Progressive or severe neurological deficit
Severe back pain/ sciatica with functional
impairment that persists > 1 year

Surgery
Spinal fusion

(75% still had pain)

Repair for herniated disk

(70% still had pain)

Repeat surgery

(66% still had pain)

Turk (2002), CJP

Failed-Back-Surgery Syndrome
Reoperations
60% due to postspinal surgery
complications
40% due to uncorrected or new
structural abnormalities of the
spine

Failed-Back-Surgery Syndrome
Postsurgical causes of back pain

Recurrent or retained disk fragment

Postoperative instability

Dural adhesions

Root injury

Arachnoiditis

Pseudomeningocele

Failure to relieve the original pathologic condition

Postoperative wound and disk infection

Key Points about low back pain

>90% are due to mechanical causes and
will resolve spontaneously within 6 weeks
to 6 mths
Pursue diagnostic workup if any red flags
found during initial evaluation
If ESR elevated, evaluate for malignancy
or infection
In older patients initial Xray useful to
diagnose compression fracture or tumor

THANK YOU