LOW BACK PAİN Prof. Dr. Hidayet SARI
KEY POINTS • Low back pain (LBP) is the second most comman condition seen primary care practice, and the most common problem seen by musculosceletal specialists. It is essential that physicians be comfortable with the nuances of diagnosis and teratment of LBP.
KEY POINTS • Less common causes of LBP such as infection (fever and focal pain) and cancer (weight loss, unexplained pain,and oncologic risk factors) must be overlooked. If the pain persists and is unexplained, then the case must be investigated further.
KEY POINTS • Magnetic resonance imaging (MRI) images have a 30% false-positive rate, and therefore must be used in a discrminating manner. Remember that most patients with acute LBP and without neurologic signs and symptoms will respond to conservative therapy, and need no diagnostic tests.
KEY POINTS • Prolonged bed rest is harmful. An extended period of inactivity is a risk factor for converting acute LBP into chronic LBP. Start an appropriate regimen of exercise as soon as possible to preserve strength and flexibility in the muscles that support the lumbar spine.
KEY POINTS • Sensitization of peripheral or central pain processing systems will explain some cases of chronic LBP that persist despite the correction of the anatomical factors. Therefore, the first 3 to 6 months of assessment and treatment of patients with LBP are critical with regard to preserving and optimizing function of the lumbar spine.
INTRODUCTİON • LBP can affect up to 80% of the population at some point in their lives, making it second only to the common cold as an illness affecting the general population, and the fourth or fifth most comman reason for a visit to the physician’s office in the United States.
INTRODUCTİON • Acute LBP usually resolves spontaneously, but up to 10% progress to chronic LBP resulting in temporary or permanent disability. This results in a loss of more than 1,000 work days per 1,000 workers each year, costing more than $20 billion annually and disabling several million individuals in the United States alone at any on time.
INTRODUCTİON • Risk factors for the development of LBP include heavy manual work, poor job satisfaction, exposure to vibration, cigarette smoking and pregnancy. A sedentary lifestyle is also probably a cause. • Most patients with acute and chronic LBP have “idiopathic“ LBP, meanng that despite testing, no clear cause can be found for their pain.
INTRODUCTİON • Most patients who present with acute LBP in the absence of significant neurologic physical findings need no diagnostic tests and will respond to conservative management. • Patients who do not respond to a conservative regimen may need imaging studies, and rarely surgery
ETIOPATHOGENESİS • Any of the components of the lumbosacral spine when combined with related conditions listed in the subsequent text may be responsible for LBP. I- VERTEBRAL BODY (fracture,osteoporosis, metastatic disease, sickle cell disease and infection) II- INTERVERTEBRAL DİSC (herniation and infection) III-JOINTS (osteoarthritis and ankylosing spondylitis) A- Apophyseal joints B- Sacroiliac joints
ETIOPATHOGENESİS IV- LİGAMENTS(strain and rupture) A- Anterior and posterior longitudinal ligaments) B- Interspinous ans supraspinous ligaments C- Iliolumbar ligaments D- Apophyseal ligaments. V- NERVE ROOTS (herniated nucleus pulposus and spinal stenosis) VI- PARASPİNAL MUSCULATURE (strain and spasms)
IV- LİGAMENTS(strain and rupture) A- Anterior and posterior longitudinal ligaments) B- Interspinous ans supraspinous ligaments C- Iliolumbar ligaments D- Apophyseal ligaments. V- NERVE ROOTS (herniated nucleus pulposus and spinal stenosis) VI- PARASPİNAL MUSCULATURE (strain and spasms)
VII- PAIN FROM ADJACENT STRUCTURES (referred pain) A- Kidney (pyelonephritis and peripheric abscess). B- Pelvic strucures (pelvic inflammatory disease, ectopic pregnancy, endometriosis and prostate disease) C- Vascular (aortic aneurysm and mesenteric thrombosis) D- Intestinal (diverticulitis) VIII- Pain amplification syndromes where there is no identifiable abnormality of the peripheral tissue, but there is localized or widespread hyperalgesia (e.g., myofascial pain and regional forms of fibromyalgia).
PREVALENCE • Prevalence of LBP ranges from 38 to 39 per 1,000 population, with female sex, white ancestry, and increasing age being independent risk factors for increased incidence.
CLINICAL MANIFESTATIONS I. Clinical history of the patients is of great importance in obtaining information regarding associated symptoms and establishing a pattern of pain. A thorough review of symptoms that would suggest a nonmechanical cause for LBP is required.
CLINICAL MANIFESTATIONS • I. Clinical history A- Fever or chills would raise the possibility of an infectious process. B- Weight loss, chronic cough, change in bowel habits, or night pain may suggest malignancy C- Similar pain or morning stiffness in different areas of the body would increase the suspicion of a more generalized rheumatic condition such as ankylosing spondylitis, psoriatic arthritis, or reactive arthritis (ReA9
CLINICAL MANIFESTATIONS • I. Clinical history D- If fatigue or sleep disturbance is present, in the setting of a diffus pain syndrome, the diagnosis of fibromyalgia should be considered. E- Morning stiffness or back pain that improves with exercise should prompt consideration of a spondyloarthropathy such as ankylosing spondylitis.
CLINICAL MANIFESTATIONS II- PAIN The quality of pain, its distribution, and modulating factors are helpful in determining etiology.
CLINICAL MANIFESTATIONS • II- PAIN A- Onset of pain 1. Sudden onset especially following trauma suggests injury. 2. Indolent onset suggests a nonmechanical cause. 3. Episodic or colicky pain suggests an intra-abdominal or pelvic source. B- Localization of pain 1. Localized pain provides a focus for the diagnostic workup. 2. Radicular pain, suggesting nerve root impingement. 3. Pain thatn is not easily localized, migratory, or multifocal suggests fibromyalgia.
CLINICAL MANIFESTATIONS • II- PAIN C- Modulating factors 1. Exercise-induced pain, especially on walking, suggests osteoarthritis or spinal stenosis, whereas pain that improves with exercise especially following morning stiffness suggests an inflammatory process, for example, a spondylarthropathy. 2. Valsalva maneuvers such as coughing, sneezing, or bowel movements that worsen pain suggest nerve root impingement.
CLINICAL MANIFESTATIONS III- NEUROLOGİC SYMPTOMS. The presence of neurologic symptoms should be spesifically sought in patiets with LBP. Their presence can not only help to delineate the site of the abnormality but also can prompt more rapid intervention.
CLINICAL MANIFESTATIONS • III- NEUROLOGİC SYMPTOMS. A-Weakness, numbness, or paresthesias in a dermatomal distribution suggests nerve root impingement. 1. The most common cause of nerve root impingement in individuals between the ages of 20 and 50 years is a herniated nucleus pulposus. 2. Radicular symptoms in individuals older than 60 are more likely to be secondary to spinal stenosis resulting from osteoarthritis.
PHYSICAL EXAMINATION • Spesific abnormalities and provacative maneuvers designed to elicit pain associated with certain synrromes should be tested for in patients with LBP.
CLINICAL MANIFESTATIONS • III- NEUROLOGİC SYMPTOMS. B- Bowel or bladder dysfunction suggests the presence of cauda equina syndrome and should prompt emergent investigation. C- LBP in the presence of fever and neurologic symptoms should trigger the mind to the possibility of an epidural abscess.
PHYSICAL EXAMINATION 1- PATIENT IN STANDING POSITION A. Note the alignment of the spine looking for a pelvic tilt may indicate a paravertebral spasm , for loss of normal lumbar lordosis that could indicate either spasm or ankylosis, and for evidence of structural scoliosis. B. Evaluate gait, station, and posture. C. Evaluate the patient’s ability to flex, hyperextend, rotate, and tilt the spine.
PHYSICAL EXAMINATION 2- PATIENT IN SUPINE POSITION A. Straight leg raising (SLR).Flex each leg at the hip with knee extended and record the angle at which pain occurs and whether it radiates below knee. A true positive SLR test is defined as radicular pain radiating belox the knee, is a sensitive indicator of nerve root impingement, and should be confirmed by extending the knee while the patient is sitting, to eliminate malingering.
2- PATIENT IN SUPINE POSITION B. A crossed SLR test (radicular pain contralateral to the leg being raised) is highly predicitive of nerve root compromise. C. Evaluate hip and knee range of motion to eliminate these areas as a source of pain. D. Carry out thorough neurologic examination and symptoms define a “root signature,” allowing the physician to localize the source of the problem and potentially correlate it with the results of the imaging test.
3- PATIENT IN PRONE POSITION A. Look for evidence of sciatic notch tenderness, sometimes seen in sciatica. B. Results of the femoral stretch test (extending the hip) may be positive in L4 radiculopathy. C. Palpate bony structures, especially the vertebral structures, for localized tenderness, and examine for the resence of trigger points, not only in the low back but also in other areas of the body.
DIAGNOSTICINVESTIGATIONS I- Laboratory tests should be performed as indicated by the history and physical examination, age of the patient, and duration of symptoms. A. The erytrocyte sedimentation rate (ESR) and C-reactive protein, reflect acute phase reactants and will usually be elevated in infection, inflammatory joint disease, and metastatic malignancies. B. Determinations of calcium, phosphorus, and alkaline phosphatase levels screen for metabolic bone diseases. C. Serum and urine protein immunoelectrophoresis should be performed if multipl myeloma is suspected because of the coexistence of back pain, elevated ESR, and anemia.
IMAGING STUDIES A- Imaging studies are not performed until the patients fails a trial of conservative therapy or unless neurologic or constitutional symptoms are present.
IMAGING STUDIES 1- Plain films should be taken as an initial study in the evaluation of LBP. a. Anteroposterior, lateral end cone-down views of the lower two interspaces are standard procedure. b. Oblique views will identify subtle spondylosis and help to visualize the neural foramina, but are not routinely necessary. c. Fleksion extension views may be obtained to document instability and range of motion.
IMAGING STUDIES 2- Bone scintigraphy is useful as a screening study when malignancy (other than multipl myeloma), infection, or occult fracture, which are not visualized on plain films, are suspected.
IMAGING STUDIES 3- Magnetic resonance imaging (MRI) has revolutionized the imaging of the lumbosacral spine and can visualize both bony and soft tissue structures well. MRI is now the imaging modality of choice for imaging intraspinal pathology. The principal problem with MRI is the high rate of false-positive results. Up to 30% of asymptomatic individuals will be shown to have significant abnormalities on MRI. Therefore, MRI-defined abnormalities need to ve viewed in the context of the findings based on history and physical examination.
IMAGING STUDIES 4- Computed tomography (CT) scan. When used without intradural contrast, CT scan is the modality of choice for delineating the bony structures of the spine (e.g., to detect spinal stenosis). With the addition of intrathecal metrizamid, the sensitivity for detecting neural involvement is enhanced.. CT scan dopes not detect intraspinal pathology as well as MRI does, and false-positive results may also be present as in MRI.
IMAGING STUDIES 5- Myelography outlines the dural theca and its contents after injection of a contrast media into the dural sac. This is a good study to delineate neural compression. It remains the study of choice when metal hardware is present or when arachnoiditis is suspected. Myelography is slowly falling from favor because of its invasiveness, side effects, and because of the improvement in imaging techniques with MRI and CT scan.
IMAGING STUDIES 6- Diskography is performed by injecting dye into the disk space. If symptoms are reproduced during the procedure, iı may be particularly helpful, especially if other imaging studies have been nondiagnostic.
IMAGING STUDIES 1- Degenerative disk disease. Radigraphic abnormalities correlate poorly with symptoms and they must be correlated with the patient’s history and physical examination findings. a. Narrowing of the intervertebral disc. b. Vacuum phenomenon defined as radiolucency in the disc space. c. Traction osteophytes defined as anterior osteophytes on the lumbosacral spine indicative of spinal instability.
IMAGING STUDIES 2- Osteoarthritis • Osteophytes formation • Facet joint arthritis. • Spinal stenosis • Acquired spondylolisthesis
IMAGING STUDIES 3- Congenital and developmental defects • Spondylosis refers to the dissolution or failure of the develoment of the neural arch, typically noted as a lucency in the “neck” of the “Scotty dog” noted on oblique spine radiographs (the “eye” of the Scotty dog is the pedicle, the “ear” is the superior articulation of that vertebral body, and the “neck” is the pars interarticularis). Failure of the pars can lead to slippage (usually anteriorly) of one vertebral body over the other. • Spondylolisthesis is slippage of one vertebral body on another. It can be a consequence of spondylolysis or an acquired condition. • Transitional vertebrae, with lumbarization of S1 or sacralization of L5. • Schmorl’s nodes are defects in the vertebral end plates that allow vertikal disk herniation. • Scoliosis or kyphosis.
IMAGING STUDIES 4- Spondyloarthropathies (ankylosing spondylitis, ReA, psoriatic arthritis, and arthritis associated with inflammatory bowel disease). • Erosions or sclerosis of the sacroiliac joints are best seen in a Ferguson (sacroiliac) view of the pelvis, a special view that allows better visualization of the joint. • Syndesmophytes Calcification of the ligamentous structures leads to a bridging of the adjacent vertebral bodies.
IMAGING STUDIES 5- Neoplasm • Typically leads to destruction of the vertebral body. • Loss of the outline of the pedicle on the anteroposterior films. • Pathologic fracture. 6- Infection should be suspected when destruction of adjacent vertebral end plates is present or bony destruction is accompanied by constitutional symptoms.
IMAGING STUDIES 7- Miscellaneous • Osteoporosis. Loss inmineralization, compression fractures with characteristic anterior wedging, “fish mouth” appearanca to the intervertebral spaces. • Metabolic bone disease (i.e., osteomalacia, Paget’s disease, or hyperparathyroidism) • Sickle cell disease.