Low back pain

By Adrian Khu,SpOT

Introduction
Low Back Pain is a symptom The pathologic basis for the pain may something within the spine or lesion outside of the spine Classified as :
Causes within the spine :
Spondylogenic Neurogenic

Causes outside the spine :

Viscerogenic Vascular Psychogenic

Spondylogenic Back Pain

Derived from lesions involving Bony components spinal column Changes in the sacroiliac joints Changes in the soft tissues
Discs Ligaments muscles

Neurogenic Pain
This pain can causes by :
Tension, irritation or compression of lumbar nerve root Lesion of central nerve system such as thalamic tumors, arachnoid irritation

Tumors involving the roots, like neurofibroma,

neurilemmoma, ependymoma and others cyste

Viscerogenic Back Pain

Can cause by disorders of the kidneys, pelvic viscera, lesions of lesser sac and retroperitoneal tumors The pain is not aggravated by activity nor its relieved by rest

Vascular Back Pain

Abdominal aortic aneurysms, peripheral

vascular disease give rise to backache

Insuff. A sup gluteal buttock pain, that can by walking and by standing still

Psychogenic Back Pain

Pure psychogenic back pain is rarely seen in clinical Caused by emotional breakdown

Spondylogenic Back Pain : Osseous Lesions

Pathological processes involving the vertebrae and intervertebral joints The pain will minor by activity, and it is not relieved by rest Divided into :
Trauma Infection Tumors Metabolic bone disease (osteoporosis)

INFECTION
Relative rare, but potential source of back pain Divide into :
Vertebral osteomyelitis :
Pyogenic Granulomatous (TB) Miscellaneous

Epidural abscess Intervertebral disc infection Intervertebral disc inflammation

TUMOR
Benign tumors and primary malignancies in the vertebral column are rare, secondary lesions are common Primary tumors of spine can be seen on plain radiographs Older patient, more likely primary tumoris malignant Most benign tumor are in the posterior elements, except GCT, eosinophilic granuloma and hemangioma

 Most primary malignant tumors will be found in the vertebral body

The incidence of neurogical compromise is 75%

in malignant tumors and 40-50% in benign

tumors, due to direct tumor extension,

pathological fractures or skeletal deformity The prognosis for malignant tumors is not very good

 Benign tumors :
chordoma, osteoid osteoma, osteoblastoma, ABC, GCT, osteochondroma, hemangioma, eosinophilic granuloma

Malignant tumors : Primary : myeloma, chondrosarcoma, osteosarcoma, Ewings sarcoma, fibrosarcoma and lymphoma Secondary : hypernephroma, thyroid, bowel ca (lytic

lesion), breast, prostate and lung tumor (blastic

lesion)

Spondylogenic Back Pain : Soft Tissue Lesions

Lesions :
Fibrositis
Myofascial pain syndromes Sacralization of lumbar vertebra Disc degeneration Disc ruptures

Fibrositis (Fibromyalgia)
Nonspecific inflammatory changes in fibrous tissue that felt for clinical syndromes of lumbago Chronic, widespread, nonarticular, musculoskeletal pain

Myofascial Pain Syndromes

If fibrositis is localized to one area of the

body, such as the low back

Sacralization
Attachment between the transverse process of L5 with the sacrum and associated with back pain

Disc Degeneration
The natural aging process, with or without repeated minor episode of trauma, results in :
loss of nuclear jelly (because of failure to reproduce the degradated proteoglycan) weakening of annulare support (because of failure of collagen linking)

 The cascade process :

1. Fibroblasts fail to reproduce new collagen to replace degradated collagen in the annulus

2. Chondrocytes fail to reproduce new proteoglycan to

replace degradated proteoglycan in the nucleus 3. Nutritional flow of glucose, O2 and sulfates to the

discs is decrease
4. These factors (number 3) change disc metabolism negatively and likely decrease the pH within the disc 5. Decrease in pH gives upper hand to degrading enzymes (protease), which further increases disc degeneration

Disc Ruptures
Divided into :
Contained :
Protrusion
Subannulare extrusions

Noncontained :
Transligamentous extrusion
Sequestered

Changes of the Sacroiliac Joints Sacroiliac Joint syndrome

Pain over SI joint Locally tenderness to palpation Referred to groin, trochanter and buttock by provocation test movement of asymmetry of the SI joint

OA degeneration post traumatic SI joint

Tenderness over lower third SI joint
Tenderness of pubic symphisis on palpation Symptoms reproduced by stressing the SI joint

Accompanying degenerative changes in symphisis pubis

Treatment
Conservative Rest limited activity program, mattress, bedrest Traction pelvic traction Acute LBP therapeutic cold,superficial heat(infrared,whirlpool bath,ultrasound) Chronic LBP ultrasound, transcutaneous electrical nerve stimulation (TENS) Medication morphine, analgesic,AIDS,steroid Occupational change Activity of daily living and faulty posture Low back exercise Low back support and braces

Treatment
Surgery
Interlaminar surgery Microlumbar discectomy Bonegrafts Interbody fusion