Low Back Pain (Long Case)

Anatomy:

2 Most common cause of Low Back Pain:

● Prolapse Intervertebral Discs
● Spondylosis
Mechanism:
Prolapse Intervertebral Disc – pain due to spinal cord being compressed from anteriorly
Spondylosis – pain due to spinal cord being compressed from posteriorly
What is Spondylosis?
Spondylosis is a form of degenerative disease. Just same like Osteoarthritis is a form of degenerative
disease and result in formation of osteophyte. Just the location this pathology different. Spondylosis
occurs at the facet joint of intervertebral disc while Osteoarthritis occurs in hip joint or knee joint.
Age:
Prolapse Intervertebral Disc Spondylosis

Younger Elderly

History Taking:
Chief Complaint + Analysis of Chief Complaint + Rule out other causes of pain
A. Chief Complaint: Low Back Pain + Duration
B. Analysis of Chief Complaint: Aim is to determine whether pain is due to compression from
anteriorly (Prolapsed Intervertebral Discs) or compression from posteriorly (Spondylosis) +
differentiate neurogenic claudication vs vascular claudication
C. Rule out other Causes of Pain:
5 Causes of Pain
1. Trauma
2. Infection
3. Tumor
4. Degenerative
5. Inflammatory Joint Disease
i. Rheumatoid Arthritis
ii. Ankylosing Spondylitis
iii. Gouty Arthritis
iv. Reiter Syndrome
v. Psoriatic Arthritis

B. Analysis of Chief Complaint

Aggravating factors:
Pain aggravated by bending forward = Prolapsed Intervertebral Discs
Pain aggravated by extension of trunk = Spondylosis
Prolapsed Intervertebral Discs Spondylosis

Pain aggravated by bending forward Pain aggravated by extension of trunk

1. Sitting 1. Go downstairs
- Pain aggravated by prolonged - Pain aggravated by going
sitting. downstairs (because trunk
2. Riding Bicycle extended when going downstairs)
- Pain aggravated by prolonged 2. Sleep Position
riding bicycle. - Sleeping in Supine position will
3. Riding Motorbike aggravate the back pain because
- Pain aggravated by prolonged the trunk will move forward.
riding motorbike. Therefore, patient will sleep in
4. Driving Car prone position to avoid pain.
 - Pain aggravated by prolonged (Ask patient whether sleep in one
driving car. position or not? What position?
5. Go Upstairs Why?)
- Pain aggravated by going upstairs - Is there any pain when changing
(because trunk bend forward when sleeping position?
going upstairs) (If Yes, suggestive of Mechanical
6. Muslim Pain)
- Complaint of cannot bend forward - Aggravated by rest
when performing prayer. Need to
always keep his or her trunk in
extended position due to pain.
7. Sleep Position
- Sleeping in prone position will
aggravated the back pain because
the trunk will bend forward.
Therefore, patient will sleep in
supine position to avoid pain.
(Ask patient whether sleep in one
position or not? What position?
Why?)
- Is there any pain when changing
sleeping position?
(If Yes, suggestive of Mechanical
Pain)

History of Claudication
Triad of Claudication: Pain, Sense of heaviness & Weakness
Differentiate Neurogenic Claudication vs Vascular Claudication:
Neurogenic Claudication: pain from proximal to distal following the course of sciatic nerve
Vascular Claudication: pain from distal to proximal
C. Rule out other causes of Pain
1. Trauma
● Direct Injury from Motor Vehicle Accident
● Fall from height in sitting position
2. Infection
● Bacterial Infection
1. Fever
2. Recurrent admission for Lung Infection
3. Recurrent admission for antibiotic treatment
4. Pus/ Sinus Discharge from back (vertebra osteomyelitis)
● TB Infection
1. Night Fever
2. Night Sweat
3. LOA/ LOW
4. Hx of TB contact
3. Tumor
● Severe pain required Opioid Analgesic to resolve the pain.
(Oral medication unable to resolve the tumour pain)
● Nocturnal Pain (disturb patient at sleep)
4. Degenerative
● Pain in the early morning.
5. Inflammatory Joint Disease
● Rheumatoid Arthritis
- Morning stiffness for small joints > 1 hour > 2 weeks, symmetrical
- Rheumatoid nodule at PIP joints, MTP joints and Elbow
- Rheumatoid arthritis hand (late stage): Boutonniere deformity of thumb, Ulnar deviation
of metacarpophalangeal joints, Swan-neck deformity of fingers.
(refer EULAR-ACR criteria)
● Ankylosing Spondylitis
 - Pain aggravated by rest and relieve by exercise
- Shortness of Breath (due to Lung Fibrosis)
● Gouty Arthritis
- Hx of recent treatment for Gout
- Pain at 1st metatarsal phalangeal joint
● Reiter Syndrome
- Joint Arthritis
- Conjunctivitis (eye redness)
- Urethritis (painful micturiction)
● Psoriatic Arthritis
- Hx of Scaly Skin Lesion

Physical Examination:
● Inspection
● Palpation
● Movement
● Special Tests

Before start examination:

1. Exposure
- Low Back Pain case: expose entire body except for the private part.
- Scoliosis case: expose everything including the private part because need to do tanner
staging.
2. Gait – no antalgic gait, only abnormal posture
● Prolapse Intervertebral Disc patient:
- Extending their back: cause cannot bend forward
- Tilting to one side while walking : cause of listing: if pain on left and tilting to left
then prolapse is at axilla, if pain is at left and tilting is to the right then prolapse is at
the shoulder.

● Spondylosis patient:
- Bending forward
● Disc prolapsed type:
A. Shoulder type (pain aggravate by moving toward the side of disc prolapse, so
patient will move away from the side of disc prolapse to avoid pain)
B. Axilla type (pain aggravate by moving away from the side of disc prolapse, so
patient will move toward the same side of disc prolapse to avoid pain)

●
 3. Squat & Stand up from squat
- To identify the power of lower limb
- If patient can squat and stand up from squat (patient having power grading at least 3)
4. Heel walking & Tip Toe walking
- To rule out Cervical Spondylosis myelopathy (CSM) from PID and Spondylosis)
- If patient cannot perform heel walking and tip toe walking, suggestive of CSM.

Inspection:
General Inspection:
- as usual
Specific Inspection: (Inspection of back)
Position: Spine case ask patient to sit
5 things to comment:
1. Sinus discharge (TB spine)
2. Tuff of hair (Spina bifida)
3. Deformity (Scoliosis)
4. Swelling (Gibbus – TB spine)
5. Cafe au lait spots (Neurofibromatosis)

In case of scoliosis, as patient to sit to see whether scoliosis disappear.

- If still there, TRUE Scoliosis
- If disappear, POSTURAL Scoliosis

Palpation:
Position: Sitting + Standing
a. Superficial Palpation:
● Temperature: only 6 regions. (4-9)
(use dorsum of hand, use one hand not both hands to compare the temperature)
- Spine got 3 regions (Thoracic, Thoracolumbar & Lumbar)
- Paravertebral muscle got 6 regions (Thoracic x2, Thoracolumbar x2, Lumbar x2)

1
4 5

6 2 7

8 3 9
 ● Soft Tissue: look for tenderness, muscle spasm
- Use palm and fingers to palpate
- only palpate for 6 regions because spine is not soft tissue

1 2

3 4

5 6

b. Deep Palpation:
Position: Standing or sitting: stand behind the patient.
- Use 2 thumbs to palpate against the spinous process,
starting from C7 and palpate until low back region.
- Elicit the level of tenderness

How to determine which level is the tenderness or how to know PID at which level?
- Iliac Crest is landmark (L4, L5)
- Lower than iliac crest: L5, S1
- Above than iliac crest: L3, L4
 In case of PID, aim of deep palpation is to determine which level of Disc prolapse.
In case of Scoliosis, aim of deep palpation is to determine curve at what level and which site
(left or right)

Movement:
Position: Standing
PID: trunk cannot bend forward
Spondylosis: trunk cannot extend & lateral flexion

Special Test for Low Back Pain (Spine):

Position: Supine
TPRS + Tension Signs
TPRS Tension Signs

T – Tone 1. Straight Leg Raising Test

2. Lasegue’s Test
P – Power
3. Bowstring Test
R – Reflex

S – Sensation

1. Tone (cannot be hypertonia because of LMNL)

a. Lifting method
- lift the leg at the knee and drop the knee. (fast and same position)
If hypertonia, leg will fall at the same side at very slow speed.
If hypotonia, leg will fall at different side/ side way, fall fast
If normotonia, leg will fall in between.
b. Log roll method: in slow phase, the big toe can follow the direction, in fast phase the
big toe cannot follow (normal), in hypotonia both phase cannot follow, in hypertonia,
both phase can follow.
- one hand stabilize thigh, one hand rolls the leg.
In hypertonia, big toe always followed.
 In hypotonia, big toe does not follow the movement at all.
In normotonia, big toe moves in between.

Low Back Pain is hypotonia or hypertonia?

Spinal cord end at lower border of L1
Lesion below L1 = Hypotonia (Lower motor neuron lesion, only spinal nerve root involved)
Lesion above L1 = Hypertonia (Upper motor neuron lesion, spinal cord is involved)

In case of PID at L4, L5 which is lesion below L1 = Hypotonia

In case of Cervical Spondylomyelopathy (CSM) which is lesion above L1 = Hypertonia

2. Power
Determine motor power
(since patient able to squat, stand up and walk, patient power at least grade 4 and 5)

Nerve Root for Lower Limb movement:

Hip Flexion: L2, L3
Knee Flexion: L3, L4
Ankle Dorsiflexion: L4, L5
Big toe Dorsiflexion: L5, S1

3. Reflex
- Ask patient to relax muscle, before performing reflex
- Technique important
Knee Jerk (hyporeflexia)
Ankle Jerk (hyporeflexia)
Clonus (negative)
Positive finding = jerking > 3 times
- Knee Clonus (sudden push down patella):
- Ankle Clonus (sudden push the ankle): flex knee 30 deg, sudden dorsiflex, min
movement of 3 is considered positive
Babinski (negative)- from lateral side to ball of toe: will be negative cause of LMNL
Positive = up going = CSM
Negative = down going = PID, Spondylosis

4. Sensation
 Thigh: L1, L2, L3
Leg: L4, L5
Sole: S1
Calf & hamstring: S2
Buttock: S3

5. Tension Sign
● PID = Positive
● Spondylosis = Negative
a. Straight Leg Raising Test
- Positive when extended Leg is raised to 20° – 70°
- Pain radiating from back to calf
(pain must be radiate below knee only can consider positive): At the level of calf
b. Lasegue’s Test
- After performing the SLR, bring down the angle to 60° to relieve the pain
- Then, dorsiflex ankle, if pain still there = positive
c. Bowstring Test
- Position the tibial or leg parallel to the table
- Use thumb to press on Popliteal Fossa
- If pain at calf = positive:
- If no pain = negative
Investigations:
● Inflammatory Marker: ESR, CRP
● X-Ray:
- Lumbosacral X-ray (AP & Lateral view): LATERAL MORE IMP
- Differentiate PID and spondylosis?
Prolapsed Intervertebral Discs Spondylosis

1. Loss of Lumbar Lordosis 1. Osteophyte

2. Reduce Intervertebral Disc Space 2. Sign of reduce joint space

(However, X-ray difficult to pick up, need

MRI scan)

3. Subchondral sclerosis (whitish

discoloration of vertebra)

● MRI scan (wont be asked much) : GOLD standard for LS and PID.

Treatment:
Non-Operative:
1. Medication
a. Pain Killer (YES)
b. Nerve Tonic (YES)
- Neurobion, Methycobalamine & Gabapentin
c. Antibiotic (NO)
d. Muscle Relaxant (YES)
- Myonal: 50mg 3 times a day (trade name) or Eperisone hydrochloride (generic name)
2. Physiotherapy
a. Short wave diathermy
b. Heat therapy
c. TENS (Trans-Electrical Nerve Stimulation)
d. Ultrasound Wave
e. Intermittent Pelvic Traction
- Relieve pain
3. Immobilization
- Lumbar Corset or Lumbar Brace
 4. Injection
- Steroid injection in facet joint
Operative:
● Prolapsed Intervertebral Disc: Discectomy
● Spondylosis: Posterior Instrumentation + fusion of facet joint: stop the facet joint from
moving.

FOR PID AND LS WILL ALWAYS BE LMNL