Back Pain

Definition
 Back pain can be defined as pain of any
nature felt in any region ranging from the
thoracic spine to the pelvis.
 Generally, back pain is classified as
mechanical or non-mechanical and can be
subdivided by regional involvement
 Aetiolog
 y causes ofback
There are numerous
 pain. Generally, pain can be attributed
1.to:Nerve root compression and
subsequent inflammation
2. Mechanical damage to and inflammation of
spinal components
3. Degenerative and bony changes
4. Others eg. psychogenic and referred.
 It should be noted, in a large proportion
of cases back pain is idiopathic.
 Specific examples
 Muscle spasms and strains (ligaments, muscles,
tendons)
 Intervertebral disc prolapse
 Osteoarthritis
 Osteoporotic compression fractures
 Traumatic injury
 Fibromyalgia
 Ankylosing spondylitis and sacroiliitis.
 Spinal stenosis (narrowing of spinal canal)
 Lateral root stenosis (narrowing of root canal)
 Spondylolysis (deficiency of pars intereticularis of
neural arch)
 Spondylolisthesis (vertebral body slips forward)
 Rheumatic disorders eg. RA and polymyalgia
rheumatica
 Paget’s disease
 Scoliosis – pain from osteoid osteoma of
vertebral pedicle
 Referred pain eg. from chest, abdomen or pelvis
 Pregnancy
 Poor posture
 Lifestyle eg. smoking
 Incidence
 Back pain is one of the
most common health
problems in the US and
 UK.
It is estimated 50 to 80% of
adults have experienced
back pain at some point.
 In the UK, 7% of the adult
population consult their GP
with back pain each year, at
a cost of £500 million and
80 million working days
lost.
 Epidemiology
Age
 Age of onset is spread relatively evenly from 16 years to the
early 40s, gradually declines thereafter and is uncommon after
the mid fifties
Sex
 No difference in incidence between men and
women
 Co-morbidity
Back pain is commonly associated with other conditions eg.
OA
 Occupation
It is generally thought back pain is more common in those
with manual occupations who undertake heavy lifting
Associations
 There is a strong association between smoking and back
pain, possibly due to complex interaction of demographic
variables
Pathology of low back pain
and sciatica
 Study by Kuslich et al. operated on
patients undergoing decompression
operations and stimulated various
tissues around the vertebrae using
mechanical force or electrical
 current.
They found sciatica can only be
produced by direct pressure or
stretch on the inflamed, stretched
or compressed nerve root. This
may occur secondary to disc
 prolapse The outer annulus of the
intervertebral disc is the tissue of
origin in most cases of low back
pain.
 In spite of what has been
previously suggested, muscle,
fascia and bone were found to be
quite insensitive.
 Clinical Features of a Disc Prolapse
 Commonest levels to be affected are between L4/5
or L5/S1
 Muscular spasms can be profound , leading to
a scoliosis and restricted flexion.
 Most patients report sharp, burning, stabbing
pain radiating down the leg to the foot ie.
sciatica.
 Pain is intermittent but made worse by
activity, coughing, sneezing and straining.
 Paraesthesia and motor weakness can also occur –
their distribution may allow the lesion to be
localised
 Specific muscles can be
assessed for power to
determine location of the
lesion eg. quadriceps are
innervated by L2, L3 and L4
nerve roots. Reflexes should
 also be tested.
If straight leg raising on the
unaffected side produces
controlateral pain, this is
highly suggestive of a disc
 prolapse.
A central herniated disc may
compress nerve roots of the
cauda equina resulting in
bladder or bowel
dysfunction (difficult
urination or incontinence).
This should be dealt with as
 Natural
History
 Most acute episodes settle within 4-6
weeks without any treatment.
 It is beneficial to provide symptomatic relief
for the first six weeks of
 symptoms.
Involvement of the bladder, anal canal or any
other severe neurological deficit should be
dealt with as an emergency and treated
immediately.
 Investigations
 Plain radiographs of the
lumbar spine are of
limited use in the
diagnosis of disc
prolapse, but may be used
to exclude other
pathology eg. fracture.
 The gold standard for
herniated disc imaging is
MRI. This allows
visualization of disc
damage and should
always be performed if
surgery is contemplated.
 Differential Diagnosis
 Mechanical back pain:
 Pain is usually restricted to the buttock and posterior thigh
ie. not sciatic distribution.
 Pain is exacerbated during standing and twisting
movements; pain from herniated disc is made worse by
positions that put increased pressure on the annular fibres
eg. sitting.
 Any other condition causing compression of
lumbar nerve root
 Lumbar spinal stenosis
 Spondylolisthesis
 Trauma
 Piriformis syndrome
 Treatmen

t
Conservative: prevention is the best remedy –
lifting and handling methods, bed rest,
physiotherapy and exercise
 Medical: analgesia, steroid or local
anaesthetic injections.
 Surgery is indicated for
 Acute central disc prolapse with balder
involvement
 Progressive neurological weakness despite bed
rest
 Unremitting pain with abnormal neurological signs
despite bed rest for 2-3 weeks
 Marked muscle weakness
 Recurrent episodes of sciatica with only partial relief
 Surger

y
Involves removal of the protruding material
through a laminotomy or partial laminectomy – may
be combined with fusion of affected segment.
 Percutaneous nucleotomy – contained disc is
decompressed by laser or instrumentation passed
into the disc under X-ray control
 Chemonucleolysis – chymopapin is injected into the
disc space to dissolve the disc. High risk of
anaphylaxis.
Laminotomy
 Prognosis
 Most acute episodes settle with bed rest only in
4-6 weeks.
 90% of cases don’t require surgery
 5% of people do go on to experience chronic
severe, incapacitating lower back pain
 After successful laminotomy or laminectomy 80-
85% of patients do extremely well and are able to
return to their job in 6 weeks.
 After one disc prolapse there is a statistically
significant increase in risk of a further prolapse.
 Summar
y
 Back pain is extremely common.
 There are multiple causes – in most cases
no underlying pathology can be
identified.
 Of the large number of patients presenting
with back pain, the main role of the history
and examination is to identify the small
number who have a serious or specific spinal
disorder.