1. APPROACH TO LOW BACK PAIN

2. LOW BACK PAIN
IS A SYMPTOM- NOT A DISEASE
 McNab

3. Cause of the pain may be -
Within the spine
Lesion outside the spine

4. Within the spine-
Spondylogenic
Neurogenic
Outside the spine
Viscerogenic
Vascular
psychogenic

5. Spondylogenic
Bony components
Soft tissues of motion segment-disc,lig,muscles
SI joints

6. Congenital- spina bifida, listhesis,
hemivertebra,sacralisation
Traumatic - fractures, lig injuries, LS strain, ruptured disc
Inflammatory-TB, pyogenic, brucellosis, RA, Anks spond
Degenerative- DDD, spondylosis, senile osteoporosis
Neoplastic-primary
 secondary

7. Neurogenic
Tension
Irritation
compression

8. Discogenic pain
Disc herniation
Annular tear
Sinuvertebral nerve
Decrease pH within a deg disc –irritate the nerve root

9. Arise frfom ventral root
and gray rami
communicants near DRG
Innervates PLL,ant
dura,post annulus,blood
vessels
ALL,lat & ant annulus –
sympathetics
SP.VIP,CGRP

10. FACET JOINT PAIN
Innervated by medial branches of dorsal primary rami
Facet capsule-contains encapsulated,non encapsulated & free
nerve endings
Mechanoreceptors-inflamation sensitizes these to movements of
facet jt
Nociceptors-unmyelinated & plexiform fibres sensitizes to
chemical or mechanical stimulus

11. mechanism
Injury to articular cartilage as in OA
DEGEN changes of facet jt-static n dynamic compression of
nerve root-lateral recess stenosis
Blockage of facet by synovial fold

12. radiculopathy
Mechanical deformation-intraneural tissue rreactions
Nerve roots –no effective blood nerve barrier --lack epineurium
Inflammation with mechanical compresion

13. Outside the spine
Abdominal – pancreatitis, cholecystitis , peptic ulcer
Pelvic – ovaries,tubes,intrapelvic tumours
Vascular- aortic aneurysms,PVD
Psychogenic- Wadells signs

14. AIM
TO LOCALISE THE PAIN GENERATOR IN THE SPINE-
facet,disc…
THE NEUROLOGICAL LOCALISATION-
Myelopathy/Radiculopathy(root lesion)
The Aetiological/Pathological localisation –
cong/trauamatic/infective/inflammatory/degenerative/neo
plastic

15. APPROACH
HISTORY
PHYSICAL EXAMINATION
NEUROLOGICAL EXAMINATION
INVESTIGATION

16. HISTORY
PAIN- Commonest symptom
Site of pain
Axial
Radicular involving limbs
combination of both

17. Onset,Duration,Progression
Acute onset – fall,lifting weights, sports injury
Insidious onset with rapid progression-infection, path #,
tumours 1* 2*
Referred pain-pancreatitis,aortic aneurysm,pelvic and rectal
conditions

18. duration of pain
Acute- strains, sprains
Chronic- degenerative conditions
a/c on chronic
Radiation of pain
Nature of pain
Aggravating/relieving factors

19. Nature and intensity of pain
Discogenic- focal,aching in nature,increased with activity causing
axial loading,decreased with rest
Facetal pain-pain on extension of spine
 (Can be of muscle strain)
Degenerative-Pain and stiffness in morning
Inflammatory-prolonged pain with stifness > 1hr
Tumour/infection- Night Pain unrelieved by rest

20. Neurogenic pain-radicular,claudicaton
Radicular
thoracic spine-band like along the rib
Lumbar spine-radiates below knee
L3-4-Anterior thigh
L5- Dorsum of foot, 1 web space
S1-Buttock/posterior thigh

21. Neurogenic claudication
Diffuse pain n numbness
Progressive loss of walking ability/forward stooping walking
Symptoms produced by activities causing extension of spine,
relieved by flexion
To r/o vascular claudication

22. Neuorgenic vs vascular

23. Occupational history-return to heavy physical work may not
be possible
Family n social history- assess pts resources and support for
treatment plan
Other systems assessment-CVS,PULMO,GI ,GU,ENDO

24. Nonorganic physical signs-The Waddell
signs
Tenderness-superficial,nonanatomical
Simulation- axial loading, rotation
Distraction-SLR
Regional-weakness,sensory
Overreaction-disproportionate verbalization,inappropriate
facial expression,tremor,collapsing,sweating

25. INSPECTION
Gait
Antalgic one leg-nerve root irritation,muscle weakness
Sciatica :walk with hip more extended & knee more flexed
High stepping : foot drop -to clear the ground
Spastic:drags the foot

26. Trendelenburgs : L5 - abductor lurch
S1- extensor lurch
 toe walking not possible
L4-heel walking not possible

27. Look from front/back &sides
Level of shoulders
iliac crest-pelvic obliquity-LLD,Spine
Coronal plane-scoliosis
Sagittal plane-Kyphosis/lordosis
Angular kyphus
Knuckle-1 vertebra
Gibbus-2 vertebra
Round kyphus- > 2 vertebra
Overall spinal balance

28. The plumb line

29. Sciatic list
Shoulder disc Axillary disc

30. Any swellings-cold abscess.
Spina bifida-occulta/manifesta
Step sign
Any scars/sinuses

31. Palaption
Temp
Tenderness
direct pressure
Twist
deep thrust

32. Step + in > 50% slip
Paraspinal localised tenderness-facet arthritis, TP #
Cold abscess

33. movements
Flexion
Extension
Rotaton
Side bending
Schober test
Extension catch-
instability,disc pathology
Ext&lat bending-pain n
facet pathology

34. Measurements
Chest expansion-at nipple level
Should be 5 cm,< 2.5cm suggests AS
R/o LLD

35. Neurological examination
MSE
CN
Gait-type
 -Posture
Sciatica-walk with hip extended n knee flexed
 - to reduce tension on Sciatic N
Heel walking-L4
Toe walking - S1

36. motor
Bulk
Tone
Power
Coordination
Abnormal movements
reflexes

38. L2

39. L3

40. L4

41. L5

43. coordination
Heel shin test
Rombergs sign
Involuntary movements

44. sensory

45. Touch-sup
Deep
Pain& temp
Posterior column-joint sense,vibration

46. Reflexes- superficial

47. Plantar reflex

48. Bulbocavernous reflex

49. Deep reflexes

52. Bladder- voluntary control
Retention
Dribbling
frequency
Bowel
Control of sphincters
constipation

53. Nerve root tension signs
SLR LASEGUE/BRAGGARD

54. BOWSTRING TEST
SUDDEN SCIATIC
STRETCH TEST

55. FNST
Well leg raising test-
axillary disc

56. Piriformis syndrome
Entrapment of sciatic nerve by the piriformis as it passes thru the
sciatic notch
Causes:hypertrophy
Trauma
Excessive exercises
Spasm n inflammation
Anomalies of piriformis
Pseudo aneurysm of inf gluteal artery
Traumatic myositis ossifcans

57. Clinical features
History of trauma to SI or gluteal region
Exacerbation of symptoms by lifting leg or
stooping/difficulty in walking
Tenderness over sciatic notch
Sausage shaped mass over piriformis
Felt by rectal exmn-pathognomonic

58. Positive SLR,Lasegue sign
Freiberg sign-pain with forced int rotation of extended thigh
Positive sign of Pace and Nagle-pain with resistance to
abduction n ER the thigh
Tibial nerve is less affected than peroneal

59. Treatment
Physiotherapy
NSAID
Stretching
Ultrasound
Local steroid/anaesthetic
If no relief-surgical release of piriformis muscle

60. TEST FOR SI JT
COMPRESSION TEST DISTRACTION TEST

61. Axial rotation stress test
Pump handle test Gaenslen’s test

62. FABER test

63. Hip joints/other joints
Other systems

65. investigations
Blood
Plain x ray
Ct
Mri
Bonescan
Injection studies
Biopsy

66. Plain Xray
 AP
Alignment of vertebral column
Lesion of pedicles/ TP
Side to side collapse
Paravertebral soft tissue shadows
scoliosis

67. Lateral view
Shape n size of vertebralbody
Anterior n posterior walls integrity
Superior n inferior surfaces of body
Wedging
Disc space
Spinal canal-between post end of body n lamina-space
occupied by cord

68. oblique views-for pars defects
Scannograms-to view the entire spinal column
Ct-demonstrates bony lesions better
Mri- demonstrates soft tissues better
Scrrening of whole spine