Low Back Pain: Diagnosis to Treatment!

Objectives
• General Knowledge (facts, stats, etiology,
definition)
• Examination and Diagnostic Modality
Options with the Low Back Pain Patient
• Treatment Options

Low Back Pain Defined
• Pain felt in your lower back may come from the spine, muscles,
nerves, or other structures in that region. It may also radiate from other
areas like the mid or upper back, a inguinal hernia, or a problem in the
testicles or ovaries.
• A variety of symptoms may exist in the presence of back pain. There
may be a tingling or burning sensation, a dull aching, or sharp pain.
Weakness in the legs or feet may also exist.
• There won't necessarily be one event that actually causes low back
pain. The patient may have engaged in common activities of daily
living improperly -- like standing, sitting, or lifting -- for a long time.
Then suddenly, one simple movement, like reaching for something in
the shower or bending from your waist, leads to the feeling of pain.

Numbers
• Low back pain affects 60-80% of U.S. adults at some time
during their lives, and up to 50% have back pain within a
given year
• Back symptoms are among the 10 leading reasons for
patient visits to emergency rooms, hospital outpatient
departments, and physicians' offices
• Back pain is the most frequent cause of activity limitation
in people younger than 45 years old
• Fifteen million American adults currently suffer lower
back pain

Co$t
• Low-back pain (LBP) is the most common condition
leading to workers' compensation claims associated with
time loss (i.e., injuries sufficiently severe to lead a worker
to miss days from work
• Americans spend at least $90 billion each year on back
pain
• Each year, Americans lose 93 million days of work, at a
cost of $11 billion, due to low back injuries. They spend
another $5 to $24 billion in direct medical expenses

Adding Up The Numbers
A billion dollars is more than
10,000 dollars a day for 300 years!
Perspective…..
Now Multiply That By
90!

Etiology
(Shedding light on the subject)
• Non - Spinal Causes
of Low Back Pain
• Spine Related Causes
of Back Pain

Non-Spinal Related Causes
Bladder Infection Kidney Disease
Ovarian Cancer Ovarian Cyst
Testicular Torsion Fibromyalgia
Pelvic Infections Appendicitis
Pancreatitis Prostate Disease
Gall Bladder Disease
Abdominal Aortic Aneurysm

Spine Related Causes
Arthritis
Fibromyalgia
Kyphosis
Lordosis
Rheumatoid Arthritis
Ankylosing Spondylitis
Arachnoiditis
Bone Cancer
Chiari Malformation
Compression Fractures
Discitis
Epidural Abscess
Facet Joint Syndrome
Fixed Sagittal Imbalance
Osteomyelitis
Osteophytes
Pinched Nerve
Ruptured Disc
Spina Bifida
Spinal Cord Injury
Spinal Tumor
Spondylolisthesis
Spinal Stenosis
Spinal Cord Injury
Spinal Tumor
Sprain or Strain
Synovial Cysts
Wedge Fractures

Low Back Pain….The Patient
History
Physical Exam
Diagnostic Studies

History
Location
Specific Point vs. Across Back
Superficial vs. Deep
Involve Any other region (lower extremity)

History
Quality
Dull Ache (tooth ache)
Sharp/Stabbing
Burning
Tearing/Pop

History
Quality/Severity
Intermittent
Constant
Pain Scale 1-10

History
Setting
Time of day when worst/better
After strenuous activity

History
Aggravating/Relieving Factors
What Makes Better What Makes Worse
BEWARE OF THE PATIENT THAT SAYS NOTHING MAKES PAIN BETTER!

History
Associated Manifestations
Numbness
Tingling(pins/needles)
Burning
WeaknessIncontinence
Falls

Physical Exam
General Survey
Muscle Bulk/Wasting
Posture
Alignment
Gait*
Patient Should always be examined in an examination gown

Physical Exam
Motor Assessment
• Motor Strength - assess to breaking
• Tone
• Bulk Measurements
• Rapid Alternating Movements
• Point-to-Point Discrimination

Physical Exam
Testing Muscle Strength
•0 - No muscular contraction detected
•1 - Barley detectable trace or flicker of contraction
•2 - Active movement of body part with gravity eliminated
•3 - Active movement against gravity
•4 - Active movement against gravity with some resistance
•5 - Active movement against full resistance without evidence
of fatigue

Physical Exam
Motor Strength Feedback
Muscle Nerve of
Innervation
Muscle Nerves of
Innervation
Iliopsoas L2 – L4 Hip
Adductors
L2 - L4
Hip
Abductors
L4 - S1 Gluteus
Max.
S1
Quads L2 – L4 Hamstrings L4 – S1
Dorsiflexors L4 – L5 Plantar
Flexiors
S1

Physical Exam
Sensory
Pain
Light Touch
Position Sense
Vibration
Temperature Spinothalamic Tract
Posterior Column

Physical Exam
Reflexes
•Patellar - mediated by L2, L3, L4
•Achilles - mediated by S1
•Babinski - ⇑ toes = upper motor neuron
dysfunction
•Clonus - rhythmic oscillation between dorsi
& plantar flexion indicates central nervous
system disease

Physical Exam
Reflexes
• Usually graded on a 0 to 4+ scale
• 4+ Very Brisk, Hyperactive with clonus
• 3+ Brisker than average, possibly, but not
indicative of disease
• 2+ Average; Normal
• 1+ Somewhat diminished; low normal
• 0 No Response
• ** There is no minus in this score system

Diagnostic Studies
• Plain X-Ray
• MRI
• CAT Scan
• Myelogram
• Discogram
• Bone Scan
• Facet Block
• SI Joint Block
• EMG
• SSEP
• DEXAscan
• Bone Scan

Diagnostic Studies
X-Ray
• taken to assess the structure of the spine and to
determine the alignment of the vertebra

Diagnostic Studies
MRI
• Extremely Sensitive for
assessment of Soft tissue
structures (nerves, disc)
• One of the most commonly
ordered test to assess low back
pain
• $$$$$$$$$$$$$

Diagnostic Studies
CAT Scan
• Most often used to assess
bone structures of spine.
• Faster and cheaper than
MRI
• Can be very effective tool
when using reconstruction
images or combined with
other modalities

Diagnostic Studies
Myelogram & Post CT
• myelogram consists of a
series of plain xrays
with a contrast agent
injected into the thecal
sac.
• The C.A.T. scan that
usually follows the
myelogram depicts this
same anatomy from a
C.A.T. scan perspective

Diagnostic Studies
Myelogram & Post CT
The injection of iodine based contrast into the thecal
sac containing the nerves and/or spinal cord, promotes
better definition of those structures than the images
obtained on the regular C.A.T. scan. Cross-sections and
reconstructions of the images in different planes
(including 3-D) allows different perspectives on the
anatomy. This test is often used to visualize the spinal
cord and nerves in relation to the surrounding spine
structures (bone, joint, disc, etc)

Diagnostic Studies
Discogram
• Involves the injection
of contrast material
into the disc space
• Concordant vs.
Discordant Pain…..??
• Helpful in assessing
discogenic pain
• VERY
“uncomfortable” test

Conditions
• Strains & Sprains
• Stenosis
• Disc Herniation
• Spondylolisthesis
Signs & Symptoms
Diagnostic Findings
Treatment Options}

Strains & Sprains
• Muscle strains and lumbar sprains are the most
common causes of low back pain
• May refer to both injuries as a category called
"musculoligamentous injuries“ (it doesn't matter
what you call the problem because the treatment
and prognosis for both back strains and sprains is
the same)

Strains & Sprains
Signs & SX
• Pain isolated to low back, which may increase with flexion
or extension of the lumbar spine
• generally relieved with sitting, but symptoms are
exacerbated with activities such as prolonged standing or
bending
• Pain described as deep, dull, sharp at times
• P.E. usually shows normal motor and sensory function
although pt. may appear weak 2° to pain
• P. E. may reveal point tenderness and evidence of spasm

Strains & Sprains
Diagnostic Findings
• No tests are typically necessary during the
first 4 weeks of symptoms if the injury is
non-traumatic
• If, however one is ordered, evidence of
edema on MRI will be seen in severe
musculoligamentous injury, as well as
straightening (flattening) of the lordotic
curve is presence of spasm

Strains & Sprains
Treatment
• Initial treatment involves rest from aggravating activities, medication
for pain control, and modalities to decrease pain and inflammation.
• The use of cold packs to decrease edema during the first 48 hours
after sprain/strain and the application of moist heat or cold thereafter
to reduce pain and muscle spasm can be helpful.
• Bed rest for up to 48 hours may be beneficial but prolonged bed rest is
discouraged. (Extremely Controversial) Relative rest by avoiding
activities that exacerbate pain is preferable to complete bed rest.
• Temporary use of a lumbosacral support when out of bed may reduce
pain and muscle spasm and increase activity tolerance.
• A short course of NSAIDs, acetaminophen, or muscle relaxants may
be beneficial. Narcotics are generally not necessary but may be used in
the very acute stage

Lumbar Spinal Stenosis
• The disorder can be congenital or acquired
• Acquired lumbar stenosis usually is caused by
degenerative disease of the spine and is typically
associated with hyperplasia, fibrosis, and cartilaginous
changes in the annulus, posterior longitudinal ligament,
and ligamentum flavum
• Also can be caused by Spondylolisthesis, spondylolysis, a
defect in the pars interarticularis, may be related to injury,
bony overgrowth such as occurs in Paget's disease,
ankylosing spondylitis, rheumatoid arthritis, and diffuse
idiopathic skeletal hyperostosis

Signs & SX
•Patients present with pain that is
brought on by activity and released by
rest or leaning forward
•The pain involves the lower back
and one or both legs, typically in a
radicular distribution, and may be
accompanied by numbness or
weakness
•Examination often reveals no
abnormality, except perhaps for a
depressed knee or ankle reflex. SLR
is usually negative

Diagnostic Findings

Diagnostic Findings
• MRI is the most
sensitive technique for
detecting the disorder
• Stenosis may be
multifactorial…..
Which will impact
upon treatment options

Treatment
• Conservative Management
– Non-steroidal anti-inflammatory drugs, such as aspirin, naproxen
(Naprosyn), ibuprofen (Motrin, Nuprin, Advil), to reduce
inflammation and relieve pain. New generation Cox-2 inhibitors
have shown remarkable results in many cases
– Corticosteroid injections into the outermost of the membranes
covering the spinal cord and nerve roots to reduce inflammation
and treat acute pain that radiates to the hips or down a leg.
– Physical therapy and/or prescribed exercises to maintain motion
of the spine and build endurance to help stabilize the spine
– lumbar brace or corset to provide some support and help the
patient regain mobility

Treatment
• Surgery
– most common surgical solution to spinal
stenosis is a laminectomy
– Other procedures include Laminotomy,
Decompressive Laminectomy, Foraminotomy,
Medial Facetectomy, Lumbar Discectomy and
Fusion

Treatment

Disc Herniation
• In the lumbar spine, at least 90% of disc
herniations occur at the L5–S1 or L4–5 levels.
L3–4 herniations make up only 5% of cases, with
the remainder occurring at L2–3 and L1–2
• Clinically, a herniated disc at one level usually
affects the nerve root that exits at the level below.
For instance, a left L4–5 disc herniation usually
compresses the left L5 nerve root

Disc Herniation
Signs & SX
• Initial complaints are backache, and in most of those
affected, there is no history of antecedent trauma
• Prior similar complaints of back pain or sciatica are
common complaints
• The patient 's back pain is usually followed by severe pain
that radiates into the lower extremities
• Numbness or paresthesias may occur in the same
distribution as the pain, and weakness of selected muscle
groups can occur

Clinical Findings of Common
Lumbar Disc Herniations
Disc Nerve
Root
Pain Sensory
Change
Motor
Deficits
Reflex
Loss
L3–4 L4 Anterior thigh,
anterior leg, and
medial ankle
Anterior leg Quad Knee
jerk
L4–5 L5 Posterior hip and
posterolateral thigh
and leg
Medial
dorsum of
foot and
occasionally
medial ankle
Foot and
toe
extension
None
L5–
S1
S1 Hip, buttock, and
posterior thigh and leg
Lateral foot
and ankle
Plantar
flexion
Ankle
jerk

Disc Herniation
Signs & SX
• Physical Exam
– Paraspinal muscle spasm is frequently present
– Radicular pain on flexion of the straight leg at the hip
present
– Complete motor, sensory, and reflex testing should be
performed, however variability should be expected due
to subtle neuroanatomic differences in patients or to
specific characteristics of the actual disc herniation
– Motor, Sensory, and reflex findings may be present
individually or in combination

Disc Herniation
Diagnostic Findings

Disc Herniation
Treatment – Non Surgical
• The mainstay of therapy for herniated lumbar disc is conservative
treatment due to the majority of patients the symptoms resolving or
subsiding to a level allowing normal activity within 4-6 weeks.
• Analgesics or muscle relaxants often help to relieve pain.
• The most commonly prescribed drug therapy involves NSAIDS
reducing inflammation that may be the causative factor underlying
nerve root pain.
• Physical Therapy has also become a mainstay in treating patients with
HNP in order to strengthen the core support musculature
• Patients must be advised that continued home exercise is a must in
order to prevent recurrent pain
• The vast majority of patients are treated with nonoperative techniques.

Disc Herniation
Treatment – Surgical
• Indications for surgery include radicular pain that does not improve with
conservative measures, recurrent episodes of incapacitating pain, disc
herniations associated with significant weakness in the appropriate muscle
groups, or massive midline herniations with signs of cauda equina
compression
• EVIDENCE OF FOOT DROP OR INCONTINENCE IS A
NEUROSURGICAL EMERGENCY. Pressure must be taken off the nerve
root within 24hrs, or damage may become permanent

Disc Herniation
Treatment – Surgical
The standard treatment of these disorders uses a midline
incision over the affected interspace followed by a
hemilaminectomy to expose the dural sac and nerve root.
Gentle medial retraction of these structures exposes the
herniated disc fragments, which are removed along with
any loose disc material identified within the disc space.
The nerve root is then explored thoroughly along its course
to ensure that it is adequately decompressed. In cases of
large disc herniations or in those cases with a free,
extruded disc fragment, a complete laminectomy at the
appropriate level may be necessary (microdiscectomy)

Spondylolisthesis
• Spondylolisthesis is the anterior
displacement of one vertebral
body over another
• The severity of the slippage in
spondylolisthesis is classified
according to the migration of
the cephalad vertebrae over the
caudad. Grade I represents 0%
to 25% slippage; grade II, 25%
to 50% slippage; grade III, 50%
to 75% slippage; and grade IV,
75% to 100% slippage

Spondylolisthesis
Signs & SX
• The patient usually complains of gradual onset of
low back pain.
• Pain is characterized as deep and aching and is
localized to the affected levels.
• Patients may also complain of pain in the buttock
or iliac crest.
• Movement makes the pain worse, as do Valsalva
maneuvers
• Radicular type symptoms exist most often due to
nerve root irritation

Spondylolisthesis
Diagnostic Findings
• Most all diagnostic
imaging modalities
can pick up a Spondy,
however dynamic
studies are the most
telling

Spondylolisthesis
Treatment Non-Surgical
• If the spondylolisthesis is non-progressive,
no treatment except observation is required.
Symptoms often abate once precipitating
activities cease. Conservative treatment
includes, restriction of activities causing
stress to the lumbar spine (e.g. heavy lifting,
stooping), physical therapy, anti-
inflammatory and pain reducing
medications, and/or a corset or brace.

Spondylolisthesis
Treatment Surgery

Low Back Pain: Diagnosis to Treatment!

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