619 GLA 8/27 Back Pain

Clinical Definition of Low Back Pain

pain, muscle tension, or stiffness localized below the costal margin (ribs) and above the inferior gluteal folds

can be localized or diffuse

may be accompanied with radiation into the legs (must go past gluteal folds, indicates sciatica)

Sciatica

pain or discomfort associated with the sciatic nerve, localized at one or more lumbosacral nerve roots (L4-S2)

sciatica is not a diagnosis, it is a nerve pain symptom that indicates an underlying condition

Risk Factors Assocaited with Low Back Pain Complaints

smoking, obesity, chronic diseases, sleep disturbances, increased age, female, physically strenuous work, low educational attainment

workers comp insurance being involved in the patient’s low back pain case, job dissatisfaction, psychological factors such as somatization disorder/anxiety/depression

Ways to Characterize Back Pain

how long it has been happening

etiology

Time as a Way to Characterize Low Back Pain

acute low back pain lasts less than 6 weeks

subacute lasts between 6 and 12 weeks

chronic persists more than 12 weeks (3 months)

Prognosis of Acute Low Back Pain is Favorable

most pain decreases rapidly within one month, and slowly decreases for three months until it is gone REGARLESS of what treatment modality is applied (supporting osteopathic principle of self-healing)

once it reaches chronic it remains almost constant

Chronic Low Back Pain

10% of back pain patients will go on to have chronic low back pain

can be recurrent within 6 months

Etiology

character of back pain, the study of cases, origins, or reasons behind pain

commonly stems from muscle or ligament strains caused by heavy lifting, sudden movements, or poor posture

Difficulty in Diagnosis of Back Pain

since the spine is so complicated, the pathophysiology is complex and multifacetes

trying to pinpoint the specific anatomical structure that is causing pain is difficult

3 Non-Mechanical Causes of Low Back Pain

neoplasia

infection

inflammatory arthritis

visceral (viscerosomatic)

Neoplasia

non-mechanical cause of low back pain, uncontrolled abnormal growth of cells or tissues on the body, can be benign with normal growth or malignant with aggressive growth/invasion/metastasization

multiple myeloma, spinal tumors, metastatic lesions

Inflammatory Arthritis

non-mechanical cause of low back pain, includes rheumatoid arthritis, psoriatic arthritis, inflammatory bowel disease, adult-onset still’s disease, scleroderma, juvenile idiopathis arthritis, and systemic lupus erythematosusidiopathic

ankylosing spondylitis, sporatic spondylitis, reiter syndrome

Visceral (Viscerosomatic)

non-mechanical cause of low back pain, aortic aneurysm, prostatitis, endometriosis, pelvic inflammatory disease, pancreatitis, cholecystitis

Most Common Cause for Disability in the US

arthritic conditions

Red Flags of Low Back Pain (Things you Don’t Want to Miss)

possible fracture

possible tumor

possible infection

possible cauda equina syndrome

Possible Fracture

red flag of low back pain, unless the vertebrae are weak from disease it takes a high energy trauma to fracture your spine

pain is usually axial, non-radiating, severe and disabling

pain begins immediately following the trauma

High Energy Trauma

a type of injry caused by a force that transfers a large amount of kinetic energy to the body, resulting in extensive damage to the tissues

often have multiple injuries, and are at risk for spinal cord injuries

Types of High Energy Trauma

car accident (+45 mph), motorcycle accidents, fall from height greater than 10 ft, hard fall at high speed, gunshots, physical assault

Possible Tumor

red flag of low back pain, if patient currently has or has had a history of cancer, then you need to be suspicious that back pain could be from a tumor

Common “Red Flags” of Possible Tumor

unexplained weight loss, fevers associated with back pain, extreme night time pain, age older than 50, failure to improve after 6 weeks

Possible Infection

red flag of low back pain, suspected if the patients back pain is also associated with fever or chills or if the patient has a rash in the location of their back
ex: osteomyelitis, septic discitis, abscesses, shingles

2 Risk Factors for Possible Spinal Infection

history of IV drug use

patient is immunosupressed

Possible Cauda Equina Syndrome

red flag of low back pain, results from any lesion tha compresses the cauda equina nerve roots

Symtoms of Cauda Equina Syndrome

saddle sensory anesthesia (can’t feel around where a saddle is)

bladder and bowel dysfunction (erectile dysfunction in men)

lower back pain

unilateral or more typically bilateral sciatica

variable lower extremity motor and sensory loss in the legs

What two symptoms distingush cauda equina from radiculopathy?

saddle sensory anesthesia and bladder/bowel dysfunction (+ erectile dysfunction in men)

Cauda Equina Syndrom is a Surgical Emergency

early neurological neurologic,or orthopedic consultation are recommended

damage may be irreversible

bowel, bladder, and sexual functions are the least likely to return fully and take the longest time to show any sign of recovery

Initial Assessment o Patients with Acute Low Back Pain

detection or red-flags through a problem-focused history and physical exam

any patient with low back pain should have an initial focused neurological exam performed to make the most specific diagnosis

musculoskeletal exam and osteopathic structural exam to look for somatic dysfunction

Neurological Examination of Lower Extremities (should be done even in the absence of sciatica)

deep tendon reflexes of the lower extremity

motor strength testing of the lower extremity by nerve root

sensation testing of the lower extremity by dermatome

straight leg raising test (tests for radiculopathy)

Imaging in the First 4 Weeks of Low Back Symptoms

usually not helpful in the absence of red flags, waiting 4 weeks allows most patients to recover spontaneously and avoid unnecessary cost/radiation/procedures

one acception is progressive neurological deficits or worsening symptoms

2 Overall Categories of Low Back Pain

those without radiation into the legs

those that cause radiation into the legs

Types of Low Back Pain Without Radiation Into the Legs

lumbar strain (psosas syndrome)

lumbar strain (iliolumbar ligament syndrome)

facet arthritis

spondylosis

Types of Low Back Pain that Cause Radiation Into the Legs

lumbosacral radiculopathy

cauda equina syndrome

lumbar spinal stenosis

piriformis syndrome

trigger point in the gluteus minimus

Lumbar Strains

one of the most common causes of low back pain, muscle strains and tears from violent muscular contraction during an excessively forceful muscle stretch

can also be due to overuse (fatigue induced muscle disorder, delayed onset muscle soreness)

present as non-radiating low back pain

Strains

tears, either partial or complete, of the muscle-tendon unit

Key to Lumbar Strain Diagnosis

mechanism of injury

Muscles in Lumbar Strain

can be any posterior spinal muscle, but the ones that span several joints are most common

Muscle-Tendon Unit

tendon injuries are considered strains, but if the tendon completely ruptures then tendon rupture is the prefered term (not common in spine)

Lumbar Strain History

trauma history may be very elusive (patient doesn’t remember staring point), any abnormalities that alter our posture can cause muscle stress

onset is immediate or delayed by 24 hrs, pain is localized to lumbar or lumbosacral areas

pain is increased with activity and relieved by rest, any muscle contraction causes recreation of pain

Lumbar Strain Physcial Exam

palpation of muscle spasm or muscle hypertonicity indicates that those muscles are involved

remember to evaluate the hamstrings (they can cause overstretching of erector spinae muscles and slowly recover over time)

3 Degrees of Muscle Strains

1st degree (microscopic muscle tears)

2nd degree (macroscopic muscle fiber tears)

3rd degree (complete disruption with joint instability)

What degree of strain is more uncommon with low back pain?

3rd degree

Psoas Syndrome Image

Psoas and Iliacus Muscles

Psoas Major Muscle

responsible for psoas syndrome, can flex the thigh or help flex the spine, so deep that you can only see it at the back of the abdominal wall

Psoas Syndrome

type of muscle strain that causes low back pain, caused by contraction of psoas major on one side, pelvis is usually shifted to opposite side of psoas spasm to help maintain balance (lumbar sidebending)

Presentation of Psoas Syndrome

abrupt low back pain

complaint of new, sudden onset scoliosis

inability strand up straight due to shortened psoas major

Key Somatic Dysfunction of Psoas Syndrome

L1 or L2 Type 2

Psoas Syndrome to Sciatica

can induce piriformis syndrome on the opposite side of the spasmed psoas

Sprains

ligamentous injuries caused by sudden violent contraction, sudden torsion, severe direct blows, or a foreceful straigntening from a crouched position

What ligaments are prone to injury?

most can sustain sprains, but the posterior ligaments are most prone to injury

Sprain vs Strain

can occur together, but sprain usually occurs immediately after injury, pain typically worsens with movement and improves with rest, plapating anatomy can help differentiate

sprain: intermittent pain

strain: constant ache

Iliolumbar Ligament Syndrome

easily identifiable sprain, occurs when the iliolumbar ligament is strained or stressed, pain in multifidus triangle

Iliolumbar Ligament Syndrome Pain Pattern

pain in multifidus triangle that often radiates around the iliac crest and possibly into the groin on the ipsilateral side

minica inguinal hernia, often mistaken as hip joint issue

Iliolumbar Ligament

Mutifidus Triangle

area extending from L4 lateral to both iliac crests an then down to the lower third of the sacrum

2 Causes of Lower Back Pain from Degenerative Changes from the Discs and Joint of the SPine

intervertebral discs

facets

Facet Causes of Low Back Pain

facet arthritis

spondylosis

spondylolisthesis

spondylolysis

Facet Arthritis

facet cause of low back pain, the presence of nonreceptive fibers in the various tissue structures of facet joints, as well as the existence of autonomic nerves there

hard to diagnose without invasive techniques

Spondylosis

facet cause of low back pain, a degenerative process affecting the vertebral disc and facet joints, gradually develops with age

Spondylolisthesis

facet cause of low back pain, a forward translation of a vertebral body with respect to the vertebral below

Spondylolysis

facet cause of low back pain, a unilateral or bilateral defect of the pars interarticularis that affects one or more of the vertebrae, can lead to spondylolisthesis

Spondylylosis Involving L5

Predispositions of Spinal Injury or Low Back Pain

preexisting structural deformities such as scoliosis, spondylolysis, or spinal fusions

Degenerative Changes as a Natural Part of Aging

also consequence of poor nutrition, smoking, atherosclerosis, job related activities, genetics

discs begin to degenerate in 20s

usually gradual onset of stiffness with or without pain

THIS is why x-ray is not useful

Degenerative Changes Key Elements

discogenic pain and facet pain without nerve root involvement typically is vague, diffuse, and distributed axially

activities that increase intradiscal pressure (lifting, valsalva maneuver) intensify symptoms

vibrational stress from driving also exacerbates discogenic pain

disc herniation may coexist

Lumbosacral Radiculopathy

back pain with radiation down the leg, results from nerve root impingement or inflammation that has progresses enough to cause neurologic symptoms in the ears that are supplied by the affected nerve roots

Radiculopathy

some causes of acute and chronic low back pain are associated with radiculopathy, but radiculopathy is not a cause of low back pain

Lumbosacral Radiopathy vs Radiculopathy

lumbosacral: pain, numbness, tingling, or weakness along the course of the nerve

radiculo: problem occurs at or near the root of the nerve as it is exiting the neural foramen

Herniated Lumbar Disc Image

Lumbosacral Radiopathy Symptoms

onset is sudden with low back pain (back pain can get better when leg pain appears)

coughing, sneezing, and sitting can make it worse and radiate down the posterior or posterolateral leg to the foot

Most Common Causes of Lumbosacral Radiopathy

most common location for disc herniation is L4, L5, and S1

4 Causes of Nerve Root Impingement (Lumbosacral Radiopathy)

herniated disc

spinal stenosis

tumor

hematoma

Diagnosis L4 Nerve Root Impingement

Diagnosis of L5 Nerve Root Impingement

Diagnosis of Si Nerve Root Impingement

Combining History and Physical Exam to Diagnose Radiculopathy

abrupt onset of low back pain with radiation into one or both legs

coughing or sneezing makes it worse

no change in bladder or bowel habits

radiation of pain follows a dermatome

positive straight leg test (possible decreased sensation along affected dermatome, decreased deep tendon reflexes, weakness in the appropriate muscles)

Lumbar Spinal Stenosis

spinal canal narrowing with possible subsequent neural compression, narrowing can occur in the central canal or lateral recess (intervertebra foramen), can cause radiculopathy, radicular leg pain predominates back pain

Causes of Lumbar Spinal Stenosis

compression of intervertebral foramen

ligamentum flavum hypertrophy, facet hypertrophy of the cephelad vertebra, vertebral body osteophytosis, vertebral body compression fractures, herniated nucleus pulposus

Patient Presentation of Lumbar Spinal Stenosis

severe lower extremity pain, weakness, numbness in the legs while walking, with or without back pain (neurogenic claudication)

pain is worse with spinal extension and better with flexion (comfortable with pushing cart)

Normal Exam Findings of Lumar SPinal Stenosis

negative slrt, dtrs can be diminished bilaterally or normal, muscle strength intact, sensory loss may or may not be present

must differentiation between neural and neurogenic

Neurological Symptoms of Lumbar Spinal Stenosis

reproducted by extension an eased by flexion, use stoop test

diagnosis confirmed with MRI or CT

Piriformis Synrome

when the piriformis muscle compresses the sciatic nerve, affects peripheral nerve but not nerve roots

What Piriformis is and Isn’t

it is truly a problem with the sciatic nerve

it is not radiculopathy

Piriformis Muscle

external roation and abduction of hip

attaches to sacrum and anterior/posterior trochanter