Orthopaedics-by-Maheshwari-7th-Edition-NotesMed

Causes of Low Back Pain

• Congenital Causes

  • Spina bifida

  • Lumbar scoliosis

  • Spondylolysis

  • Spondylolisthesis

  • Transitional vertebra

  • Facet tropism

• Traumatic Causes

  • Sprain, strain

  • Vertebral fractures

  • Prolapsed disc

• Inflammatory Causes

  • Tuberculosis

  • Ankylosing spondylitis

  • Seronegative spond-arthritis (SSA)

• Degenerative Causes

  • Osteoarthritis

• Neoplastic Causes

  • Benign:

    • Osteoid osteoma

    • Eosinophilic granuloma

  • Malignant:

    • Primary: Multiple myeloma, Lymphoma

    • Secondaries from other sites

• Metabolic Causes

  • Osteoporosis

  • Osteomalacia

• Pain Referred from Viscera

  • Genitourinary diseases

  • Gynaecological diseases

• Miscellaneous Causes

  • Functional back pain

  • Postural back pain

    • Protuberant abdomen

    • Occupational bad posture

    • Habitual bad posture

Overview of Low Back Pain

• Prevalence:

  • Nearly 80% of individuals in modern industrial societies experience back pain at some point.

  • 70% of cases resolve within a month, but many experience recurrent pain.

• Aetiology:

  • The exact cause of most back pain cases is unclear.

  • Common causes include postural issues and trauma.

  • Back pain may indicate a more systemic condition, such as a genitourinary or gynaecological disease.

Clinical History

• Age Factors:

  • Children: Rare back pain often linked to organic disease.

  • Adolescents: More likely due to posture and trauma.

  • Adults: Common disorders include ankylosing spondylitis and disc prolapse.

  • Elderly: Likely to experience degenerative arthritis, osteoporosis, or metastatic disease.

• Sex Factors:

  • Women, especially those with multiple pregnancies, exhibit higher back pain prevalence due to factors like weight gain and muscle tone reduction.

• Occupation History:

  • Occupational habits can provide insights into back pain risk factors. Sedentary jobs and certain professions (e.g., surgeons, truck drivers) increase vulnerability.

• Past Medical History:

  • A history of spinal diseases may indicate a recurrence potential for back pain.

Features and Symptoms of Pain

• Location, Onset, and Pain Characteristics:

  • Location: Can be lower, middle or upper back; conditions vary by location.

  • Onset: Traumatic episodes often precipitate acute pain.

  • Localisation: Tendon/muscle injuries result in localized pain; deeper structures often cause diffuse pain with possible neurological signs.

• Pain Progression:

  • Trauma-related pain peaks at onset and may decrease over time.

  • Chronic arthritis pain tends to be more constant and aggravated by activity.

• Relieving and Aggravating Factors:

  • Most back pains intensify with activity and ease with rest, except for certain conditions like ankylosing spondylitis, which worsen after rest.

• Associated Symptoms:

  • Stiffness, joint pain, neurological symptoms, and indications of extra-skeletal events must be evaluated.

Physical Examination

• Standing Position Observations:

  • Look for structural anomalies such as scoliosis and asymmetric pelvis alignment.

  • Evaluate for muscle spasm, tenderness, swelling, and range of motion limitations.

• Supine Position Evaluations:

  • Straight leg raising test for nerve root compression detection.

  • Neurological exam for sensory, motor skills, and reflexes.

  • Check peripheral pulses for vascular pain causes.

Investigations

• Diagnosis Approach:

  • Diagnosis of low back pain is primarily clinical and X-rays should be reserved for cases persisting beyond three weeks.

• Imaging Techniques:

  • Initial X-rays (AP and lateral views) are crucial, while CT and MRI are used for additional evaluation when necessary.

• Blood Investigations:

  • Conducted if malignancy, metabolic disorders, or chronic infections are suspected.

Treatment Principles

• Conservative Management:

  • Rest, medication (analgesics and relaxants), physiotherapy, and education on back care are recommended.

• Surgical considerations:

  • Indicated based on symptoms and underlying conditions requiring intervention.

Major Conditions Associated with Low Back Pain

• Congenital Disorders:

  • Spinal anomalies, though common, aren't always symptomatic.

• Traumatic Disorders:

  • Back strains and sprains arise frequently from daily activities. Compression fractures are a concern in elderly patients.

• Inflammatory Disorders:

  • Conditions like spinal tuberculosis are crucial for diagnosis and management.

• Degenerative Disorders:

  • Noteworthily, osteoarthritis and prolapsed discs are key considerations.

Sciatica

• Definition and Causes:

  • Sciatica refers to pain radiating along the sciatic nerve, typically from degenerative changes or disc prolapse.

• Management:

  • Treatment varies based on underlying pathology, focusing on pain relief and addressing causes.