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Low Back Pain
I. Lumbosacral problems
A. Low back pain
1. General Considerations. Low back pain is ubiquitous low back pain, backache, back ache. Eighty percent of the population as a whole will experience an episode of low back pain during their lives. In 1981, the Quebec Task Force on Spinal Disorders noted a 3% incidence in males between the ages of 20 and 40 and a 25% incidence in females.
3. Differential diagnosis
a. Tumors
1) Benign
a) Tumors involving nerve roots or meninges (eg, meningioma)
b) Tumors involving vertebrae (eg, osteoid osteoma, Paget's disease, osteoblastoma)
2) Malignant
a) Primary bone tumors (eg, multiple myeloma)
b) Primary neural tumors
c) Secondary tumors (eg, metastases from breast, prostate, kidney, lung, thyroid)
b. Trauma
1) Lumbar strain (non-specific - poor diagnosis)
2) Fracture (compression v. burst)
3) Subluxated facet joint (facet syndrome)
4) Spondylolysis and spondylolisthesis
c. Toxicity
1) Heavy metal poisoning (eg, radium)
d. Metabolic disorders (eg, osteoporosis)
e. Inflammatory disease (eg, rheumatoid arthritis, ankylosing spondylitis)
f. Degenerative disorders (eg, spondylosis, osteoarthritis, herniated disc, herniated nucleus pulposus, spinal stenosis -nerve root entrapment syndrome)
g. Infections
1) Acute (eg, pyogenic disc space infections)
2) Chronic (eg, tuberculosis, chronic osteomyelitis, fungal infection)
h. Circulatory disorders (eg, abdominal aortic aneurysm)
i. Mechanical causes
1) Intrinsic (eg, poor muscle tone, chronic postural strain, myofascial pain, unstable vertebrae)
2) Extrinsic (eg, uterine fibroids, pelvic tumors or infections, hip disease, prostate disease, sacroiliac joint infections and sprains, untreated lumbar scoliosis)
j. Psychoneurotic problems (eg, hysteria, malingering, compensatory low back pain - "green poultice" syndrome)
5. Treatment
a. Bed rest, followed by active mobilization are the cornerstones of initial treatment of nonradicular back pain. The study of Wiesel et al, conducted in a military setting with enforced compliance, demonstrated that low back patients assigned to bed rest of no more than 48 hours had a faster return to duty than those required to remain ambulatory. The value of which is questionable. At L5 S1, 25% of body weight is needed to overcome soft tissue resistance.
b. Aside from bedrest and active mobilization, anti-inflammatories or aspirin should provide the mainstay of treatment. Both Naproxen and aspirin have been shown to be superior to placebo in clinical trials. Muscle relaxants and narcotics provide symptomatic relief but have not been shown to facilitate recovery.
c. Physiotherapy should be instituted within 48 hours of onset. The use of modalities (heat, ultrasound) may be beneficial, but only within six weeks.
d. Trigger point injections, whereby Lidocaine and steroid are installed in a point of tenderness in the fascial plane have been shown to be of little lasting benefit. A Prospective study presented at the International Society.
B. Lumbar disc prolapse
1. General consideration and presentation
a. In general, axil pain is the result of noncompressive disc degeneration. Sciatica, however, is produced by lumbar disc prolapse causing significant nerve root compression. Typically the patient will present with radicular pain, and a positive straight leg raising test. Neurologic examination will aid in localizing levels. 80-90% of nuclear prolapse in the lumbar spine occurs.
2. Treatment
a. Ninety percent of disc Prolapses will respond to conservative measures within 12 weeks. These include 24-48 hours of bedrest, NSAIDS, or possibly oral or epidural steroids. The optimal time for surgical referral occurs after approximately 8 weeks of persistent symptoms. Surgical discectomy (laminotomy, not really "laminectomy') should yield a 95% success rate.
C. Stenosis
1. General considerations and clinical presentation
a. In central lumber stenosis, with circumferential compression of the cauda equina, the associated clinical syndrome is one of neurogenic claudication. Patients note unilateral or bilateral lower extremity pain related to activity. When patients sit, they are pain-free. A key differential point between neurogenic.
2. Physical findings and initial treatments
a. Neurological examination is as a rule unrevealing, and the diagnosis is made clinically and on the basis of appropriate imaging modalities (ie, MRI). Conservative treatment revolves around epidural therapy, and flexion exercises.
3. Surgery
a. Surgical intervention consists of decompression, with appropriate stabilization should the extent of decompression so merit. Based on the literature, the expectation of long-term relief in the patient with 2-3 level spinal stenosis and claudication is 80%.
D. Spondylolisthesis (Spondylolysis)
1. Congenital (L5-S1)]
2. Degenerative (L4-5), component of stenosis
E. Metastatic disease
1. General considerations
a. Historically, the incidence of metastatic disease of the spine was thought to approach 70%. In a recent study from Canada (MacNab), the true incidence was closer to 36E/o. However, as many as 10% of patients with unknown primaries will present with back pain, and this remains an important differential in initial work-up in the older patient.
2. Classification scheme and treatment
a. The lumbar and thoracolumbar regions are most commonly involved, due to the arrangement of Batson's valveless vertebral plexus. Harrington has described a classification system for metastatic disease of the spine, which is useful for diagnostic and prognostic reasons. This classification is as follows: Class 1 - no significant neurological involvement, Class 2 - bony involvement without collapse, Class 3 - neurological impairment in the absence of bony involvement, Class 4 - vertebral collapse.
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