1. Reginald Ajakwe, MD

2.  Low back pain (LBP)is the fifth most common reason for all
physician visits.
 Second most common symptomatic reason (upper
respiratory symptoms are the first)
 50 to 80 percent of adults experience LBP
 LBP is the leading cause of disability and lost production in
the US, with associated direct and indirect costs of $50
billion per year
 Despite the widespread opinion that 75-90% of patients with
LBP recover within about 6 weeks, irrespective of treatment,
pain may persist in up to 72%, and disability in up to 12% of
patients one year after their first episode of LBP

3.  Poor Physical Fitness and comobidity
 Social Class, occupation, and employment status
 Increasing age
 Obesity
 Dimensions of the Spinal Canal
 Smoking
 Substance Abuse History
 Hard physical Labor

4.  Radicular leg pain
 Poor self-rated health status
 A positive straight leg raised test
 Reduced Elasticity/Flexibility of the Back
 Poor Coping Strategies
 High Levels of distress, depression, and
somatization
 Lower activity level
 Anxiety

5.  Mechanical Low Back Pain:
 It is defined as pain secondary to over use of a normal anatomic
structure (e.g. muscle strain) of pain secondary to trauma or
deformity of an anatomic structure (e.g Herniated nucleus pulposus).
This typically accounts for 90% of all LBP
 The other 10% percent of adults typically have non-mechanical LBP.
Typically the symptoms of LBP in the individuals are a manifestation
of a systemic illness.
 The challenge of the practicing physician is to separate individuals
with mechanical disorders from those with systemic illness.
 Usually, the patient’s symptoms and signs, along with radiographic
and laboratory data designate specific disorders within these two
major groups

6.  Onset: Was there trauma or unusual period of
strenous activity?
 Duration and Frequency: Systemic disorders cause
chronic LBP that is more persistent than episodic
 Location and Radiation: These help identify the
structures that are possible pain generators
 Aggravating and Alleviating factors: Characterize
the mechanical Quality of the disorder

7.  The time of the day associated with maximum degree of
pain is associated with certain disorder.
 For example, inflammatory arthritis causes most
symptoms in the morning versus mechanical disorders
that are typically worse at the end of the day
 Quality of the pain: can help separate musculoskeletal
pain (aching) from neuropathic pain (burning)
 The intensity of the pain is to help to document and
determine improvement, but does not discriminate
between mechanical and systemic disorders

8.  Fever and Weight loss: These patients are more
likely to have an infectious etiology as a cause of
LBP.
 Nocturnal Pain and Pain with Reccumbency:
Tumors of the spinal column are of prime concern
in these patients.
 The mechanism of increased nocturnal pain with
benign or malignant tumors is unknown.
 Increased pressure associated with increased
blood flow at night has been suggested as one
possible cause.

9.  Local Vertebral Column Pain: These patients
usually have fractures of the vertebral body or
expansion of the bone marrow space.
 Some systemic processes can increase mineral
loss from bone (eg osteoporosis, pagets disease)
 Hypertrophy or replacement of bone marrow cells
with inflammatory or neoplastic cells (multiple
myeloma, hemoglobinopathy).
 Both lead weaken the vertebral to the degree that
fracture may occur spontaneously or with minimal
impact

10.  Prolonged morning stiffness: Morning stiffness lasting
for more than one hour is a common symptom of
spondyloarthropathy.
 These include ankylosing spondylitis, reactive arthritis,
psoriatic arthritis, and enteropathic arthritis.
 Visceral Pain Disorders of the Vascular, genitourinary,
and gastrointestinal systems can cause stimulation of
sensory nerves that results in the perception of pain in
damaged areas and superficial tissues supplied by the
same segments of the spinal cord

11.  Detailed History and PEX identifying conditions that require
immediate attention
 For most patients, imaging and aggressive interventions should be
delayed until the patient has undergone 4-6 weeks of non-operative
care
 Patients should be reassured that LBP only rarely leads to disability
 Patients should be encouraged to return to normal activity and begin
light aerobic exercises immediately while avoiding strenuous
activities until symptoms resolve.
 Over-the-counter analgesics, NSAIDS, and acetaminophen are first-
line medications for pain relief
 If symptoms have resolved or improving by 4-6 weeks, there is no
need for further investigation

12.  If symptoms progress or stabilize at an unacceptable level, clinical
assessment and imaging are indicated
 Plain radiographs initially. MRI follows and is considered the
diagnostic imaging modality of choice
 If there is bony pathology on plain radiographs or a history of trauma,
CT scan is indicated
 Usually, surgical intervention is an option only for patients with
identifiable pathology on imaging studies that is consistent with their
clinical presentation
 Early surgical consideration is given to patients with neurologic deficit
due to nerve root compression, incapacitating pain, or progressive
neurologic deficits
 Evidence of cauda equina syndrome with loss of bowel or bladder
control is an indication for emergent imaging and surgical
decompression

14.  Lumbosacral Strain
 Lumbar Facet Arthropathy
 Lumbar Radicular Syndrome
 Sacroiliac joint Dysfunction
 Piriformis syndrome
 Spinal Stenosis
 Ichial-Gluteal bursitis

16.  Pain is limited to a local area
 Pain often occurs simultaneously with an injury
 Decreased ROM from reflex contraction of the
involved muscle and the surrounding muscles
 Exacerbation of pain with motion that contracts
the injured muscle

17.  Muscular and ligamentous injuries
 Continuous mechanical stress from poor
posture
 Small tears in the annulus fibrosus

18.  Any active motion of the involved muscle
against resistance causes pain
 Tenderness to palpation of the damaged
muscle
 Increased contraction and firmness compared
with the surrounding muscle
 Trigger points with “jump sign”
 Normal neurologic exam

19.  Controlled Physical Activity
 Medications—NSAIDS, Centrally Acting Muscle
Relaxants
 The recommendation to maintain activity as
tolerated is important
 Trigger point Injections with or without local
anesthestic may be helpful

21.  The axial spine rests on the sacrum, a triangular fusion
of vertebrae arranged in a kyphotic curve and ending
with attached coccyx in the upper buttocks. Iliac wings
attach on either side forming a bowl with a high back
and shallow front. Three joints arise from this union; the
pubic symphosis in front, and the right and left SI joints
in the back
 It is diarthrodial joint: adjacent bones are lined by
cartilage, joint cavity contains synovial fluid lined with a
synovial membrane, reinforced by a fibrous capsule and
ligaments, some degree of free movement.

23.  The SI joint is innervated at its anterior and
posterior aspects.
 Posterior innervation is from the lateral
branches of the posterior primary rami of L4
through S4.
 Anterior innervation is from the ventral rami of
L5 through S2 via branches of the sacral plexus

24.  The incidence of SI joint pain in patients with
back pain is 15 to 30 percent
 Sources may be intra-articular or extra-articular
sources.
 Examples of intra-articular sources include
infection and arthritis.
 Examples of extra-articular sources include
enthesopathy, fractures, and ligamentous
injury.

25.  Leg length discrepancy
 Gait abnormalities
 Prolonged vigorous exercise
 Scoliosis
 Trauma
 Pregnancy
 Spinal fusion to the sacrum.

26.  Unfortunately, medical history, physical examination, and imaging
studies perform very poorly in identifying the dysfunctional SI joint as
a pain generator.
 Unilateral pain (unless both joints are affected) localized
predominantly below the L5 spinous process.
 Point specific tenderness over the sacral sulcus and posterior
sacroiliac spine is consistent physical finding
 There are several SI joint pain provocation tests that have been
developed to detect SI joint dysfunction.
 Some of the more commonly used tests include FABER (also known
as Patrick’s test), Gaenslen’s test, Yeoman’s test, and Pelvic rock
 A combination of FABER (Flexion, Abduction and External Rotation),
POSH (Posterior shear), and READ (Resisted Abduction) tests has a
sensitivity of 70% to 80% and a specificity of 100%.

27.  Degenerative changes of the joint on standard x-ray are
uncommon and non-specific, as most patients with SI
joints dysfunction have normal appearing joint on
roentgenography.
 Other imaging modalities such as CT scan, bone
scintigraphy, and MRI also do not play a major role in the
selection of patients with SI joint dysfunction.
 Essentially, resolution of axial back pain following intra-
articular injection of local anesthetic under fluoroscopic
or CT guidance is the best available diagnostic tool.

28.  Multimodal approach
 Medication: NSAIDS
 Physical Therapy
 SI joint injection with fluoroscopy using local
anesthetic and steroids
 Radiofrequency Ablation (RFA) of L4-L5 dorsal
rami and S1 through S3 lateral branch nerves
 Direct Denervation of the SI joint with RF

30.  A Flat and pyramid –shaped muscle.
 Originates anterior to the S2-S4 vertebrae,
near the sacroiliac capsule and the upper
margin of the greater sciatic foramen
 It passes through the greater sciatic notch
and inserts on the superior surface of the
greater tronchanter of the femur.
 As it courses through the sciatic notch it
comes in close proximity to the sciatic
nerve (SN)
 Innervated by L5, S1, S2 nerve roots
 There are developmental variations
between the SN and piriformis muscle.
 In 20% of the population, the belly is split
by the SN.
 In 10%, the tibial/peroneal are not
enclosed in a common sheath.

31.  6:1 female:male predominance
 In 50% of cases it is associated with direct trauma to
sciatic notch and gluteal region.
 Blunt injury causes hematoma formation and
subsequently scarring between the sciatic nerve and
piriformis muscle
 Other causes include prolonged sitting; prolonged
combined hip flexion, adduction, and internal rotation
 Certain sport activities like cyclists who ride for
prolonged periods and tennis players who constantly
internally rotate their hips

32.  Deep aching pain in the buttocks of the affected side
 Pain may radiate to hip, lower back, and posterior thigh,
but rarely below the knee.
 Squatting, climbing stairs, walking, and prolonged sitting
(especially on hard surfaces) worsens pain
 Pain is typically unilateral
 Often associated with a limp on the affected side.
 Freiberg test elicits pain on forced internal rotation of
the extended thigh
 The pace test elicits pain with resisted
abduction/internal rotation

33.  Physical Therapy
 Piriformis stretch
 Standing hamstring
stretch
 Pelvic tilt
 Medication therapy with
NSAIDs
 Intramuscular Piriformis
injection with local
anesthetic and steroid
 Intramuscular injection
with botulinum A toxin
(100 units)
Piriformis Muscle injection

35.  This is pain originating from the facets joints
 Prevalance my be as high as 10 to 15% in individuals
with LBP
 With aging lumbar facet joint become weaker and their
orientation changes from coronal to saggital positioning
 This predisposes them to injury from rotational stress
 L3-4, L4-5, and L5-S1 are exposed to the most strain
during lateral bending and forward flexion.
 Thus they are more prone to repetitive strain,
inflammation and joint hypertrophy.

36.  Each facet joint is formed by the superior and inferior
articular process of consecutive lumbar vertebra.
 Each joint is named by the segmental number of
vertebrae that form it.
 Each facet joint has the typical structure of a synovial
joint
 The joints are innervated by the the medial branches of
lumbar dorsi rami
 Each joint receives innervation from the ipsilateral
medial branch nerve, and from the medial branch
above. Thus the L4-5 joint is innervated by the L3 and
L4 medial branches

38.  There are no discrete history and physical findings pathognomonic for
lumbar facet arthropathy.
 Some helpful indicators on PEX:
 1. Pain not relieved when rising from forward flexion
 2. Pain well relieved by recumbency
 3. Pain not exacerbated by coughing
 4. Pain not worsened by hyperextension
 Most often pain is referred to the region of the buttocks or proximal thigh.
 Medial Branch nerve blocks with fluoroscopy is currently the standard
diagnostic test for establishing a diagnosis of zygopophyseal joint pain.
 The correct target points for this block lies midway between two points: the
notch between the Superior articular process and the transverse.

40.  Multimodal treatment regimen including
 Medication therapy with NSAIDs, Cymbalta.
 Physical therapy for functional rehabilitation
 Radiofrequency Neurotomy: Done with fluoroscopy.
This is standard of care. It involves coagulating,
percutaneously, the medial branch nerves that
innervate nerves that innervate the joint.
 Intraarticular steroid injection is rarely done for
treatment of facet arthropathy.

42.  Primarily caused by herniated disk and
degenerative spinal disorders 98% of the time.
 The incidence of radicular symptoms in
patients with LBP ranges from 12 to 40%
 Even though radicular pain can be a feature of
radiculopathy, it is a separate condition from
radiculopathy.
 Radiculopathy implies numbness, weakness, or
loss of DTR or any combination of the three.

43.  The epidural presence of the herniated part of
the disk can induce structural and functional
changes in the adjacent nerves and sensitize
the nerve roots to produce pain
 Proposed mechanism for pain from herniated
disc include neural compression with
dysfunction, vascular compromise,
inflammation and biochemical influences

44.  Back pain can be the major symptom,
especially in central herniated disks
 Follows nerve root distribution
 The pain is described by patients as sharp,
shooting, superficial, lancinating, “like an
electric shock”
 Paresthesia may be present
 Worse with flexion

45.  Better with extension
 Radiation below the knee
 May have sensory alterations
 Objective weakness possible
 Atrophy possibly present
 Positive root tension signs (SRL)

46.  History and PEX, including a detailed neurologic
examination
 Diagnostic imaging
 Plain film to exclude systemic pathology. Helps
with demonstration of foraminal stenosis,
tumors and infection
 CT or MRI. Both offer greater resolution for
identification of soft tissue
 EMG and NCS

47.  Treatment options depend on severity of the
symptoms and patient’s preference. They
include:
 Conservative Management
 Interventional Management
 Surgical Management

48.  Back school
 Muscle relaxants
 Exercise therapy
 Behavioural Therapy
 Traction
 Manual Therapy
 Athrosis—lumbar corcets
 TENS
 Acupuncture

49.  NSAIDS– Not very effective in radicular pain
 Centrally acting muscle relaxants—helpful with
back pain but not with radicular pain
 Sytemic steroids-routinely used, but not yet
shown to be more effective than placebo
 Neuropathic pain medication: neurontin, Lyrica,
Cymbalta, Savella
 Opioids

50.  Caudal epidural steroid injections
 Lumbar transforaminal epidural steroid
injection
 Lumbar interlaminar epidural steroid injection
 Dorsal column stimulation with epidurally
placed spinal cord stimulator electrodes

52. L5-S1 Translaminar ESI

53. Right L5-S1 Transforaminal ESI

54.  Spia
Epidurally placed spinal
cord electrodes
Inplantable Pulse Generator

55.  Typically reserved for cases where objective
neurological deficits are present often with
identifiable pathology on imaging studies that is
consistent with clinical presentation.
 Such deficits may include motor deficits, sensory
deficits, severe intractable pain, urinary or bowel
incontinence.
 Evidence of cauda equina syndrome with loss of
bowel or bladder control is an indication for
emergent imaging and surgical decompression

56.  The Evaluation of low back pain can be a daunting task
 The disease possibilities are numerous
 Diagnostic options are often complicated and expensive
 90% of patients have a mechanical reason for their low back pain.
 The remaining 10% have back pain as a symptom of a systemic illness.
 The practicing physician therefore has the challenge of separating the
patients with mechanical disorders from those with systemic illness.
 The patient’s signs and symptoms often give clues for this differentiation.
 Treatment ranges from conservative management, to interventional
techniques, to surgery.
 Despite the widespread opinion that 75-90% of patients with LBP recover
within about 6 weeks, pain may persist in up to 72%, and disability in up to
12% of patients one year after their first episode of LBP