IRAQ - LOW BACK PAIN GUIDELINES

NOVEMBER 2022 BAGHDAD - IRAQ
Lumbago
General Term for LBP
By: Dr. Muhannad M. Hadi Almukhtar
Supervised by: Prof. Dr. Iyad Abbas Salman

LBP
DEFINITION
• Global Burden of Disease studies have de
fi
ned low back pain (LBP) as:
• “pain in the area on the posterior aspect of the body from the lower margin of
the twelfth ribs to the lower gluteal folds with or without pain referred into one
or both lower limbs that lasts for at least one day”

INTRODUCTION
• Low back pain is a common global problem.
• The point prevalence of low back pain (LBP) in 2017 was estimated to be
about 7.5% of the global population, or around 577.0 million people.
• LBP has been the leading cause of years lived with disability (YLDs) since
1990 and remains a signi
fi
cant global public health concern.
• 85-95% of people presenting to primary care providers do not have a speci
fi
c
identi
fi
able pathoanatomical origin for their pain

INTRODUCTION
• Low back pain is extremely common. Most is ‘mechanical’, and caused by
degenerative changes in discs and facet joints (spondylosis).
• More than 90% of these patients are mostly pain free within 8 weeks,
although recurrences are common.
• Analyse the symptoms using ‘SOCRATES’.
• For back pain, ask speci
fi
cally about:
• occupational or recreational activity that may strain the back
• Red
fl
ag features suggesting signi
fi
cant spinal pathology..

Red Flags
• Serious spinal pathology is rare. However, the
fi
rst step in the assessment of back pain is to eliminate ‘red
fl
ags’
secondary to serious spinal pathology. A mnemonic to identify the red
fl
ags is TUNA FISH:
• Trauma, history of a fall.
• Unexplained weight loss/history of malignancy.
• Neurological
fi
ndings: cauda equina syndrome (unsteady gait, perineal numbness and sphincter
disturbance).
• Age >55 years.
• Fever/systemic illness.
• Immunocompromised.
• Steroid use.
• History of HIV, tuberculosis, cancer.

Yellow flags are psychosocial patient factors that although
not associated with serious organic pathology nonetheless
indicate an increased likelihood of chronic back pain and
resultant long term disability and potential loss of work

Classification
• Low back pain can be classi
fi
ed depending on the duration into:
• 1. Acute low back pain:
• Low back pain persisting for less than 6 weeks.
• 2. Sub-acute low back pain:
• Low back pain persisting between 6 and 12 weeks
• 3. Chronic low back pain:
• Low back pain persisting for 12 weeks or more.

Causes
What is the cause of lumbago? Below are 15 medical conditions that may cause lumbago and low back pain:
• Muscle strain
• Ligament injury
• Sciatica
• Osteoporosis
• Osteoarthritis
• Spinal stenosis (compression of the
spinal nerves)
• Herniated disc
• Degenerative disc disease
• Scoliosis (or the related conditions lordosis
and kyphosis)
• Tumors near the spine
• Fibromyalgia
• Spondylitis
• Spondylosis
• Osteomyelitis
• Broken bone near the spinal region Sprain

Pathophysiology
• In a large number of mechanical spinal pain cases, it may not be possible to
identify the precise pain generator as many spinal structures are involved in
nociception.
• Nociceptors are primary sensory neurons specialized to detect intense
stimuli and represent, therefore, the first line of defence against any
potentially threatening or damaging environmental inputs
• the distribution of lumbosacral nociceptive receptor systems, known at that
time to be sensitive to mechanical and chemical tissue dysfunction, as
being present in:

• 1. Fibrous capsules of zygapophysial (facet) joints and in sacroiliac joints.
• 2. Longitudinal spinal (anterior and posterior), interspinous, flaval, and
sacroiliac ligaments.
• 3. Periosteum on vertebral bodies and arches (and attached fasciae, tendons
and aponeuroses).
• 4. Dura mater and epidural fibro-adipose tissue.
• 5. Walls of blood vessels supplying the spinal and sacroiliac joints, and in
vertebral cancellous bone.

• 6. Walls of epidural and paravertebral veins.
• 7. Walls of intramuscular arteries within lumbosacral muscles.
• 8. Skin, subcutaneous and adipose tissue.

• Pain in any structure requires the release of inflammatory agents, including
bradykinin, prostaglandins, and leukotrienes, which stimulate pain receptors
and generate a nociceptive response in the tissue and it is known that the
spine is unique in that it has multiple structures that are innervated by pain
fibres (Haldeman et al 2002).
• For example, stretching and distorting the articular capsule of a facet joint
may result in traumatic synovitis with release of noxious neuropeptides,
kinins, or other inflammatory agents.

Mechanical Back Pain
• The term ‘mechanical’ refers to ‘movement’ and is generally due to a
musculoskeletal cause.
• Not all pain radiating to the leg is ‘sciatica’.
• In most patients with back and leg pain, this is due to a musculoskeletal
cause with referred pain to the lower limbs.
• Mechanical back pain can originate from the bone, joints, discs or the
adjacent soft tissues such as muscles and ligaments.

• about 3% of patients presenting with back pain have non-MSK causes.
• a signi
fi
cant proportion of women have pelvic conditions such as ovarian
cysts or endometriosis. Pain may be cyclical.
• Alway ask the Women of reproductive age (15-49 years) population

Anatomy
Any structure in the spine (bone, joint, intervertebral disc, nerve
root, ligament) or the surrounding structure (muscles, viscera) can
become the source of pain (pain generator) causing LBP.
Hence treating physician should be aware of the anatomy and the
pain patterns caused by these structures.

The Lumbar Vertebra
• There are 5 lumbar vertebrae, articulated with each other by:
• intervertebral discs anteriorly
• and facet joints posteriorly with forward lordotic curve.
• Each vertebra has two pedicles projecting posteriorly, two transverse
processes, a pair of superior and inferior articular processes, a pair of lamina
and one spinous process.

• Each vertebra is divided into three
functional components namely:
• The vertebral body(anterior element),
• The pedicle with intervertebral foramen
(middle element).
• lamina and its processes (posterior
element)

• It is supported by various ligaments
like anterior and posterior
longitudinal ligaments which are
present on the anterior and posterior
surface of the vertebral body and the
disc,
• Interspinous ligament which is
present between the two consecutive
spinous processes,
• Supraspinous ligament which
connects tip of two spinous
processes.
• Ligamentum
fl
avum which connects
the laminae of consecutive vertebrae

• The lumbar spine is strengthened by numerous
paraspinal muscles which include:
• The spinalis, longissimus,
• Quadratus lumborum,
• Iliopsoas, iliocostalis.
• These muscles stability as well as mobility to
the spine.
• In between the anterior and posterior elements
is spinal canal which contains spinal cord
surrounded by vertebral body intervertebral
disc anteriorly,
• Pedicle and vertebral foramen laterally
• Lamina with ligamentum
fl
avum posteriorly.

• Anterior element is supplied by:
• Sympathetic chain and
Sinuvertebral nerve which again is
a part of grey rami communicants.
• Posterior element is supplied by:
• posterior rami of spinal nerve which
again has three branches namely
medial, intermediate and lateral.
• All anterior and posterior elements
have nerve supply except inner 2/3rd
of annulus
fi
brosus and nucleus
pulposus of intervertebral which are
the potential pain generators.

Sacrum and Coccyx
• Sacrum is a single triangular or wedge shaped bone formed by the fusion of 5
sacral vertebrae.
• It articulates with the L5 vertebra above.
• It also articulates with the right and left iliac bones to form right and left
sacroiliac joints.
• The sacrum has 4 anterior and 4 posterior sacral foramina through which the
anterior and posterior rami of the upper four sacral spinal nerves exits.

Sacroiliac Joints
• The sacroiliac joint is a diarthrodal joint but only anteroinferior part of the joint
is synovial.
• The sacroiliac joints are designed primarily for stability.
• Their functions include the transmission of the truncal load to the lower limbs.
• The sacroiliac joint is largely immobile and is maximally loaded while sitting.

Coccyx
Tail Bone
• is formed by fused 3–5 coccygeal vertebrae.
• It is articulated to the sacrum by sacrococcygeal joint and sometimes can be
mobile.
• The spinal cord ends at the level of lower border of L1 but the dural sac
continues till the level of S2.

• The spinal nerve roots exit the spine via the intervertebral foramen.
• Each nerve root exits below the corresponding vertebra.

How to diagnose LBP
Vertebral Column

SOCRATS
Aggravating and Relieving Factors
• Discogenic pain again increases on axial loading (sitting, lumbar
fl
exion) and
reduced by recumbancy.
• Similarly the pain due to vertebral compression fracture also increases when
the patient is sitting.
• Pain due to ligament sprain and myofascial pain syndrome is aggravated by
movements which stretches the a
ff
ected ligament and muscle.
• In case of myofascial pain syndrome a
ff
ecting quadratus lumborum,
• the pain is worsened in sitting position as the muscle stretched in this position
and relieved by standing.

SOCRATS
Aggravating and Relieving Factors
• Whereas pain of iliopsoas is least in sitting position and aggravated during change of posture
from sitting to standing.
• Pain due to piriformis syndrome is aggravated during squatting which again stretches the
piriformis muscle.
• Similarly, interspinous ligament pain is more while the patient is sitting or bending forwards.
• Radicular pain is aggravated by bending forwards which stretches the a
ff
ected nerve,
coughing and straining (which increases the intradiscal pressure momentarily) and partial
relief is obtain when patient is at rest.
• Patients with lumbar canal stenosis give a typical history of back pain, numbness and
heaviness in the lower limbs while walking which are completely relieved by rest and forward
bending.

History
• Radicular pain caused by sciatic nerve root compression radiates down the posterior
aspect of the leg to the lower leg or ankle (sciatica).
• Groin and thigh pain in the absence of hip abnormality suggests referred pain from L1–
2.
• Consider abdominal and retroperitoneal pathology, such as abdominal aortic aneurysm.
• Mechanical low back pain:
• is common after standing for too long or sitting in a poor position.
• Symptoms worsen as the day progresses and improve after resting or on rising in the
morning.

History
You should Exclude Axial Spondyloarthritis
• Insidious onset of back or buttock ache and sti
ff
ness in an adolescent or
young adult suggests in
fl
ammatory disease of the sacroiliac joints and lumbar
spine (Axial Spondyloarthritis, Box 13.13).
• Symptoms are worse in the morning or after inactivity, and ease with
movement.
• Morning sti
ff
ness is more marked than in osteoarthritis, lasting at least 30
minutes.
• Other clues to the diagnosis are peripheral joint involvement, extra-articular
features or a positive family history.

History
• Acute onset of low back pain in a young adult, often associated with bending or
lifting, is typical of acute disc protrusion (slipped disc).
• Coughing or straining to open the bowels exacerbates the pain.
• There may be symptoms of lumbar or sacral nerve root compression.
• Cauda equina syndrome occurs when a central disc prolapse, or other space-
occupying lesion, compresses the cauda equina. There are features of sensory
and motor disturbance, including diminished perianal sensation and bladder
function disturbance. The motor disturbance may be profound, as in
paraplegia. Cauda equina syndrome and spinal cord compression are
neurosurgical emergencies.

DN4 Questionnaire for Neuropathic Pain

‫الحمداني‬ ‫فراس‬ ‫ابو‬
ِ‫يه‬ّ‫ق‬َ‫و‬َ‫ت‬ِ‫ل‬ ‫ن‬ِ‫ك‬َ‫ل‬ ِ‫ر‬ َ
‫لش‬ِ‫ل‬ ‫ال‬ َّ‫ر‬ َ
‫الش‬ ُ‫فت‬َ‫ر‬َ‫ع‬
ِ‫فيه‬ ‫ع‬َ‫ق‬َ‫ي‬ ِ‫ر‬‫ي‬َ‫خ‬‫ال‬ َ‫ن‬ِ‫م‬ َّ‫ر‬ َ
‫الش‬ ِ‫ف‬ِ‫ر‬‫ع‬َ‫ي‬ ‫م‬َ‫ل‬ ‫ن‬َ‫م‬َ‫و‬
3 Messages Should you know

History and Examination
A normal measurement is greater than or equal to 2 cm.

• Look for obvious deformity
(decreased/increased lordosis,
scoliosis) and soft-tissue
abnormalities such as a hairy
patch or lipoma that might
overlie a congenital
abnormality: for example, spina
bi
fi
da.
Palpate the spinous
processes and
paraspinal tissues.
Note overall alignment
and focal tenderness.
• After warning the
patient, lightly percuss
the spine with your
closed
fi
st and note any
tenderness.
- Flexion.
- Extension.
- Lateral Flexion.
Examination

Examination
Look (Inspection)
• Look for asymmetry or deformity; skin lesion, muscle wasting, muscle
hypertrophy, muscle fasciculation, gait, posture, range of motion.
• Muscle wasting may be sign of motor neuron disease.
• Gait may be antalgic (painful) gait, steppage gait (due to foot drop) or a gait
abnormality due to sti
ff
back as a result of paraspinal muscle spasm.
• Posture is again a cause for chronic strain on di
ff
erent ligaments.

Feel (Palpation)
• 1. Tenderness
• 2. Swelling
• 3. Local rise of temperature.
• Tenderness over particular part indicates pathology which can extend from
super
fi
cial skin to underlying organ.

Examination
Move (ROM)
• Flexion: (40°) ask the patient to try to touch their toes with their legs straight.
Record how far down the legs they can reach. Some of this movement
depends on hip
fl
exion. Usually, the upper segments
fl
ex before the lower
ones, and this progression should be smooth.
• Extension: ask the patient to straighten up and lean back as far as possible
(normal 10−20 degrees from a neutral erect posture).
• Lateral
fl
exion: ask them to reach down to each side, touching the outside of
their leg as far down as possible while keeping their legs straight.

Neurological Examination
Motor Testing

Muscle Power

Deep Re
fl
exes

Sensory
•

You should always remember to
do …
Neurological
Examination
Why ?? —>

I see the following…
• It will precisely locate the level of lesions.
• The radiculopathic symptoms are not always mentioned by the patients. So
you should look for the signs by the Neurological examination.
• In order to know the extent of the damage caused to the patient, by
di
ff
erentiating between radiculopathy and radicular pain.

Radiculopathy vs Radicular Pain
• Chemical Irritation of the nerve root causes severe radicular pain which is
generally worse distally than proximally.
• Caused by damage of disc which causes release of local in
fl
ammatory
chemicals.
• Chemicals damage and irritate the nerve root at that level.
• Radicular pain is generally caused by chemical irritation, not mechanical
compression.
• Sharp, burning pain is greater distally.

Radiculopathy vs Radicular Pain
Radiculopathy:
• Mechanical compression of the nerve root causes parethesias in a
dermatomal pattern and other neurological symptoms.
• Numbness
• Tingling
• Eventually, muscle atrophy
• LMN signs

Radiculopathy = Mechanical Compression
Radicular Pain = Chemical irritation

Do not miss …
The Sensory
Examination
Light Touch
Pin Prick

Sensory - Pin Prick Test
Wartenberg wheel, also
called a Wartenberg
pinwheel or Wartenberg
neurowheel

Dermatome

Special Tests
The Lasegue straight leg raising test (SLR)
• The basis for the SLR is the belief that the stretching of the lumbar nerve
trunks that form the sciatic nerve is non-painful in healthy but is painful when
in
fl
amed, irritated or entrapped.
• This test also has good correlation with positive
fi
ndings on (MRI) of the
lumbar spine and lumbar plexus as well as (EMG).
• Normally an individual can tolerate 90°
fl
exion of hip joint with full knee
extended without any pain except if any sti
ff
ness in hamstrings is there.

Special Tests
• At 30° of hip
fl
exion the nerve roots begins to replace in its foramen and in
presence of any compression reproduction of the same pain which patient is
experiencing is felt in the distribution of sciatic nerve. It has high sensitivity
but low speci
fi
city. However, if it is positive it is a very useful test in 85-90% of
the cases
• 2- to 7-mm distal migration of the spinal nerve roots during performance this
test.
• The classic SLR test is considered positive when the supine leg is elevated to
between 30 and 70 degrees and pain is reproduced down to the posterior
thigh below the knee.

Special Tests
• Pain below 30 degrees is not considered to be related to nerve root irritation.
• SLRs with pain induced beyond 70 degrees of leg elevation is not believed to
be due to nerve root tension. {{Mostly Joints Pain}}
• In patients with herniations from L4 to S1, positive SLR was noted in 96% to
98% of cases, while in those with herniations from L1–L2 to L3–L4, it was
positive in only 73%. Of note, 88% of those patients with negative exploration
had a positive SLR on examination.

Special Tests
SLR + Ankle dorsi
fl
exion = Bragard’s Sign
• Bragard’s sign If the Lasegue test does not cause pain on the examined side,
the examination should be appended by performing dorsiflexion of the ankle
(Bragard’s sign).
• If pain is provoked by this manoeuvre, a radicular irritation is suspected.
• Neri’s test,
fl
exing the neck to bring the head on to the chest, indicating dural
irritation.

• The pain is assumed to be caused by
stretching of an irritable femoral nerve
when there is compression of the L2, L3, or
L4 nerve roots.
• It has been observed that these traction
forces result in a 2-mm movement of the
L4 root.
• It is probably the single best screening test
to evaluate lumbar radiculopathy
secondary to an upper lumbar disc
herniation.
• It has been shown to be positive in 84%
to 95% of patients with a high lumbar disc.
FEMORAL NERVE STRETCH TEST

• 94.2% of patients with frank disc
herniation had pain reproduction
with slump testing compared
with 78% of those with bulging
discs and 75% with no positive
imaging
fi
ndings on CT or MRI.
THE SLUMP TEST

After History and Examination
• Patients presenting with back pain can be categorised into three groups:
• Simple mechanical back pain +/- referred pain to the lower limbs.
• Back pain + radicular pain (due to nerve root irritation — ‘sciatica’).
• Serious spinal pathology.

Blood Tests
• Complete hemogram with in
fl
ammatory markers like ESR, CRP, platelets, RA
factor, HLA B 27, uric acid levels is must when infective or in
fl
ammatory
back pain is suspected.

When will you refer the Patient to
Surgeon ??
?

Recommendations and levels of evidence for treatment of CLBP
By the clinical guidelines committee of the ACP.
• The initial approach to chronic CLB should focus on:
• nonpharmacologic treatment, including exercise, multidisciplinary rehab,
acupuncture, mindfulness-based stress reduction (moderate evidence).
• Tai chi, yoga, motor control exercise, progressive relaxation, EMG
biofeedback, low level laser therapy, operant therapy, cognitive behavior
therapy, or spinal manipulation (low quality evidence).

By the clinical guidelines committee of the ACP.
• 2. If there is an inadequate response to nonpharmacologic therapy,
• consider pharmacologic treatment:
• NSAIDs as
fi
rst line or tramadol or duloxetine as second line;
• Opioids only if failed other treatments and only if the bene
fi
ts outweigh the
risks (weak recommendation).

The ACP clinical guidelines committee has rated the evidence for nonpharmacologic treatment of CLBP and concluded that:
• super
fi
cial heat moderately improved pain relief (at
fi
ve days) and disability (at
four days) and, combined with exercise, improved Roland disability
questionnaire (RDQ) scores at seven days, with better outcomes than
acetaminophen/ibuprofen treatment;
• Acupuncture was found to have con
fl
icting evidence for e
ffi
cacy but did show
a moderate improvement in pain intensity;
• Massage therapy gave some relief to some patients and is considered safe.

The ACP clinical guidelines committee has rated the evidence for nonpharmacologic treatment of CLBP and concluded that:
• Spinal manipulation therapy improved pain and function if used for four weeks
or less, but there was no long term bene
fi
t observed;
• Exercise, including stretching, strengthening, or
fl
exion/ extension, are not
recommended by either the United States or European guidelines. However,
exercise is known to confer other bene
fi
ts;
• Optimal time to start exercise after the onset of LBP symptoms is unclear; for
patients in the:
• Subacute phase (less than four to eight weeks), rehabilitation (physician,
physical therapy, psychological or vocational interventions) are moderately
e
ff
ective (yoga and tai chi have had some promising outcomes for CLBP).

Pharmacologic Therapy for LBP
2017 ACP clinical practice guideline:
• Acetaminophen (APAP): appears to be no di
ff
erent from a placebo for acute or subacute LBP
regarding pain intensity or function through four weeks; no indication for chronic LBP (moderate
quality evidence); NSAIDs showed no di
ff
erence than acetaminophen at three weeks or less; although
estimates favored NSAIDs for pain relief, acetaminophen had a lower risk for side e
ff
ects.
• NSAIDs: were associated with greater mean improvements in pain intensity than placebo for acute
back pain; for chronic LBP, NSAIDs were associated with greater mean pain relief than placebo after
12 weeks; no clear di
ff
erences between NSAIDs for acute or chronic LBP; for radiculopathy, small and
inconsistent e
ff
ects were found. NSAIDs were associated with more adverse e
ff
ects than placebo, but
COX-2 inhibitors had a lower risk for adverse events (AEs).
• Opioids, tramadol, and tapentadol: no di
ff
erence for acute LBP between oxycodone or
acetaminophen plus naproxen or placebo plus naproxen; for chronic LBP, strong opioids were
associated with greater short term relief than placebo; tramadol also resulted in greater short term
relief than placebo. Opioids had a higher risk for nausea, dizziness, constipation, vomiting,
somnolence, and dry mouth than placebo.

Pharmacologic Therapy for LBP
2017 ACP clinical practice guideline:
• Skeletal muscle relaxants: superior to placebo for short term pain relief; evidence insu
ffi
cient to determine
e
ff
ects on function or for CLBP; no signi
fi
cant di
ff
erences among various skeletal muscle relaxants on any
outcome.
• Benzodiazepines: no clinically signi
fi
cant bene
fi
t compared with placebo were associated with CNS AEs
(somnolence, fatigue, and lightheadedness).
• Anti-depressants: no di
ff
erence in pain between tricyclic anti-depressants or selective serotonin reuptake
inhibitors for CLBP; can be e
ff
ective, but their mechanisms of action are not clearly understood; serotonin
norepinephrine reuptake inhibitor (SNRI) duloxetine was associated with lower pain intensity at 12 to 13
weeks, although e
ff
ects were small; duloxetine associated with greater improvement in function on the BPI.
Anti-convulsant medications: gabapentin provides small short term bene
fi
ts for radiculopathy; evidence
insu
ffi
cient to determine e
ff
ects of pregabalin versus other medication or pregabalin plus another
medication versus the other medication alone.
• Systemic corticosteroids: no di
ff
erences were found for nonradicular and radicular LBP compared with
placebo when

Internal Disc Disruption
Vertebral Column

Internal Disc Disruption
a painful disc: IDD, Discogenic Pain, and painful DDD
• Discogenic back pain is the most common cause a
ff
ecting nearly half of the
patients with low back pain.
• is thought to account for up to 42% of chronic low back pain
• This produces the discogenic pain syndrome caused by disc degeneration
not related to sciatica or nerve root referred pain
• is a condition characterized by a set of chemical, morphological, and
biophysical features.

Pathological Mechanisms of LBP
• It is precipitated by a small fracture of the vertebral endplate, as a result of severe
compression injury or fatigue failure under compression.
• This results in progressive degradation of the nuclear matrix, and the development of
radial
fi
ssures into the annulus
fi
brosus
• In the healthy back, only the outer third of the annulus
fi
brosus of the intervertebral
disk is innervated.
• Pathomechanism for LBP is thought to be sensory nerve ingrowth into the inner layer
of the degenerated intervertebral disk.
• Extensive innervation of intervertebral disks has been found in patients with
diskogenic pain

• These chemical and morphological changes a
ff
ect the biophysical properties
of the disc.
• Various proin
fl
ammatory molecules such as:
• Tumor necrosis factor-α, interleukin-1, interleukin-6, interleukin-8, inducible
nitric oxide synthase, prostaglandin E 2 , and nerve growth factor have been
found in intervertebral disks.

Quality of Pain
• Discogenic pain is very vague, and not well localized.
• Radicular pain and pain due to entrapment neuropathy is sharp, shooting,
lancinating or electric in nature.
• There are no specific characteristics in the patients’ history that confirm or
disprove the diagnosis of discogenic low back pain.
• More typical features include persistent, nociceptive low back, groin and/or leg
pain that worsens with axial loading and improves with recumbence.
• Patients may have experienced a prior episode of acute, intense pain caused
by an acute tear in the innermost part of the AF

Physical Examination
• There are no typical characteristics of discogenic pain in the physical
examination.
• Biphasic straightening from flexion is considered by some to be an indication of
a disk complaint. Pain as a result of pressure on the processus spinosus is
considered characteristic of discogenic low back pain (“Federung”).
• Vanharanta has described pain radiating from the disk due to provocation with a
tuning fork pressed on the processus spinosus of the a
ff
ected segment.
Although suggestive, these physical examination characteristics have not been
validated, and the current criterion standard for confirming a clinical diagnosis of
discogenic pain is a positive discogram and the demonstration of a Grade 3 AF
tear

• Lumbar X-rays of IDD patients do not have any characteristic signs.

Can MRI accurately predict Discogenic LBP?

Normal or bulging disc in the presence of an HIZ

Disc protrusion in the presence of an HIZ

Lumbar Discography
In Brief
• Definitions Stimulation of a discus intervertebralis
is a procedure that was developed for the purpose
of confirming or refuting a clinical hypothesis of
discogenic low back pain.
• The procedure is performed by inserting a needle
in the NP of the target disk and injecting contrast
agent (or another suitable medium) in order to test
the sensitivity of the disk to gradually increasing
distending pressures.
• Disk stimulation is the more accurate name for a
procedure that until now has often been described
as (provocative) discography.

Treatment Options
Core muscle Exercise
• MADI Clinic - Jeunju - South Korea

• Pharmacologic treatment typically includes (NSAIDs) and muscle relaxants,
but the literature support for e
ffi
cacy of treatment is not strong with only
minimal improvements in pain and function.
• Chronic opioid therapy is only marginally e
ff
ective and is associated with
signi
fi
cant side e
ff
ects and risk of addiction and overdose.
• Physical therapy with core muscle strengthening along with manipulation has
some temporary bene
fi
t and long-term e
ff
ects

4 Important Exercise
Pelvic Tilt
Purpose: To strengthen your lower abdominal
muscles and add
fl
exibility to your low back
How to perform a pelvic tilt:
•Lie on your back with your feet
fl
at on the
fl
oor.
•As you exhale, squeeze your abdominal
muscles, push your belly button toward the
fl
oor, and
fl
atten your low back.
•Hold for 5 seconds. Relax.
•Repeat 10 times, holding for 5 seconds each
time.

Knee to Chest
Purpose: To reduce pressure on your lumbar spinal nerves
and alleviate back pain.
How to perform a knee to chest:
•Lie on your back with feet
fl
at on the
fl
oor.
•Bring your right knee toward your chest, using your hands to
hold your leg in the stretched position. Hold for 10 seconds.
•Lower your right leg and repeat the exercise with the left
knee. Hold for 10 seconds.
•Repeat with each leg 3 to 5 times.
•After stretching each leg individually, perform the exercise
by holding both knees in the stretched position. Hold for 10
seconds and repeat 3 to 5 times.

Lower Trunk Rotation
Purpose: To increase your spine’s mobility and
fl
exibility.
How to perform a lower trunk rotation:
•Lie on your back in the hook lying position (knees
bent and feet
fl
at on the
fl
oor).
•Rotate your knees to 1 side, holding them for 3 to
5 seconds.
•While contracting your abdominal muscles,
slowly rotate your knees to the other side and
hold for 3 to 5 seconds.
•Repeat up to 10 times on both sides.

All Fours Opposite Arm and Leg Extension
Purpose: To strengthen and stabilize your abdominal
and low back muscles.
How to perform an all fours opposite arm and leg
extension:
•Start in an all fours, or tabletop, position, contracting
your abdominals throughout the entire exercise.
Engaging your abdominals will keep your back in a
straight position.
•Gently raise your left leg behind you and hold for 3 to
5 seconds.
•Repeat with your right leg and hold for 3 to 5 seconds.

How Do These Exercises Reduce Lumbar Degenerative Disc Disease Pain?
These low-impact exercises focus on strengthening and conditioning your
spine’s support system—your core (abdominal muscles) and spinal muscles.
What’s the link between a strong core and back health? Your core and spinal
muscles act as an internal brace to support your spine. Keeping these
structures strong puts less pressure on your spine, so you’ll feel less pain.
That’s why exercises designed to strengthen your spine and increase
fl
exibility
are so important—stronger spines resist pain.
Staying active also helps keep your discs healthy, as spinal discs need
movement for nutrients.

Other Treatment Options
• Epidural injections are performed for patients with discogenic low back pain and have been
shown to produce fair results.
• Intradiscal electrothermal annuloplasty (IDET) was used to treat discogenic low back pain
starting in 1996, and a more recent meta-analysis of its e
ff
ectiveness has shown that this
also produces fair results.
• There are therapies that are focused on:
• either treating the in
fl
ammatory pathways (i.e., steroid injections)disrupting the
nerve conduction from the painful disc (i.e., methylene blue, ozone, biaculoplasty,
etc.).
• These types of therapies may be successful in reducing pain but do not have the ability to
heal the disc or reverse the degenerative changes suspected to be responsible for the pain.

• Research e
ff
orts have been focusing more on the development of treatments
that will repair or regenerate damaged intervertebral discs.
• Treatments have been focused on restoring the cellular health of the
intervertebral disc and on reducing the pain associated with IDD.
• The bene
fi
ts of biologic treatments likely originate from tissue repair and
changes in cytokine expression following injection of biologic material.
• Some of the biologic materials that have been injected into the intervertebral
disc include
fi
brin sealant, isolated growth factors, juvenile chondrocytes,
platelet-rich plasma, and mesenchymal stem cells (MSCs)

Intradiscal Biologic Treatments
Understudy
• I. Fibrin Adhesives: Injection into the disc with
fi
brin adhesives involves
fi
brinogen combined with thrombin just prior to injection into the nucleus
pulposis with enough volume to
fi
ll the potential space of the nucleus and
extend into and seal the annular defects from inside
• II. Bone Morphogenic Protein : GDF-5 with saline.
• III. Alpha-2-Macroglobulin
• IV. Platelet-Rich Plasma

Interventional Procedures
• I. Intradiscal electrothermal therapy
(IDET):
• The procedure consists of percutaneous
insertion of a thermocoil into the disk
under radiographic examination.
• The catheter must be placed along the
internal aspect of the posterior AF.
• The distal portion of the catheter (5 cm) is
heated for 16 min to 90°C.

Intradiscal corticosteroid injections
• The goal of intradiscal corticosteroid
injections is the suppression of the
inflammation that is considered to be
responsible for discogenic pain.
• The group with Modic Type-1 changes
had significantly better results after
intradiscal steroid injection compared with
the group without Modic Type-1 changes.

Biacuplasty
• is the latest in a series of minimally invasive posterior AF heating
techniques. This technology works specifically by concentrating
RF current between the ends of two straight probes.
• Two TransDiscal 18 G electrodes via introducers are placed
bilaterally in the posterior AF of the discus intervertebralis.
• The generator controls the delivery of RF energy by monitoring
the temperature measured by a thermocouple at the tip of the
probe. The temperature increases gradually over a period of 7–8
min to 50°C, with final heating at 50°C for another 7 min.
• It should be noted that although the temperature is set to 50°C on
the RF generator, tissue temperature reaches 65°C due to ionic
heating.

• The incidence of disc related pain was greatest in patients
younger than 40 years of age.
• The pain was located primarily in the low back and buttock
regions.
• The onset of pain was precipitated by a torsion injury of the
low back and was exacerbated by axial loading such as with
prolonged sitting and standing.
• Although the pain experienced from disc pathology is
characteristically axial in nature, it may also refer to the
lower extremities in a non-dermatomal distribution.

The Grading or Degree of IDD
• In grade I disruption,
fi
ssures
reach the inner third of the
annulus.
• In grade II disruption
fi
ssures
reach the middle third of the
annulus.
• Grade III disruption arises when
the
fi
ssure reaches the outer third,
and becomes grade IV if the
fi
ssure then extends
circumferentially.

There are six possible categories that describe the severity of the radial annular tear.
• The grade 0 is a normal disc; where no contract material leaks from the nucleus.
• The grade 1 tear will leak contrast material only into the inner 1/3 of the annulus.
• The grade 2 tear will leak contrast through the inner 1/3 and into the middle 1/3 of the
disc.
• The grade 3 tear will leak contrast through the inner and middle annulus. The
contrast spills into the outer 1/3 of the annulus.
• The grade 4 tear further describes a grade 3 tear. Not only does the contrast extend
into the outer 1/3 of the annulus, but it is seen spreading concentrically around the
disc. To qualify as a grade 4 tear the concentric spread must be greater than 30
degrees. Pathologically, this represents the merging of a full thickness radial tear with
a concentric annular tear.
• The ‘evil’ grade 5 tear describes either a grade 3 or grade 4 radial tear that has
completely ruptured that outer layers of the disc and is leaking contract material out
of the disc. This type of tear, which I most likely su
ff
ered from, can cause a chemical
radiculopathy in one or both of the extremities and result in the dreaded

I. Lumbar Radicular Syndrome
ALWAYS EXCLUDE HIP
PATHOLOGY

Introduction
• A lumbosacral radicular syndrome (LRS) is characterized by a radiating pain in one or
more lumbar or sacral dermatomes; it may or may not be accompanied by other
radicular irritation symptoms and/or symptoms of decreased function.
• The terms radicular pain and radiculopathy are also sometimes used interchangeably,
although they certainly are not synonyms.
• Pain completely or partially resolves in 60% of the patients within 12 weeks of onset. 6
However, about 30% of the patients still have pain after 3 months to 1 year.
• In patients under 50 years of age, a herniated disk is the most frequent cause of an
LSR.
• After the age of 50, radicular pain is often caused by degenerative changes in the spine

Symptoms
• The patient may experience the radiating pain as sharp, dull, piercing,
throbbing, or burning. Pain caused by a herniated disk classically increases
by bending forward, sitting, coughing, or (excessive) stress on the lumbar
disks and can be avoided by lying down or sometimes by walking. 5 Inversely,
pain from a lumbar spinal canal stenosis can typically increase when walking
and improve immediately upon bending forward. 8 In addition to the pain, the
patients also often report paresthesia in the a
ff
ected dermatome. The
distribution of pain along a dermatome can be indicative in the determination
of the level involved; however, there is a large variation in radiation pattern.
The S1 dermatome seems the most reliable. 9 If present, the dermatomal
distribution of paresthesia is more specific.8

Symptoms
• Pain, paresthesia, and numbness in a dermatomal distribution
• a positive straight-leg raise (SLR) test,
• with or without accompanying signs of sensory loss, weakness, and
diminished re
fl
exes, are mediated by sensory spinal NRs (SSNRs) or dorsal
root ganglia (DRG).
• These symptoms of lumbar radicular syndrome (LRS) can be present in
isolation.

• The incidence of LRS in patients with LBP is reported to range from 12% to
40%.
• The term sciatica is also often used synonymously with LRS.
• It is usually extended below the knee (radicular pain), can result from
mechanical nerve root compression and chemical irritation from various
in
fl
ammatory mediators that leak out of degenerated discs.
• Unlike referred pain from joints, muscles, and discs, the pain typically
radiates in a dermatomal distribution.

• Herniated nucleus pulposus is the most common cause of radicular pain.
• From a radiological perspective:
• Absolute central lumbar stenosis refers to anteroposterior spinal canal
diameter smaller than 10 mm,
• Whereas foraminal stenosis relates to a neuroforaminal diameter smaller than
3 mm.
• A herniated disc is diagnosed when the nucleus pulposus extends beyond the
normal con
fi
nes of the annulus
fi
brosis, but involves less than 25% of the
circumference.

Examination
Neurodynamic Test
• SLR
• SLUMP
• FNST

Interventional management
• Epidural administration of corticosteroids is generally indicated in cases of
subacute radicular pain.
• In patients with chronic radicular complaints, corticosteroids will not provide
any improvement in the outcome in comparison with local anesthetics alone.
• This indicates that epidural corticosteroids are more e
ff
ective for (sub)acute
radicular pain where a significant inflammatory pain component is present.
• PRF treatment is a treatment option for chronic radicular pain.

• I. Interlaminar corticosteroids
• II. Transforaminal corticosteroids
• III. Caudal corticosteroids
1. Epidural corticosteroid administration

2. Adhesiolysis and epiduroscopy
• The goal of lysis of epidural adhesions is to remove barriers in the epidural
space that may contribute to pain generation and prevent delivery of pain
relieving drugs to target sites.
• 1. Chemical Adhesiolysis: include
• (1) Hyaluronidase1500 - 3000 iu
• (2) hypertonic saline solution;
• 2. Mechanical adhesiolysis

3. Spinal cord stimulation in FBSS
• I. Interlaminar corticosteroids
• II. Transforaminal corticosteroids
• III. Caudal corticosteroids

Lumbar Spinal Stenosis
Lumbar Neurogenic
Intermittent Claudication
NIC

Definition
IASP
• “lumbar spinal pain of unknown origin either persisting despite surgical
intervention or appearing after surgical intervention for spinal pain originally in
the same topographic location.”
• Comprehensive history should include evaluation of:
• Preoperative risk factors (psychosocial factors, smoking, obesity),
• Intraoperative risk factors (operating at a single level, operating at the
wrong level),
• Postoperative risk factors.

Lumbar Spinal Stenosis
• LSS is de
fi
ned as the clinical syndrome of neurogenic claudication or
• radicular symptoms from narrowing of the spinal canal, neuroforaminae, and/
or lateral recess generally assumed to be from compression of the neural
elements.
• NIC is the most common reason for spine surgery in patients over 65 years of
age.
• The hallmark is the induction of gluteal and lower extremity pain with upright
exercise or speci
fi
c postural positions and relieved by forward
fl
exion, sitting,
or recumbency.

• The most common, the acquired degenerative variety, of LSS is
characteristically because of disc degeneration and its sequelae. The typical
lesions include
• 1) loss of disc height,
• 2) AF bulging,
• 3) facet joint hypertrophy,
• 4) thickening and redundancy of the ligamentum
fl
avum,
• 5) local osteophyte formation

• Central stenosis can cause compression of the NRs of the cauda equina,
• whereas lateral stenosis typically results in compression of the exiting spinal
NRs.
• The L5 NR is most commonly involved (75%),
• followed by the L4 (15%),
• L3 (5.3%),
• L2 (4%) NRs

• compression and/or ischemia of the neural structures is generally thought to
be responsible for the clinical manifestations, and in contrast to HD, the role
played by the in
fl
ammatory changes is less clear.
• In contrast to vascular claudication, the pain of neurogenic claudication
continues to be present with standing and is eased by walking in a
fl
exed position, such as pushing a walker or shopping cart.

Treatment
• Non-operative Treatments
• including medications, activity modi
fi
cation, bracing, and physical therapy,
• ESIs, particularly IL-ESIs, are e
ff
ective in the short term treatment of acute pain
exacerbations and can provide symptomatic control of episodically worsening
symptoms of neurogenic claudication.
• Fluoroscopically guided TF-ESIs appears to be a treatment better suited for
radicular symptoms secondary to LSS and have been shown to have both short
term and long-term e
ffi
cacy.
• Percutaneous image-based lumbar decompression (PILD) is a minimally
invasive procedure indicated for lumbar spinal stenosis with neurogenic
claudication primarily caused by hypertrophy of the ligamentum
fl
avum.

Lumbar Facet Syndrome
ALWAYS EXCLUDE HIP
PATHOLOGY

• The lumbar facet or zygapophyseal joints (LFJs) are synovial joints composed
of an articular surface, synovial membrane,
fi
broadipose meniscoid, and
fi
brous
capsule.
• Each joint is composed of two articular processes, the superior and the inferior.
• The orientation of facet joints is distinct at the lumbar, thoracic, and cervical
levels, with the LFJs having a curved and oblique pro
fi
le.
• The medial branch (MB) of the posterior primary ramus traverses the base of
the superior articular process (SAP) at its junction with the transverse process
to innervate both the facet joint at the same level and the vertebral level below.

• Each facet joint receives innervation from its corresponding vertebral level and
the vertebral level above.
• The course of the MB is relatively
fi
xed as it originates from the dorsal ramus,
proximally at the base of the SAP.
• The L5 dorsal ramus passes over the sacral ala at the base of the sacral SAP.
• The
fi
brous capsule and the synovium of the LFJs are richly innervated by
nociceptive
fi
bers

Radiation
• Non-dermatomal radiation
• The upper lumbar facet joint pain may be referred to
fl
anks, hips and lateral thigh,
• The lower lumbar facet joints pain are referred to
posterior thigh.
• Facet joint pain is rarely referred below knees

Diagnostic Injections for Lumbar Facet Syndrome
• Local anesthetics of di
ff
erent duration, used on two separate occasions
(double comparative blocks), with the patient reporting corresponding
duration of pain relief, can enhance diagnostic speci
fi
city.
• double comparative blocks are generally recommended for appropriate
diagnosis of LFS to avoid the unacceptably high false-positive response rate
of the single diagnostic procedure.
• a definitive treatment is carried out if a patient experiences 50% or greater
pain reduction lasting for the duration of action of the local anesthetic (e.g.,
>30 minutes with lidocaine and 3 hours with bupivacaine).

Facet Denervation
• Denervation of a painful facet joint, referred to as facet rhizotomy, neurotomy, or
ablation, is accomplished by lesioning of the MB at the painful vertebral level
and one level above.
• Optimal electrode p ing is con
fi
rmed both radiologically and by appropriate
sensory and motor testing prior to the lesion creation.
• The size of RF electrodes used varies between 18 and 22 gauge, the
temperatures range between 80°C and 90°C, and the duration of RF lesioning
can last from 60 to 90 s.
• three RCTs of RFA for LFS e
ffi
cacy are available; while two demonstrated
improved chronic LBP following the procedure, the third showed no bene
f

• Currently, the gold standard for treating facetogenic pain is RF treatment. The
major advantage of temperature-controlled TRF

Key Points
• Lumbar spondylolisthesis may result
from:
• congenital,
• isthmic,
• trauma-related,
• degenarative,
• iatrogenic causes.
• A variety of radiographic studies may
be necessary to comprehensively
evaluate spondylolisthesis.
• Di
ff
erentiating between stable and
unstable spondylolisthesis may assist
in selecting the appropriate treatment.
• Treatment is variable and must be
customized based on the presenting
complaints and the underlying
structural abnormalities.

Key Points
• Lumbar spondylolisthesis is de
fi
ned as an acquired anterior displacement of
one vertebra over the subjacent vertebra, associated with degenerative
changes, without an associated disruption or defect in the vertebral ring.
• The term spondylolisthesis is derived from the Greek for spondylos (vertebra)
and olisthesis (to slip or slide down).
• The direction of the spondylolisthesis is de
fi
ned based on the displacement
of the upper vertebra as anterolisthesis or retrolisthesis. The intervertebral
discs, the superior and inferior articular processes, the ligaments, and the
paravertebral muscles work together to provide segmental stability.

• Disc dysfunction and horizontalization of the lamina and the articular process
have been implicated as factors responsible for the development of
spondylolisthesis.
• During the aging process, the intervertebral discs undergo degenerative
changes characterized by loss of hydration and delamination, ultimately
resulting in segmental instability.
• The L4–5 segment is particularly vulnerable to this issue because the almost
completely sagittal orientation of the superior and inferior articular processes
of the facet joint render it vulnerable to anteroposterior sheer forces.

Classification
• 1. Congenital or dysplastic: caused by congenital defects of L5 and/or the upper sacrum
• 2. Isthmic: caused by pars interarticularis defects
• 3. Degenerative: due to articular process degeneration or abnormal orientation
• 4. Traumatic: caused by fracture or dislocation of the lumbar spine, not involving the pars
• 5. Pathologic: due to infection, malignancy (either primary or metastatic), or other types of
abnormal bone
• 6. Iatrogenic/postsurgical.
• Isthmic spondylolisthesis, the most common subtype, is caused by pars interarticularis
defects. Congenital or dysplastic spondylolisthesis is due to failure of normal genesis of the
superior articular process.

Diagnostic Imaging
• Most commonly standing lateral radiographs, typically including
fl
exion–
extension views, are the appropriate
fi
rst step in detecting DLS.
• One speci
fi
c element of radiographic assessment is the need to understand
whether there is
fi
xed or dynamic deformity at the a
ff
ected level. Typically
standing lateral
fl
exion–extension radiographs are used to make this
determination. Typically, the standard for DLS has been 5 mm of vertebral
slippage. Dynamic deformity is suspected when there is incongruity between
fl
exion–extension radiographs as noted by attenuation or reduction of
slippage between these views.

Lateral upright radiographs of
patient with grade II
spondylolisthesis at L5–S1.

Treatment
• There are typically at least three general goals:
• (1) reduce in
fl
ammation,
• (2) reduce mechanical stressors,
• (3) improve strength and stability.
• All of these theoretically result in improved pain control.

Treatment
• In
fl
ammation can be reduced in several ways.
• Oral or injected medications may be a way to modulate in
fl
ammation.
• There is good evidence supporting the use of NSAID and acetaminophen in the treatment of
acute low back pain, and empirically their use has been common in DLS.
• There is fair evidence supporting the use of muscle relaxants in acute LBP, and these agents
are commonly prescribed in patients with chronic LBP, including that resulting from DLS.
• We believe that traditional muscle relaxants such as cyclobenzaprine, methacarbamol, and
metaxalone have very little role in the treatment of spasm associated with DLS;
• instead, medications such as baclofen and tizanidine, which block spinal mono- and
polysynaptic re
fl
exes should be considered.
• These agents may also provide bene
fi
t in patients with primarily myofascial complaints.

Treatment
• Bracing may be particularly bene
fi
cial in those with DLS complicated by other
spinal alignment issues such as scoliosis, lateral listhesis, or hyperlordosis.
• Typically bracing is used in a time-limited fashion, as overdependence on
bracing may result in weakening of the core musculature, further
exacerbating structural issues.
• Braces are typically used only during daytime hours or whenever the patient
expects to be active or in a pain-provoking position.

• It has been postulated that interlaminar and transforaminal steroid injections
as well as intra-articular facet injections and medial branch neurotomy may
provide pain relief and targeted delivery of potent anti-in
fl
ammatory agents to
the site of the pathology in DLS.
•

Sacroiliac Joint Complex
(SIJC) Pain
Vertebral Column

Intro
• is a true diarthrodial joint with the articular surfaces of the sacrum and ilium
separated by a joint space enclosed in a
fi
brous capsule.
• It bears the characteristics of a synovial joint, especially in the superoanterior
and inferior aspects.
• The superoposterior joint surface lacks a joint capsule and contains the
interosseous ligament.
• The posterior aspect also contains the posterior sacroiliac, sacrotuberous,
and sacrospinous ligaments that stabilize the joint.

Innervation
• The anterior joint is suggested to be innervated by the ventral rami of L4 and
L5 of the lumbosacral trunk .
• The posterior innervation is presumed to be from lateral branches of the
posterior rami of L5–S4.
• The superior gluteal nerve (ventral rami of L4–S1) contributes to the
innervation of the joint according to some study .

• back pain (LBP), with a reported
prevalence rate ranging between
10% and 33% in individuals with a
suspected mechanical etiology
predominantly below L5.
• Although sacroiliac joint pain most
frequently presents in the buttocks,
over two-thirds of individuals will
have lumbar pain; in approximately
50% of cases, the pain radiates to
the leg, sometimes below the knee.

• Intra-articular pathology is more common in older people,
• whereas younger individuals with prominent tenderness and a traumatic
cause are more likely to have extra-articular pathology.

I. Sacroiliac Joint Complex (SIJC) Pain

Diagnosis
History
• Constant pain and Localized around the SIJ and upper leg.
• Radiated into the posterior buttocks and backs of the thigh and the groin.
• Usually doesn't cross below the knee.
• Aggravated by Sitting, from sitting to standing, and Stepping up and down.
• Interfere with sleep.
• Fortin Finger Test

Please don’t depend on:
- Local Tenderness.
- Faber test. ONLY
USE Cluster of Laslett for Diagnosis
SN: 0.77
SP: 0.28
SN: 0.94
SP: 0.78

Bertolotti syndrome
Unusual pain syndromes

In Brief
• low-back pain due to a lumbosacral transitional vertebra (LSTV).
• LSTV is an anatomical variation of the most caudal lumbar vertebra in which
an enlarged transverse process can articulate or fuse with the sacrum or ilium.
• is a congenital abnormality, it is often clinically manifested only after the
second decade of life.
• It is estimated this syndrome accounts for 4.6% - 7% of cases of LBP in
adults, and for more than 11% of patients with LBP who are under 30 years
old.

Castellvi’s classification
• Type I – dysplastic transverse process with
height> 19 mm
• Type II – incomplete lumbarization/sacralization
(diarthrosis)
• Type III – complete lumbarization/sacralization
with complete fusion with the neighboring sacral
basis
• Type IV – mixed
• The type II transitional vertebra has been
associated with an increased number of disc
prolapses, and related to discogenic and/or
contralateral facetogenic low back pain.

Symptoms
• chronic, progressive midline, or paramedian LBP that is deep, sharp, or dull in nature
or a sensation of pulled muscle or unilateral upper buttock pain.
• The severity of pain is moderate to severe,
• worse with physical exertion, and better with rest.
• The provocative factors of pain include heavy lifting, forward
fl
exion, excessive
extension or lateralization of the back to the same side of the megaapophysis.
• It may be accompanied with sciatica, medial thigh cramping, leg radicular pain,
weakness, or numbness.
• Patients may have signi
fi
cant ambulatory and functional limitations.

Examination
• Physical examination demonstrates
• focal tenderness along the base of the LSS and near the PSIS, provoked by
super
fi
cial and deep palpation.
• Patients may have normal and symmetric muscle bulk and tone in their paraspinal
muscles and in all extremities.
• SLR test, may be positive;
• range of motion may be impaired.
• Pronator drift, Romberg signs, patellar and Achilles deep tendon re
fl
exes, and
sensation test usually are intact.

Diagnosis
• The correct diagnosis is made based on imaging studies which included
• LS CT scans,
• plain x-rays,
• and MRI scans
• in the context of typical history of low back pain and physical exam.

Treatment
• Course of conservative management including:
• activity modi
fi
cation,
• medication management with NSAIDs, muscle relaxants, opioids,
• rehabilitative physical therapy
• should be o
ff
ered initially, with the recognition that these therapies are
less likely to result in satisfactory pain control.

Treatment
• If the primary origin of the pain is at the pseudoarticulation between the transverse process
and ilium due to the arthritic changes, a local anesthetic and corticosteroid can be injected
into this pseudoarticulation.
• These blocks should be performed with a minimal amount of anesthetic delivered precisely to
the point of interest to achieve temporary pain relief.
• If rapid pain relief doesn’t occur almost instantaneously, alternative pain generators should be
sought.
• The anesthetic block can be repeated if in doubt.
• If the patient experiences temporary pain relief and the pain is truly localized in the transitional
joint without evidence of disc pathology, a minimally invasive approach may be taken to resect
the anomalous transverse process with the accompanying pseudoarticulation.

Iliac Crest Pain Syndrome
Iliolumbar ligament syndrome

In Brief
• The iliolumbar ligament has not explicitly been shown to have an innervation but
presumably it is innervated by the dorsal rami or ventral rami of the L4 and L5
spinal nerves.
• Biomechanically, the iliolumbar ligament serves to resist
fl
exion, rotation and lateral
bending of the L5 vertebra and could therefore be liable to strain during such
movements.
• The evidence implicating the iliolumbar ligament as a source of back pain is
inconclusive.
• Tenderness over the PSIS is a sign of iliolumbar ligament sprain, but this is hard to
credit, for the ligament lies anterior to the ilium and is buried by the mass of the
erector spinae and multi
fi
dus.

In Brief
• Some Investigators have claimed to have relieved back pain by in
fi
ltrating the
iliolumbar ligament.
• all investigators have overlooked is that the site of tenderness in iliac crest syndrome
happens to overlie the site of attachment of the lumbar intermuscular aponeurosis
(LIA), which constitutes a common tendon for the lumbar
fi
bres of longissimus
thoracis.
• The LIA attaches to the iliac crest rostromedial to the posterior superior iliac spine and
exhibits a morphology not unlike that of the common extensor origin of the elbow.
• Thus, a basis for pain and tenderness in this region could be a tendonopathy of the
LIA. On the other hand, it could be no more speci
fi
c than tenderness in the posterior
back muscles, which has been recognised for many years under di
ff
erent rubrics.

In Brief
• Iliac crest syndrome is de
fi
ned simply as tenderness over the medial part
of the iliac crest, the kappa score for its diagnosis is 0.57.
• If the criteria are extended to include reproduction of typical pain, the kappa
score rises to 0.66.
• These scores indicate that the syndrome can be identi
fi
ed. Its prevalence
seems to be about 30–50%.
• However, as long as the syndrome amounts to no more than tenderness, it is
not evident whether it is a unique disorder or a feature that could occur
in association with other sources and causes of back pain.

Treatment
• Recognising the syndrome, however, has
little impact on treatment.
• Injecting the area with local anaesthetic
is signi
fi
cantly more e
ff
ective than
injecting it with normal saline, but only
some 50% of patients bene
fi
t and only
30% obtain more than 80% improvement

Iliolumbar ligament
• Originates from the L-5 transverse and is made up of an anterior and
posterior band
• Clinical Features:
• Unilateral or bilateral low back pain
• Exquisite tender point at the posterior iliac crest (Figure 56-8)
• Positive hip
fl
exion test and Patrick maneuver
• Constant ache aggravated by prolonged sitting and standing—referral pain
to the greater trochanter and into the groin (“my testicles are in a vice”)

Introduction
• Deep gluteal syndrome is characterized by pain and dysesthesias in the buttock area, hip, or
posterior thigh due to a non-discogenic sciatic nerve entrapment in the subgluteal space.
• It is caused by multiple pathologies:
• “piriformis syndrome,”
• the presence of
fi
brous bands,
• obturator internus/gemellus syndrome,
• quadratus femoris/ischiofemoral pathology,
• hamstring pathology,
• gluteal disorders.

Introduction
• The subgluteal space is delimitated:
• Posteriorly by: the gluteus maximus muscle,
• Anteriorly by the posterior surface of the femoral neck,
• Laterally by the linea aspera and the iliotibial tract (the union of middle and deep
gluteal aponeurosis and the tensor fasciae latae muscle),
• Medially by the sacrotuberous and falciform fascia,
• Superiorly by the inferior margin of the sciatic notch,
• Inferiorly by the hamstring tendons.

Introduction
The subgluteal space contains:
• Superior and Inferior gluteal nerves
and vessels,
• Sacrotuberous and Sacrospinous
ligaments,
• Internal pudendal vessels,
• Sciatic nerve.
• Piriformis,
• Obturator internus and externus,
• Gemelli,
• Quadratus femoris
• Hamstrings.

Ischiofemoral Impingement IFI
&
Hamstring Syndrome
Quadratus femoris (QF) impingement
Extra-articular hip impingement
Distal Causes of Deep Gluteal
Syndrome

• patients with IFI are more
comfortable sitting, and walking
during terminal hip extension when
the space between ischium and the
lesser trochanter is diminished,
exacerbating the pain.

Internal and External Rotation of the Thigh

Internal Rotator muscles of the hip …
• Muscles that Internally Rotate the Hip:
• Gluteus Medius (anterior
fi
bers)
• Gluteus Minimus.
• Piriformis (when
fl
exed past 90 degrees)
• Tensor Fascia Latae.
• Adductor Longus.
• Adductor Brevis. Gracilis.

External Rotator muscles of the hip …
• Piriformis.
• Superior and Inferior gemelli.
• Obturator Internus.
• Quadratus femoris.

• The present study shows normal and speci
fi
c sciatic nerve behavior during isometric
contraction of the external and internal rotator muscles of the hip.
• External rotators increase their volume by contracting (speci
fi
cally the gemelli, the
internal obturator, and the quadratus femoris), causing the sciatic nerve dorsal to them
to bulge to a posterior direction to adapt to the muscle dynamics.
• In contrast, the obturator internus tendon, owing to its anatomical arrangement, is
tensioned in the opposite (anterior) direction. This combination of increased volume of
the gluteal muscles in the posterior direction with the tension of the internal obturator
tendon in the anterior direction increases the sciatic nerve curvature signi
fi
cantly and
repeatedly deforms it during isometric contraction movements. Conversely, during
isometric contraction of the hip internal rotator muscles, the nerve tends to stretch
(Figure 9).

PIRIFORMIS
(Deep Gluteal Pain Syndrome)
ALWAYS EXCLUDE HIP
PATHOLOGY

• Piriformis syndrome, an etiology related to prolonged or
excessive contraction of the piriformis muscle and its close
relationship to the sciatic nerve and the inferior gluteal artery,
is associated with pain in the buttocks, hip, and lower limb.
• Pain aggravated on sitting, external tenderness near the
greater sciatic notch, pain on any maneuver that increases
piriformis muscle tension, and limitation of straight leg
raising are features commonly observed in this syndrome.
Injections of local anesthetics, steroids, and botulinum toxin
into this muscle using ultrasound for guidance are often
performed for diagnostic and therapeutic purposes.

Introduction
• The piriformis muscle originates from
the anterior surface of the sacrum
and inserts on the upper surface of
the greater trochanter, leaving the
pelvis through the greater sciatic
foramen.

Introduction
• The piriformis syndrome is characterized by a clinical presentation with
sciatica-like symptoms.
• The etiology is not clearly known, but the entrapment and irritation of the
sciatic nerve in the hip region could be in
fl
uenced by the piriformis muscle
(contracture of the piriformis muscle, anatomical abnormalities of the
piriformis muscle, problem after spinal surgery, overuse of the piriformis
muscle, trauma, or sports injury).

Diagnosis
Special Test
• After central spinal cause of the Pain.

Ischiogluteal Bursitis
• is also referred to as weaver’s bottom because traditionally weavers would sit in a
position that aggravates the ischiogluteal bursa.
• the ischiogluteal bursa lies between the hamstring tendon and the pelvic bone (ischial
tuberosity).
• Patients typically experience pain in the lower buttock,
• it is estimated to account for less than 1% of cases.
• Risk factors for ischial bursitis include obesity, autoimmune diseases, excessive or
inappropriate exercise, and a sedentary lifestyle characterized by long periods of sitting;

Ischiogluteal Bursitis
• On physical examination, tenderness to palpation was a prominent objective
sign. MRI can be helpful in the diagnosis and may show low or intermediate
signal intensity on T1 and T2 hyperintensity in the region of the ischial bursa.
• The treatment of ischial bursitis is symptom-oriented and may include
ergonomic modi
fi
cation, PT, NSAIDs, and steroid injections.

Maigne Syndrome
Robert Maingne
(1923-2012)
Underdiagnosed Cause
of
Low Back Pain

Pathomechanic
• I. The TLJ may be more susceptible to
biomechanical disturbances due to lower stability
compare to the thoracic spine as the last two ribs
are not attached to the sternum.
• II. The alignment of the facet joints from frontal
plane in the thoracic facets to the sagittal plane in
the lumbar facets, this transitional plane make the
TLJ more susceptible

• Irritation of facets joint and / or articular capsule and / or excessive paraspinal
muscle tone cause irritation of the neural structures (dorsal rami, ventral rami
of the T11 - L2 NRs) produce clinical symptoms

Diagnosis
• Tenderness upon palpation and pressure of TLJ
• irritation of dorsal rami refer pain to the unilateral iliac crest upper gluteal
region.
• Irritation of the ventral rami can lead to unilateral
• Pain is triggered by extension and or rotation but it doesn’t cross the half of
the body.
• Sharp pain on Tenderness upon iliac crest 7 cm laterally (rub the crest in an
up and down motion) due to irritation of cutaneous branches of T11 - L1.

Cellulalgia (skin and subcutaneous tissues hypersensitivity to pinch and roll test)
• Cellulagia located on iliac crest, inguinal canal and or greater trochanter of
both side.
• Kipler Fold Test

SUPERIOR & MIDDLE CLUNEAL
NERVE ENTRAPMENT

CLINICAL ANATOMY
The posterior hip and buttocks receive sensory innervation from a variety of
sources, including the:
- T12 nerve,
- the superior cluneal nerves.
- the middle cluneal nerves.
- The superior cluneal nerves provide sensory innervation of the upper, more
lateral portion of the buttocks .
The superior cluneal nerves are the terminal branches of the dorsal rami of
the L1, L2, and L3 nerve roots.

• Myofascial pain is probably the most common reason for isolated low back
pain.
• The highest percentage of axial weight is carried in the lower back. With
increased tension patients may develop muscle spasm or strain.
• Muscle changes include the formation of taut muscle bands, painful taut
muscle bands are known as trigger points

• Muscles, fascia, and ligaments can also be pain generators.
• Muscles that can potentially contribute to low back pain include:
• deep intrinsic (eg, multi
fi
dus or rotatores)
• The more super
fi
cial longissimus, spinalis, and iliocostalis muscles, collectively referred to as erector
spinae muscles.
• Back muscles are integral to normal spine sti
ff
ness and function, and chronic low back pain could be
paradoxically associated with both atrophy and increased myoelectric activity, which is consistent with
studies showing both increased and decreased activation depending on context.
• Muscle pathology represents an underappreciated source of low back pain, often misdiagnosed as non-
speci
fi
c, and frequently arises consequent to other primary pathology.
• Myofascial pain might result from overuse, acute stretch injuries or tears, and di
ff
use or localised (eg, trigger
points) muscle spasm.

• At the lumbar levels, the lateral branches of the dorsal rami of the lumbar
spinal nerves innervate the iliocostalis muscle
• While the intermediate branches innervate the longissimus.
• The spinotransverse muscle group is innervated by the medial branches of
the dorsal rami of the appropriate spinal nerves.

Iliocostalis Lumborum
• Iliocostalis lumborum TrPs at the upper
lumbar level refer pain strongly
downward, concentrating on the mid-
buttock, and is a frequent source of
unilateral posterior hip pain.

• When a patient has iliocostalis lumborum TrPs, the patient commonly draws
an up-and-down pattern to represent the pain referred from iliocostalis TrPs
but a crosswise pattern in the same region of the back to demonstrate the
pain referred from TrPs in the lower rectus abdominus muscle.

longissimus Thoracis
• Trigger points in the lower thoracic level
of the longissimus thoracis muscle refer
pain strongly low in the buttock.
• This remote source of buttock pain is
easily and often overlooked.
• Longissimus thoracis TrPs in the most
caudal portion of the muscle fibers,
which are located in the upper lumbar
area, usually refer pain several segments
caudally but still within the lumbar region

• When the longissimus muscles are involved bilaterally, often at the L1 level,
the patient has difficulty rising from a chair and climbing stairs if he or she
faces forward in the usual manner.

Multifidi Muscles
• Refers pain primarily to the region around the
spinous process of the vertebra adjacent to
the TrP.
• Multifidus TrPs located from L1 to L5 may
also refer pain anteriorly to the abdomen,
which is easily mistaken as visceral in origin
(Figure 48-4B on the right).
• The multifidus muscle at L5 can also refer to
the posterior thigh and/or leg and, less
frequently, to the anterior thigh.
• Multifidus TrPs at the S1 level project pain
downward to the coccyx and render the
coccyx hypersensitive to pressure (referred
tenderness).
• The condition is often identified as coccydynia.

Quadratus Lumborum Syndrome
• Origin: Posterior half of iliac crest and iliolumbar ligament.
• Insertion: Inferior border of twelfth rib, transverse
processes of
fi
rst to fourth lumbar vertebrae.
• Action: Extends and laterally
fl
exes trunk; stabilizes
twelfth rib during inspiration.
• Innervation: Anterior rami of twelfth thoracic and
fi
rst to
fourth lumbar nerves.

• is one of the most common causes of low back pain.
• The quadratus lumborum muscle connects at the 12th rib, iliac crest, and
lumbar vertebrae.
• It is responsible for lateral bending of the lumbar spine.
• Patients with QLS often have unilateral hip elevation because of muscle
shortening.
• Active quadratus lumborum trigger points refer pain to the hip and buttock

• QLS lacks the characteristic features of radicular pain (such as
radiating extremity pain, numbness, or weakness).
• What causes quadratus lumborum pain?
• Pain in the quadratus lumborum can be due to overuse, stress,
and strain. Sometimes muscles cause pain and sti
ff
ness when
they’re weak or too tight.
• Activities such as sitting for long periods of time can reduce
blood
fl
ow to an area, especially in the QL and surrounding areas.
• Pain can also result from repetitive motions and weak back
muscles, which lead to poor posture.

IRAQ - LOW BACK PAIN GUIDELINES

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