2. Mechanics of the Back
Vertebral column is pillar like structure supported in all directions by
musculature;
Anteriorly, the recti and the abdominal muscles
Posteriorly, erector spinae and quadratus
If any of these supports give away, vertebral column will move to the other
side, and most of the times its anterior musculature that gives away.
Since lumbar vertebrae (L1-L5) supports much of the weight of the upper
body, pain mostly occurs in the lower back.
3. Lower Back Pain (LBP)
Pain and discomfort between the costal margin and inferior
gluteal folds with or without leg pain
An estimated 80% of the normal population will experience
lower back pain in their lifetime
7. Risk Factors
Age (4th – 5th decade)
Gender (Men:Women = 3:1)
Obesity
Smoking (1.5-2.5 more risk)
Alcohol and drug abuse
Heavy lifting
Strenuous physical activity
Occupational driving
Poor posture
Previous back injury
Psychosocial and social factors
Family history
8. Clinical Features
Mechanical:
dull, aching pain which doesn’t radiate down the leg
aggravated with movement and relieved on rest
usually not possible to clinically distinguish the source of pain
Discogenic:
pain on flexion
Facetogenic:
pain on hyperextension
Neurogenic:
pain radiating down to the buttocks and posterior thigh
poor walking distance
9. Red Flags
(Indicate conditions in addition to back pain and warrant
investigations to exclude serious pathology)
Age on onset < 20 yrs or > 55 yrs
Recent history of trauma
Constant progressive, non mechanical pain
Thoracic pain
Past history of malignant tumour
Prolonged use of corticosteroids
Drug abuse, immunosuppression, HIV
Systemically unwell
Unexplained weight loss
Widespread neurological symptoms
Structural deformity
Fever
10. Yellow Flags
(Indicate psychosocial factors that increase the risk of
chronicity and disability from back pain)
Belief that back pain is harmful or potentially severely disabling
Fear and avoidance of activity or movement
Tendency to low mood and withdrawal from social interaction
Expectation of passive treatment(s) rather than a belief that active
participation will help
11. Examination
Inspection
Contour of the spine (kyphosis, lordosis or scoliosis)
Restriction of back movements
Palpation
Tenderness over spine or para-spinal muscles
Provocative tests
Straight leg raise sign (L4-S1)
Femoral stretch test (L2-L4)
Slump test
Neurological examination
Motor (Knee extension-L4, Dorsiflexion of foot and big toe-L5, Plantar flexion of foot-S1)
Sensory
Reflexes (Patellar tendon reflex-L4, Medial hamstring reflex-L5, Ankle reflex-S1)
Hips are examined to exclude hip joint pathology
Sacroiliac joints are routinely assessed by FABER/Patrick’s test
12. Straight leg raise test
If the patient experiences
sciatic pain, and more
specifically pain radiating
down the leg
(radiculopathy), when the
straight leg is at an angle of
between 30 and 70
then the test is positive and
a herniated disk is a
cause of the pain.
13. Femoral nerve stretch test,
also known as Mackiewicz
sign is a test for disc
protrusion
and femoral nerve injury.
The patient lies prone, the
knee is passively flexed to
the thigh and the hip is
passively extended.
The test is positive if the
patient experiences anterior
thigh pain.
14. Slump test
Positive sign is any kind of
sciatic pain (radiating, sharp,
shooting pain) or
reproduction of other
neurological symptoms.
This indicates impingement
of the sciatic nerve, dural
lining, spinal cord, or nerve
roots
15. The examiner lowers
the test leg toward the
examining table while
compressing the
opposite anterior
superior iliac spine.
A positive result
occurs when
the test leg remains
above the opposite leg,
usually with pain and
may indicate hip
disease, iliopsoas
spasm, or sacroiliac
disease.
16. Investigations
X-rays
May be normal
Flattening of the disc space and marginal osteophytes (Intervertebral disc
degeneration)
Slight displacement of one vertebra upon another, either forward
(Spondylolisthesis) or backward (retrolisthesis)
Blood Tests
FBC and ESR (screen for non-mechanical causes
In elderly, serum protein electrophoresis and prostate specific antigen should
be part of the workup
17. Investigations
CT & MRI
May reveal disc degeneration
Early features of OA in facet joints
Bone scan & SPECT scan
Active inflammatory conditions will show increased uptake in the facets and
sacroiliac joints.
Vertebral fractures and metastatic neoplasms can also be appreciated.
18. Diagnosis
Goal is to categorize the pain into three categories:
1. Serious spinal pathology
2. Neural pain
3. Non-specific back pain
History and examination are first directed at distinguishing between any
serious pathology and musculoskeletal back pain
Then, decide if there is a neural element of pain (spinal stenosis or
radiculopathy). If the neural pain source is absent from clinical findings,
the problem can be characterized as non-specific lower back pain
This assessment should be supported by X-rays, FBC and ESR.
Where there are “red flags” and/or abnormal specific findings, further
imaging (CT, MRI, Bone scan) may be required
19. Treatment
Conservative treatment
Reassurance
Medication (Paracetamol, NSAIDS, Short course of opioids or non-
benzodiazepine muscle relaxants for acute, TCAs for chronic and
Gabapentin for radiculopathy)
Activity modification
Physical therapy
Spinal support
Psychological support
Injection therapy (Nerve blocks in chronic radiculopathy, Epidural
steroids in spinal stenosis)
20. Treatment
Surgery
Very strict guidelines should be followed to avoid ‘failed back surgery’
1. Repeated examinations should ensure no other treatable pathology
2. At least some response to conservative treatment
3. Unequivocal evidence of pathology at specific level
4. Patient should be emotionally stable and should not exaggerate his/her symptoms
5. Patients expectations should be in line with the surgeons expectations
6. Surgery is effective in pain relief and deformity in infections, tumours and fractures.
Surgery is also cost effective and superior in degenerative conditions with neural
pain
7. Surgery for non-specific back pain is far less effective.
22. Intervertebral Disc
An intervertebral disc lies between adjacent vertebrae in the
vertebral column. Each disc forms a fibrocartilaginous joint to allow
slight movement of the vertebrae, to act as a ligament to hold the
vertebrae together, and to function as a shock absorber for the
spine.
From C2-C3 to L5-S1
Nucleus pulposus + Annulus fibrosus
L4-L5 disc, largest avascular structure in the body
23. Intervertebral Disc Prolapse
Intervertebral disc prolapse or herniation is a protrusion of the
nucleus of the disc into the annulus with subsequent nerve
compression.
Most common at L4-L5 and L5-S1 disc levels.
26. Pathophysiology
The cause of a herniated lumbar disc is usually a flexion injury, but many
patients don’t recall experiencing a traumatic event
The herniation compresses the spinal nerve root usually restricted to one
side. With further degeneration of the disk, may eventually produce
pressure on the spinal cord.
This sequence may take months to years, producing acute and chronic
symptoms.
27. Clinical Features
Disc may herniate without causing any symptoms
Symptoms depend on location, size, rate of development and
effect of surrounding structures
Symptomatic disc herniation may results in
pain
sensory changes
loss of reflexes
muscle weakness
28. Cervical Manifestations
Pain and stiffness in neck, shoulders and region of scapula
Pain in upper extremities and head
Paraesthesia and numbness in upper extremities
Weakness of upper extremities
29. Lumbar Manifestations
Lower back pain with varying degree of sensory and motor
dysfunction
Pain radiating to the buttocks and down the leg (Sciatica)
A stiff or unnatural posture
Some combination of paraesthesia, weakness and reflux
impairment.
30. On Examination
Patient will be tilted to his side (ipsilateral side in medial herniation and
contralateral side in lateral herniation) and will feel pain on straightening
the body or tilting to other side
Sometimes the knee on the affected side is held slightly flexed to relax the
tension on the sciatic nerve
Straight leg raise test may be positive, a crossed leg raise test-if present- is
highly specific for a disc prolapse
Femoral stretch test may be positive in high or mid-lumbar disc prolapse
31.
32. Investigations
CT and MRI usually confirms the diagnosis
Electromyography (can reveal nerve dysfunction, muscle
dysfunction or problems with nerve-to-muscle signal
transmission)
Myelogram (A special dye is injected in the spinal canal and
image is recorded by X-ray or CT fluoroscope. Myelogram can
show conditions effecting the spinal cord and nerves within
the spinal canal.
35. Treatment
The goals of treatment are
To rest and immobilize the spine to give the soft tissues
time to heal
To reduce inflammation in the supporting tissues and the
affected nerve roots in the spine
36. Non Interventional Treatment
Bed rest, heat, ice
Massage, spinal manipulation, spinal traction, acupuncture,
advice to stay active
Cervical collar or traction are widely used in case of cervical
disc prolapse
Physical exercise therapy
37. Medical Treatment
Anti inflammatory drugs such as ibuprofen or prednisone
Muscle relaxants such as diazepam or cyclobenzaprine
Analgesics, opioids may be necessary for several days acute
phase
38. Interventional Treatment
Following modalities are available
Epidural corticosteroids
Automated percutaneous discectomy
Laser discectomy
Percutaneous disc decompression
Chemonucleolysis dissolution of the nucleus pulposus by
percutaneous injection of a proteolytic enzyme (chymopapain)
39. Surgical Treatment
Indications for surgery include neurological deterioration, persistent pain
and failed conservative treatment.
The presence of prolapsed disc and its level must be confirmed by
imaging and anatomical location of disc prolapse must correlate with the
symptoms.
Different surgical techniques used are
Laminectomy
Laminotomy
Discectomy
Foraminotomy
41. Complications
Permanent neurologic dysfunction (weakness & numbness)
Chronic pain
Cauda equina syndrome: a rare disorder that is a surgical
emergency and an absolute indication for surgery. It occurs when
the bundle of nerves below the end of spinal cord is compressed or
damaged. Signs and symptoms include low back pain that radiates
down the leg, perineal numbness, and loss of bowel or bladder
control
Recurrent prolapse with sciatica (5-11%)
43. Spinal Stenosis
Refers to narrowing of the spinal canal, nerve root canals or
intervertebral foramina due to spondylolysis and degenerative
disc disease
Usually occurs in cervical or lumbar spine
More common in females
44. Etiology
Is part of aging process, it is not possible to predict who will be affected.
No clear correlation exists between the symptoms of stenosis and race,
occupation, gender or body type.
2 forms:
Primary: Congenital, uncommon, younger patients, occurs with achondroplasia
or hypochondroplasia
Acquired: Mostly a degenerative condition, but may also occur with
spondylolysis and spondylolisthesis, iatrogenic, post-traumatic, local infection
and metabolic stenosis.
45.
46. Anatomically, stenosis can be
Central Lateral Foraminal
Involves the area
between the facet
joints
Contains dural sac
and nerve roots
Lateral border of
dura to the medial
border of pedicle
defines the lateral
recess
Contains traversing
nerve roots
Situated under the
pars
Contains exiting
nerve roots
47. Pathophysiology
Degenerative disease is the most common
Involves changes in disc and facet joints
Synovitic changes, cartilage thinning and capsular laxity of facet joints allow increased
segmental motion and accelerated disc degeneration
This leads to loss of disc height and bulging or prolapse into the canal
Vertebral end-plate osteophytes also contribute to the stenosis and the normally oval
canal becomes trefoil-shaped.
Increasing canal narrowing, neural compression, vascular compromise and neural
demyelination cumulate in symptoms of spinal stenosis.
Spondylolysis, spondylolisthesis, foraminal disc herniation and a facet joint cyst
may result in stenosis
48. Clinical Features
Symptoms include aching, heaviness, numbness and paraesthesia in the
thighs and legs
Pain occurs after standing upright or walking for 5-10 mins and is relieved
by sitting, squatting or leaning against a wall to flex the spine (hence the
term ‘spinal claudication’)
Patients prefer walking uphill than downhill
49. Examination
Often the neurological examination is normal
Intact pedal pulses and absence of trophic skin changes will confirm the
claudication to be spinal
Pain is relieved on flexion of the spine, hence Shopping cart sign is present
Imperative to exclude vascular claudication, hip pathology and peripheral
neuropathy
50.
51. Investigations
X-rays
Not the most sensitive imaging study
Useful in excluding fracture, spondylolysis or neoplasm
Flexion extension views are useful to show spine instability
MRI
Investigation of choice
Non-invasive, safe, can differentiate different types
Disc degeneration, prolapse and facet arthrosis can be appreciated
CT myelogram
Indicated when MRI contraindicated
May better demonstrate canal narrowing with dynamic stenosis or scoliosis
52.
53. Treatment
Signs and symptoms of myelopathy or cauda equina
syndrome warrant urgent surgical decompression of the
spinal cord or nerve roots
Significant muscle weakness due to nerve root impingement
is also a strong indication for surgery
For the patients with LSS who do not have fixed or
progressive neurologic deficits, conservative treatment is the
first choice
54. Conservative Treatment
Reassurance and education
Analgesics and NSAIDS
Non-impact exercise programme, aerobic fitness, activity
modification
Epidural and nerve root steroid injections
55. Surgical Treatment
Posterior decompression is the mainstay of surgical treatment
Central stenosis: Laminectomy
Lateral recess stenosis: Undercutting facetectomies and removal of ligamentum
flavum
Foraminal stenosis: Fusion to decompress and maintain foramen patency
Spinal stenosis with spondylolysis, spondylolisthesis, scoliosis and kyphosis are
indications for fusion with decompression
SPORT (Spine Patient Outcomes Research Trial) confirmed the cost effectiveness of
surgery over non-operative treatment over a 4 year period for spinal stenosis