LOWER BACK PAIN
CAUSES
LUMBAR DISC DISEASE
Common cause of low backand leg pain,usually at L4-L5 or L5-S1 levels.Dermatoma sensory loss ,reduction or loss of deep tendon reflexes or myotomal pattern of weakness more informative than pain pattern for localization .Usually unilateral ,bilateral with large central disk herniations compressing multiple nerve roots__ may cause cauda equina syndrome .
Indication for lumbar disk surgery
(1) Progressive motor weakness from nerve root injury .
(2) Progressive motor impairment by EMG.
(3)Abnormal bowel or bladder function .
(4) Incapicitating nerve root pain despite conservative treatment for at least 4 weeks ,and (5)recurrent incapacitating pain despite conservative treatment .The latter two criteria are controversial.
SPINAL STENOSIS
A narrowed spinal caal producing neurogenic claudication i.e buttock ,and/or leg pain induced by walking or standing and relieved by sitting.Symptoms are usually bilateral.Unlike vascular claudication smptoms are provoked by standing without walking .Unlike lubar disk disease, ,symptoms are relieved by sitting.Focal neurogenic deficits common ,severe neurologic deficits ( paralysis ,incontinence ) rare.Stenosis results from acquired (75%) ,congenital ,or mixed acquired/congenital factors.Symptomatic treatment adequate for mild disease,surgery indicated when pain inerferes with activities of daily living or focal neurologic signs present.Surgery successful in 65-80%.25% develop recurrent stenosis within 5 yeas.
TRAUMA
Low back strain or sprain used to describe minor ,self-limited injuries associated with Low Back Pain.Vertebral fractures from trauma result in weging or compression of vertebral bodies.burst fractures involving anterior and posterior spine elements can occur.Neurlogic impairment common with vertebral fractures early surgical intervention indicated.Most common cause of non-traumatic fractureis osteoporosis,others are osteomalacia ,hyperthyroidism ,hyperthyroidism ,multiple myeloma ,or metastatic carcinoma ,glucocorticoid use may predispose vertebral body to fracture .Clinical context ,exam findings,and spine X-rays establish diagnosis.
SPONDYLOLISTHESIS
Slippage of anterior spine forward ,leaving posterior element behind .L4-L5 >L5-S1 levels, can produce LBP or radiculopathy /cauda equina syndrome.
OSTEOARTHRITIS
Back pain induced by spine movement .Increases with age radiologic findings do not correlate with severity of pain.Facet syndrome __ radicular symptoms and signs,nerve root compression by unilateral facet hypertrophy.Foraminotomy and facettectomy __ long-term pain relief in 80-90% .Loss of intervertebral disk height reduces vertical dimensions of intervertebral foramen,descending pedicle can compress the exiting nerve root.
VERTEBRAL METASTASES
Back pain most common neurologic symptoms in patients with systemic cancer.Metastatic carcinoma ,multiple myeloma and lymphomas frequently involve spine.Back pain may be presenting symptoms of cancer .pain typicaly unrelieved by rest .MRI or CT -myelography demonstrates vertebral body metastasis ,disk space is spared.
VERTEBRAL OSTEOMYELITIS
Back pain unrelieved by rest ,focal spine tender-ness,elevated ESR.Primay source of infection ( lung ,urinary tract ,or skin ) found in 40% .IV drug abuse a risk factor .Destruction of the vertebral bodies and disk space common.Lumbar spinal pidural abscess presents as back pain and fever ,exam may be normal or show radicular findings ,spinal cord involvement ,or cauda equina syndrome ,abscess extent best defined by MRI.
LUMBAR ARACHNOIDITIS
May follow inflammatory response to local tissue injury within subarachnoid space ,fibrosis results in clumping of nerve roots,best seen by MRI treatment is unsatisfactory.
IMMUNE DISORDERS
Ankylosing spondylitis ,rheumatoid arthritis ,Reiter's syndrome ,psoriatic arthritis ,and chronic inflammatory bowel disease.Ankylosing spondylitis __ typically male <40 years with nocturnal back pain.pain unrelieved by rest but improves with exercise.
OSTEOPOROSIS
Loss of bone substance resulting from hyperparathyroidism chronic glucocorticoid use ,immobilization,or other medical disorders.Sole manifestation may be pain exacerbated by movements.
VISCERAL DISEASES
Pelvis refers pain to sacral region .lower abdomen to lumbar region,upper abdomen to lower thoracic or upper lumbar region.Local signs are absent ,normal movements of yhe spine are painless.A contained rupture of abdominal aortic aneurysm may produce isolated back pain.
OTHER
Chronic LBP with no clear cause ,psychiatric disorders ,substance abuse may be associated.
CAUSES
LUMBAR DISC DISEASE
Common cause of low backand leg pain,usually at L4-L5 or L5-S1 levels.Dermatoma sensory loss ,reduction or loss of deep tendon reflexes or myotomal pattern of weakness more informative than pain pattern for localization .Usually unilateral ,bilateral with large central disk herniations compressing multiple nerve roots__ may cause cauda equina syndrome .
Indication for lumbar disk surgery
(1) Progressive motor weakness from nerve root injury .
(2) Progressive motor impairment by EMG.
(3)Abnormal bowel or bladder function .
(4) Incapicitating nerve root pain despite conservative treatment for at least 4 weeks ,and (5)recurrent incapacitating pain despite conservative treatment .The latter two criteria are controversial.
SPINAL STENOSIS
A narrowed spinal caal producing neurogenic claudication i.e buttock ,and/or leg pain induced by walking or standing and relieved by sitting.Symptoms are usually bilateral.Unlike vascular claudication smptoms are provoked by standing without walking .Unlike lubar disk disease, ,symptoms are relieved by sitting.Focal neurogenic deficits common ,severe neurologic deficits ( paralysis ,incontinence ) rare.Stenosis results from acquired (75%) ,congenital ,or mixed acquired/congenital factors.Symptomatic treatment adequate for mild disease,surgery indicated when pain inerferes with activities of daily living or focal neurologic signs present.Surgery successful in 65-80%.25% develop recurrent stenosis within 5 yeas.
TRAUMA
Low back strain or sprain used to describe minor ,self-limited injuries associated with Low Back Pain.Vertebral fractures from trauma result in weging or compression of vertebral bodies.burst fractures involving anterior and posterior spine elements can occur.Neurlogic impairment common with vertebral fractures early surgical intervention indicated.Most common cause of non-traumatic fractureis osteoporosis,others are osteomalacia ,hyperthyroidism ,hyperthyroidism ,multiple myeloma ,or metastatic carcinoma ,glucocorticoid use may predispose vertebral body to fracture .Clinical context ,exam findings,and spine X-rays establish diagnosis.
SPONDYLOLISTHESIS
Slippage of anterior spine forward ,leaving posterior element behind .L4-L5 >L5-S1 levels, can produce LBP or radiculopathy /cauda equina syndrome.
OSTEOARTHRITIS
Back pain induced by spine movement .Increases with age radiologic findings do not correlate with severity of pain.Facet syndrome __ radicular symptoms and signs,nerve root compression by unilateral facet hypertrophy.Foraminotomy and facettectomy __ long-term pain relief in 80-90% .Loss of intervertebral disk height reduces vertical dimensions of intervertebral foramen,descending pedicle can compress the exiting nerve root.
VERTEBRAL METASTASES
Back pain most common neurologic symptoms in patients with systemic cancer.Metastatic carcinoma ,multiple myeloma and lymphomas frequently involve spine.Back pain may be presenting symptoms of cancer .pain typicaly unrelieved by rest .MRI or CT -myelography demonstrates vertebral body metastasis ,disk space is spared.
VERTEBRAL OSTEOMYELITIS
Back pain unrelieved by rest ,focal spine tender-ness,elevated ESR.Primay source of infection ( lung ,urinary tract ,or skin ) found in 40% .IV drug abuse a risk factor .Destruction of the vertebral bodies and disk space common.Lumbar spinal pidural abscess presents as back pain and fever ,exam may be normal or show radicular findings ,spinal cord involvement ,or cauda equina syndrome ,abscess extent best defined by MRI.
LUMBAR ARACHNOIDITIS
May follow inflammatory response to local tissue injury within subarachnoid space ,fibrosis results in clumping of nerve roots,best seen by MRI treatment is unsatisfactory.
IMMUNE DISORDERS
Ankylosing spondylitis ,rheumatoid arthritis ,Reiter's syndrome ,psoriatic arthritis ,and chronic inflammatory bowel disease.Ankylosing spondylitis __ typically male <40 years with nocturnal back pain.pain unrelieved by rest but improves with exercise.
OSTEOPOROSIS
Loss of bone substance resulting from hyperparathyroidism chronic glucocorticoid use ,immobilization,or other medical disorders.Sole manifestation may be pain exacerbated by movements.
VISCERAL DISEASES
Pelvis refers pain to sacral region .lower abdomen to lumbar region,upper abdomen to lower thoracic or upper lumbar region.Local signs are absent ,normal movements of yhe spine are painless.A contained rupture of abdominal aortic aneurysm may produce isolated back pain.
OTHER
Chronic LBP with no clear cause ,psychiatric disorders ,substance abuse may be associated.
