low%20back%20pain
LOW BACK PAIN
It is pain, stiffness, or discomfort in the lower back area below the costal margin & above the gluteal creases.
Low back pain is also called spinal pain or lumbago.
Nonspecific low back pain is without identifiable specific causes that makes up 85-90% of all low back pain cases.  It also includes pain felt in the proximal lower extremities
Patients with low back pain maybe associated with mobility deficits caused by severe or progressive neurologic disorders or comorbidities.
Specific spinal pathology includes cauda equina syndrome, tumor, infection, ankylosing spondylitis, inflammatory disorders.
Low back pain associated w/ radiculopathy or spinal stenosis are dermatomal pain w/ or w/o neurologic deficits that most often caused by nerve root compression.

Diagnosis

Red Flags

  • Take note of symptoms that may be secondary to underlying diseases
  • Cancer
  • Infection (tuberculosis, pyogenic abscess)
  • Fracture
  • Cauda equina
  • Progressive motor weakness

Yellow Flags

  • Psychosocial factors that may contribute to the chronicity of the disease
  • Mood changes
  • Level of job satisfaction
  • Attitude toward treatment participation
  • Attitude towards the disease
  • Involvement of loved ones w/ the management

Classification

Nonspecific Low Back Pain

  • Low back pain w/o identifiable specific causes
  • Makes up 85-90% of all low back pain cases
  • Also includes pain felt in the proximal lower extremities

Specific Spinal Pathology

  • Patients w/ low back pain w/ associated mobility deficits caused by severe or progressive neurologic disorders or comorbidities
  • Specific spinal pathology includes cauda equina syndrome, tumor, infection, ankylosing spondylitis, inflammatory disorders

Low Back Pain Associated w/ Radiculopathy or Spinal Stenosis

  • Dermatomal pain w/ or w/o neurologic deficits
  • Most often caused by nerve root compression

Evaluation

Pain Intensity Level

Visual Analog Scale

  • A subjective examination that quantifies how patients rate the level of pain

Oswestry Disability Index (ODI)

  • A subjective tool used to evaluate a patient’s perceived functional disability
  • Score Perceived Disability Level
    0-20% Minimal disability
    21-40% Moderate disability
    41-60% Severe disability
    61-80% Crippled
    81-100% Bedridden

Roland-Morris Disability Questionnaire (RMDQ)

  • A disability measure to assess the subject’s disability caused by back pain
  • Patients w/ minimal disability perceives their pain as a disease that can be dealt even w/o treatment
  • Patients w/ scores of 21-40% experiences pain w/ regular movements (sitting, standing) & may complain of difficulty going to work
    • May demand conservative treatments
  • Patients w/ severely disabling pain are apprehensive to go about w/ their daily life if rigorous examinations &treatments are not provided
  • Patients w/ ODI scores of 61-80% are those whose everyday activities are greatly affected
    • Treatments & positive interventions are highly suggested

History

Pertinent Features:

  • Location of pain
  • Duration of pain
  • Frequency of symptoms
  • Medical history (previous history of pain, treatment, & treatment response)
  • Presence of weakness or neurologic deficits
  • Presence of red flags

Duration of Symptoms

Acute

  • Onset of symptoms <6 weeks
    • Early acute - symptoms occurred <2 weeks
    • Late acute - symptoms occurred 2-6 weeks

Subacute

  • Symptoms appeared >6 weeks but <12 weeks prior to consult

Chronic

  • Onset of symptoms >12 weeks before consultation
  • Continuous or recurrent pain

Physical Examination

Neurologic Exam

  • Examine muscle strength, deep tendon reflexes & sensation
  • Presence of muscle atrophy

Laboratory Tests

  • Complete blood count (CBC), erythrocyte sedimentation rate (ESR)
  • Used to rule out presence of tumor or infection

Imaging

  • Not recommended for patients w/ nonspecific low back pain
  • Should be considered if red flags are suspected, surgery is being contemplated, & presentation is unconventional

Magnetic Resonance Imaging (MRI)

  • Imaging modality of choice
  • Should be considered for assessment of radicular symptoms, asymptomatic low back pain, chronic low back pain w/ red flags, subacute or chronic radicular pain w/ no improvement seen after 6 weeks of treatment
  • Indications:
    • Neurologic deficit (foot drop, hip flexion, knee extension)
    • Cauda equina syndrome
    • Persistent & progressive severe pain even w/ conservative treatments
    • Neoplasm is highly suspected
    • Presence of infection highly likely
    • Trauma
    • Unresponsiveness to therapy & surgery is being considered

Computed Tomography (CT)

  • May be considered in patients w/ acute or subacute radicular pain unresponsive after
  • 4-6 weeks of therapy, presence of red flags
  • CT myelography may be considered in patients w/ contraindications to MRI, if MRI is inconclusive, if w/ suspected bone neoplasms or w/ severe incapacitating back/leg pain

Radiography

  • Recommended for the evaluation of obvious deformities, acute low back pain w/ presence of red flags, & vertebral compression fracture
  • Anteroposterior (AP) & lateral views are indicated for acute low back pain that persists for >2 weeks w/o red flags
  • Flexion extension & oblique views are indicated when lumbosacral spine instability, spondylolysis or spondylolisthesis are suspected
  • Myelography may be considered if presentation of disease is uncommon

Radionuclide Scanning

  • May be used in patients suspected to have vertebral cancer

Nerve Conduction Studies

  • Successfully identifies precise cause of nonradicular pain
  • May be considered for patients at high risk for extra-spinal pathologies

Electromyography (EMG)

  • May be considered for assessing acute low back symptoms & chronic nonspecific low back pain
  • Needle EMG may be considered in patients w/ probable nerve root dysfunction of the lower extremities whose symptoms persist for >4 weeks

Spinal Diagnostic Interventional Techniques

  • Eg Facet joint nerve block, sacroiliac joint injection, provocation discography
  • Consistent pain relief every time the affected nerve is anesthetized repeatedly may accurately identify the cause of low back pain

Invasive Diagnostic Procedure

Invasive Diagnostic Procedure

Lumbar Provocation Discography

  • Identifies intervertebral disc pathologies causing low back pain
  • Indicated for patients w/ chronic low back pain w/ symptoms inconsistent w/ findings of magnetic resonance imaging (MRI)/computed tomography (CT) scan
  • Studies show that lumbar discography is more accurate than myelography
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