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Lower back pain

Updated: Feb 1, 2021

Definition

LBP is defined as pain or discomfort below the costal margin and above the inferior gluteal folds, with or without referred leg pain

Localised = Axial pain

Radiating pain = Radicular


Spondylolysis = Fracture of pars interarticularis. Bilateral in 80% of cases. 90% at L5

Facet arthritis = localised pain across the back with radiation occasionally into buttock or thighs. Discomfort reproduced by lumbar extension and rotation.


Lumbar stenosis = Commonly in over 60yo and by large central disc herniation.

Other possible pathology includes: disc bulging, facet capsular hypertrophy, ligamentum flavum, spondylolisthesis, and osteophytes. Wide based gait and absent ankle reflexes can occur (though less than 50%). 20-30% of patients will be asymptomatic


Remember - sitting and lying opens up lumbar region given symptom relief. Thus, walking (neurogenic claudication) becomes uncomfortable as the nerves become ischaemic


Sacroiliac joint dysfunction = pain over the superior aspect of the buttock adjacent to the L5 vertebrae. Pain reproduced with lumbar flexion and extension. Tests include: pelvic distraction/compression, gaenslens, FABER and thigh thrust


Presentation

- CLBP is a heterogenous condition with multiple potential pathologies

- 80-85% of back pain is 'non-specific' - It cannot be related to a biological origin

- There are probably about 20 different 'phenotypes'

- There is a significant lack of clear guidelines and evidence is often poor-quality


History factors

- Red flags must always be explored including: Incontinence, saddle anaesthesia, nocturnal pain, fever, progressive leg weakness)(THIS NEEDS EXPANSION)

- Pharmacological therapies tried (e.g. opioids, substance use disorder)

- Occupational history and work performance issues

- Patient's beliefs about the problem


Epidemiology

- Leading cause of job related disability in the US (and likely Australia?)

- 80% of people will experience back pain in their lifetime

- 20% of people will experience pain at 1 year after initial pain

- 80-90% of acute back pain will self-resolve

- L5 nerve root is most common affected in radicular pain


Risk factors

- Age 50-69yo

- Lower high school education (?? More physical jobs)

- Low household income (Again - more physical job?)

- Depression

- Poor sleep


Pathophysiology


Examination

- Gait assessment (?antalgic)

- Visual inspection of the back (can mark pain - remember L4-5 at top of iliac crests)

- Palpation of the back

- Focused neurological examination

- Assessment of lumbar range of motion

- Use of special manoeuvres (SLR, FABER)

- Reflexes: Knee jerk (L2, L3, L4), Ankle jerk (S1, S2)


Sensory:

L2-proximal antero-medial, thigh;

L3-medial, knee

L4-medial, mid leg

L5-lateral, mid leg

S1 lateral, foot


Assess motor function:

L2, L3, hip flexors

L3, L4, knee extensors

L4, L5, foot dorsi-flexors

S1, S2, foot plantar flexors

S2, S3, S4 - Rectal tone


Romberg’s sign (patient standing, eyes open, steady, then falling with eyes closed)

- indicates a proprioceptive problem either in the periphery (eg, olyneuropathy) or centrally (eg, spinal cord dorsal columns).


L5 Radiculopathy = Diminished foot dorsiflexion, toe extension, and both foot inversion and eversion.

S1 Radiculopathy = Sensory change along posterior leg and bottom of foot. Weakness on plantar flexion and possibly hip extension and knee flexion. Ankle reflexes may be absent


Investigations (if required)


- Xray's

- CT = For osseous structures of the spine

- MRI = Best for marrow, intervertebral discs, soft tissues, and spinal canal structures

T1-weighted sagittal

T1-weighted image obtained following the administration of intravenous gadolinium

T2 fat-suppressed or short tau inversion recovery (STIR) sagittal

T2-weighted sagittal and axial sequences


Joint nerve blocks, such as lumbar facet joint injections, have been shown to diagnose effectively 89.5 % of patients and are able to provide pain relief in 80 % of patients (Pampati et al, 2009).


Treatment

- Initially physical therapy is critically important

- NSAIDs can be utilised

- Aims are to return to a point of function


- Interventions, acupuncture etc - used to facilitate active exercise therapy

(Core, gluteus stretching, posture, deep hip flexors)

- Address bad occupational habits

- Epidural steroid injections provide modest benefit lasting 3 mths (el-Khoury GY & Renfrew, 1991).

- Surgery is a final option (Chen et al, 2017)

  • Discectomy for a herniated disc.

  • Decompressive laminectomy for spinal stenosis, kyphoplasty.

  • Vertebroplasty for compression fractures.

  • Arthrodesis for spinal fusion.


Prognosis


Golden pearls


References / Articles / Resources


Argoff, C. E., Dubin, A., Pilitsis, J., & McCleane, G. (2009). Pain management secrets E-Book. Elsevier Health Sciences.


Chen K.Y., Shaparin N., Gritsenko K. (2017) Low Back Pain. In: Yong R., Nguyen M., Nelson E., Urman R. (eds) Pain Medicine. Springer, Cham. https://doi-org.ezproxy.anzca.edu.au/10.1007/978-3-319-43133-8_121


el-Khoury GY, Renfrew DL. Percutaneous procedures for the diagnosis and treatment of lower back pain: diskography, facet-joint injection, and epidural injection. AJR Am J Roentgenol. 1991;157(4):685–91.


Pampati S, Cash KA, Manchikanti L. Accuracy of diagnostic lumbar facet joint nerve blocks: a 2-year follow-up of 152 patients diagnosed with controlled diagnostic blocks. Pain Physician. 2009;12(5):855–66



Essential readings:




Apkarian AV, Robinson JP. 2010. ‘Low back pain’. IASP Pain Clinical Updates XVIII (6):1–6. PDF


Bogduk, N, Fraifeld, EM. 2010. ‘Proof or consequences: who shall pay for the evidence in pain medicine?’. Pain medicine 11 (1): 1–2. EZ


Bogduk, N. 2005. ‘A narrative review of intra-articular corticosteroid injections for low back pain’. Pain medicine 6 (4): 287–96. EZ



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