Approach to Low Back Pain

Dr. Ihteshamul Hoque

FCPS part-2 trainee
Medicine unit-IV
Dhaka Medical College Hospital
LBP: Introduction

• Pain below the costal margin & above the inferior gluteal folds, ± leg
pain

• ≈ 84% of adults have LBP at some time in their lives

• Most common form is NSLBP (upto 85%)- when the patho-anatomical

cause cannot be determined

• Patients with acute NSLBP are mostly (> 90%) pain free within 8 weeks
Is this really a problem?

•Number one cause of disability globally

•Commonest cause of sickness related work absence in Western

countries

•Forces more people out of the workplace than heart disease, DM,
HTN, neoplasm, respiratory disease/asthma combined

•Total costs of CLBP in USA exceed $200 billion annually

LBP: Epidemiology*

• Prevalence: 18·3%, 1-month prevalence: 30·8%

• Affects Female>Male; most common in 40–69 year- age- group

• Prevalence: greater in high-income (30·3% ) than middle (21·4%) or

low- (18·2%) income countries

*Lancet 2017; 389: 736–47 Published Online October 10, 2016

LBP: Epidemiology*

• 90% of American adults experience an episode of back pain during their

lifetime

• Only 5% - 10% patients manifest more serious pathology:

 Malignancy (0.7%)  Ankylosing spondylitis (0.3%)

 Infectious disease (0.01%)  Spinal stenosis (3%)

 Cauda equina syndrome (0.04%)  Symptomatic herniated disc (4%)

* Deyo RA, et al. JAMA.

LBP: Epidemiology(COPCORD:
Bangladesh)*
• 1/3rd of the Bangladeshi adults suffer from MSK pain (point prevalence 33.7%)

• Female(38.7%)>Male (28.4%); rural (34.5%)>urban (32.4%)areas

• Higher in homemakers (16.0%), laborers (3%), business professionals (2.9%) &

cultivators (2.8%)

• LBP (23.3%), non-specific LBP (12.7%)

*10.1136/annrheumdis-2017-eular.2562
Anatomy of lower back
Pain sensitive structures of the spine

• Periosteum of the vertebrae

• Facet joint
• Dura
• Annulus fibrosus of the intervertebral disk
• Epidural veins and arteries
• Longitudinal ligaments
Risk factors for LBP

• Obesity • Low income

• Age • Job dissatisfaction
• Heavy lifting • Smoking
• Pregnancy • Somatization disorder
• Sedentary work • Anxiety
• low educational attainment • Depression
LBP: Classification (duration)
• Acute: Lasts <4 weeks

• Subacute: Lasts 4-12 weeks

• Chronic: Lasts>12 weeks

LBP: Classification (etiology)

Specific (15-20%)
•Specific pathophysiological mechanisms (spinal/non spinal origin)
•Specific Mx required
Spinal origin Non-spinal origin
• Herniated disk
• Spinal stenosis • Pelvic organs: Prostatitis, endometriosis
• Vertebral Fracture
• Vascular: Aortic aneurysm

Nonspecific (80-85%)
•No clear nociceptive-specific cause
•Uneventful recovery in most cases, in short period of time
LBP: ETIOLOGIES
Mechanical low back pain Nonmechanical low back pain (specific) Visceral disease (specific)
Non specific Neoplasia Pelvic organs
• Lumber strain • Multiple myeloma • Prostatitis
• Metastatic carcinoma • Endometriosis
• Spinal cord tumors • Chronic pelvic
Specific LBP inflammatory disease
• Discs(spondylosis)
• Facet joints(osteoarthritis)
•Spondylolisthesis Infection
Renal disease
•Herniated disc • Osteomyelitis
• Septic discitis • Nephrolithiasis
•Spinal stenosis • Pyelonephritis
•Osteoporosis • Paraspinous abscess
• Epidural abscess • Perinephric abscess
•Fractures
• Congenital disease
- Severe kyphosis Inflammatory arthritis
- Severe scoliosis Aortic aneurysm
• Ankylosing spondylitis
• Spondylolysis • Psoriatic spondylitis Gastrointestinal disease
• Reactive arthritis • Pancreatitis
• Inflammatory bowel disease • Cholecystitis

Paget disease
LBP: Clearing up the
terms
Spondylosis :
Arthritis of the spine (arthritic changes of
the facet joint and disc space narrowing )

Spondylolysis :
A fracture in the pars interarticularis ( a
segment near the junction of the pedicle
with the lamina)

Spondylolisthesis :
Displacement of a vertebral body relative
to the one below
LBP: Clearing up the terms
Kyphosis : Outward curve of the
thoracic spine (at the level of the ribs)

Scoliosis : Sideways curvature of the

spine

Lordosis : Inward curve of the lumbar

spine (just above the buttocks)
LBP: Clearing up the terms
Spinal stenosis:
Narrowing of vertebral canal by bone or soft
tissue elements (usually bony hypertrophic
changes in the facet joints & by thickening of
the ligamentum flavum)

Radiculopathy:
Impairment of nerve root causing radiating
pain, numbness, tingling or muscle
weakness that corresponds to a specific
nerve root
LBP: Red flags
• Age <20 or >55 at presentation • I/V drug use

• Duration > 6 weeks • Major trauma

• Constant, progressive pain • Systemic upset, unexplained fever,

unrelieved by rest sweats, weight loss

• H/O: cancer, TB, HIV, systemic GC, • Focal neurologic deficit,

osteoporosis progressive or disabling symptoms
Evaluation of LBP
LBP: History

Symptom complex Possible Diagnosis

• Weight loss • Malignancy

• Long lasting pain(months)  Metastases >primary osteosarcoma
• Doesn’t vary with movement  Look for primary(breast, bronchus,
• Constant, dull, unrelieved by rest and worse at night prostate, kidney, thyroid are common)
 Most common in thoracic spine

• Young patient
• Morning stiffness for an hour or more • Spondyloarthritis
• Sacroiliac (buttock) pain
• Asymmetrical swelling of individual fingers or toes
• Enthesitis
• Person or family history of psoriasis or IBD
LBP: History

Symptom complex Possible Diagnosis

• Sudden pain • Collapse vertebral fracture

• Severe and localized
• History or risk factors of osteoporosis
• New or worsening kyphosis

• Recent infection(UTI, skin, soft tissue, bursitis, site • Vertebral osteomyelitis

of vascular access, septic arthritis)  lumber spine is most commonly affected
• Fever  Complicated by epidural or paravertebral
• Insidious onset, progressively worsen over several abscess, may result in neurological
weeks, worse at night complication (radiculopathy, spinal cord
• Immunosuppressive, H/O IV drug abuse compression)
LBP: History
Symptom complex Possible Diagnosis

• Sudden onset • Nerve root compression

• Radiates down leg
• Neurological symptoms • Sphincter disturbance and saddle anesthesia may
suggest cauda equina syndrome

• Typically in back and buttocks or legs • Lumber spinal stenosis

• Aggravate by walking or standing and relived by LBP + Wide-based gait, >90% specificity for
sitting or flexion forward lumber spinal stenosis
• Unsteadiness of gait (Wide-based gait)
LBP: History
Symptom complex Possible Diagnosis

• Mild to severe • Mechanical LBP

• Pain limited to back or upper leg Recurrent episodes
• Pain varies with physical activity (improved with Prognosis good (90% recovery at 6
rest) week)
• Recent minor injury (lifting heavy object,
twisting injury)
• No neurological symptoms or sign
• No systemic features
LBP: Examination
LOOK:
• Deformity (kyphosis, scoliosis, gibbus), scars, swelling, erythema

FEEL:
• Tenderness in spinous processes ( fracture, dislocation, infection or arthritis )

• Any step-offs( spondylolisthesis)

• Muscle spasm or tenderness (degenerative or inflammatory process, prolong

contraction from abnormal posture or anxiety)

• Sacroiliac joint tenderness (sacroiliitis)

LBP: Examination
MOVE:
• Forward flexion - Limited in PIVD, Lumbar
spondylosis

• Extension - Limited in facet joint pathology, PIVD

• Lateral flexion - Limited in early stages of

ankylosing spondylitis

• Rigid spine- Late stage of ankylosing spondylitis

LBP: Examination

Sensory:
• Sensory deficits: touch,
position sense, temperature,
vibration
• Allodynia: light touch
• Hyperalgesia: single, multiple
pinpricks
LBP: Examination

Gait:
Antalgic gait: Hip or knee disease
Walks slightly flexed: spinal canal stenosis
Heel walking: L5
Toe walking: S1
Lumbar nerve root entrapment:
symptoms and signs
Nerve Motor Screening Sensory loss Reflex
root weakness examination loss

L4 Knee extension Squat and Medial calf knee

rise

L5 Dorsiflexion of Heel walking Dorsal foot

great toe and -
foot
S1 Plantar flexion of Walking on Lateral foot Ankle
great toe and toes
foot
Special test
• SLRT (straight leg–raising test )
• Cross limb SLRT
• Femoral stretch test
• FABER test
• Schober’s test
SLR (straight leg raise test )
• The test is positive: if radicular pain is
produced between 30-700

• Dorsiflexion of the ankle further

stretches the sciatic nerve and
increases the sensitivity of the test
(Bragard’s test)

• The crossed SLR (radicular pain

reproduced when the opposite leg is
raised) is highly specific but
insensitive for a clinically significant
disk herniation
Femoral stretch test
• Patient lies on unaffected side with
lower knee & hip in slight flexion

• Support the patient’s pelvis & lift the

affected limb, slowly move it backward
to cause about 150 hip extension &
gradually flexed the knee

• Test is positive if anterior thigh pain

(stretches the L2-L4 nerve roots)
Schober’s test

• Mark the skin in the midline at the

level of posterior iliac spines (L5), Schober’s
which overlie the SI joints Test

• Draw two more marks 5 cm below

and 10 cm above this mark

• Ask the patient to touch his toes

• An increase of less than 5cm

distance between the two marks
indicates limitation of lumber flexion
FABER test
• Ankle rest above the patella of opposite limb

• Placed one hand medial side of knee & other

hand in front of iliac crest of opposite site

• Gradually press down over knee

• Other hand provide counter pressure &

stabilizes the pelvis on the table

• Test is positive if patient complain of pain on

anterior hip or groin
Nonorganic signs (Waddell's signs):

•Nonorganic tenderness: Superficial or nonanatomic distribution

•Stimulation test: Pain with axial loading

•Distraction test: Inconsistency on positional SLR

•Regional disturbances: “Giving way” weakness or non-dermatomal sensory

disturbances

•Overreacting: Inappropriate or exaggerated responses

Avoid diagnostic trap

• Disease of organs that share segmental innervation can cause

referred pain to spine:

Back pain may be the first and only manifestation

Local signs (tenderness to palpation, paravertebral muscle spasm

& increased pain on spinal motion) are absent
Avoid diagnostic trap

Referred pain:

Upper abdomen disease to lower thoracic/ upper lumber region(T8-L1/L2)

Lower abdomen disease to mid-lumbar region(L2-L4)

Pelvic disease to sacral region

 Back pain

Approach
Primary back pain
to Diagnosis Referred

Relieved by rest Not relieved by rest

Red Flag Relieved by Exercise

Localized to back Radiation Claudication

Spondyloarthritis
• Transient-
•<20 – Listhesis
Strain/Sprain Major • Focal neurological
Spinal stenosis Constitutional
•20-40 – Disc prolapse trauma deficit
• Intermittent- symptoms • Bowel/Bladder
Facet joint, IVD involvement
• Elderly –
 Compression #
 Spondylosis
• Tumor cauda equina
• Infection Fracture
syndrome
LBP: Investigations
• Laboratory studies are rarely needed for the initial evaluation of acute
NSLBP

• Indication:
Significant non mechanical component of pain
Systemic symptoms such as fever
Atypical pain pattern or distribution
Older patients (>55 years)
Not responding to standard conservative treatment of mechanical LBP
LBP: Investigations

Laboratory tests:
CBC, ESR ,CRP (Infection & inflammatory disease)
 S.protein electrophoresis (myeloma)
Prostate-specific antigen(prostate carcinoma)
HLA-B27 (axSpA)
LBP: Investigations (Imaging)

• Imaging studies are infrequently needed

• Indication:
Severe progressive neurologic deficits
S/S that suggest a serious underlying condition
When the pain doesn’t improve after 4 weeks

• Imaging techniques: Radiography, CT scan, MRI

S/S of cauda equina syndrome or Yes Emergency MRI & specialist
significant neurological deficit consultation
LBP:
No
Approach of Imaging (Acute LBP)
•Radiography suggests cancer:
yes Evaluation of malignancy
Moderate - high
risk for cancer • Radiography normal but
ESR/CRP high: MRI
No

S/S & risk factor for •Moderate to high suspicion: MRI

yes
spinal infections
•Low suspicion: ESR/CRP
No Elevated: MRI
Normal: No imaging

Risk for vertebral Yes

compression fracture Plain radiography

Conservative therapy for

No 4-6 weeks
Grade-2 sacroiliitis Grade-4 sacroiliitis
Treatment of LBP
 Focused history & physical examination

Red flags Neurologic signs & symptoms

NSLBP/Mechanical

• X-ray Conservative care

• ESR/CRP • Cauda equina
Radiculopathy without
• If high index of syndrome
serious/progressive Spinal stenosis
• Progressive
suspicion- MRI neurologic deficit
neurologic deficit If not improved:
X-ray, ESR/CRP
MRI & urgent • No serious
• Systemic disease : surgical consultation • Conservative care : 4-6
weeks neurologic deficit:
Specific Rx. • Symptoms
conservative care
manageable: continue
• No systemic disease: • No improvement: MRI conservative care
• Serious/ progressive
Conservative care
• Neurologic progression: neurologic deficit:
• Chronic LBP:
surgical consultation MRI & surgical
Interdisciplinary
consultation
rehabilitation ê CBT
Prognosis
• Prognosis of ALBP is generally excellent

• 1/3rd of patients seek medical care; 70%-90% improve within 7 weeks

• 2/3rd of patients will experiences a second episode within 1 year

• Only 5%-10% patients may develop CLBP

Myths and Facts

• Patients treated with bedrest have more

Movement makes back pain and slower recovery than ambulatory
pain worse patients

• Imaging abnormalities frequently present

A scan will show exactly
in asymptomatic individuals
what is wrong
• Early imaging rarely indicated in absence of
red flags
Take Home Message

• ≈ 84% of adults have LBP at some time in their lives

• >90% of patients with NSLBP are mostly pain free within 8 weeks

• Patients who are treated with bedrest have more pain and slower
recovery than ambulatory patients

• Early imaging rarely indicated in absence of red flags

References
1. Harrison’s Principles of Internal Medicine 21st Edition
2. Kelley’s Textbook of Rheumatology 11th Edition
3. Davidson’s Principles and Practice of Medicine 24th Edition
4. Kumar and Clark’s Clinical Medicine 10th Edition
5. Talley’s Clinical Examination 8th Edition
6. UpToDate
7. The New England Journal of Medicine (N Engl J Med 2022;386:1732-40)
8. The Lancet (Lancet 2017;389:736-47)
9. Deyo RA, et al. JAMA. 1992;268(6):760-765
10. www.ExaminationVideos.com
THANK YOU
LBP: Treatment(Acute LBP)
• 1st line : NSAIDs
Evidence of • 2nd line: Non benzodiazepine muscle relaxant(if refractory to monotherapy)
benefit • 3rd line: NSAIDs plus Acetaminophen (if cannot tolerate muscle relaxants)
Pharmacological
Mx • Acetaminophen alone: poor efficacy • Anti depressants
No evidence of • Benzodiazepines : induction of • Topical agents
benefit tolerance • Systemic glucocorticoids
• Opioids: abuse potential • Herbal therapy
• Tramadol: adverse effect • Paraspinal injections
Acute • Anti epileptics
LBP

Evidence of • Patient education

benefit • Ergonomic correction of work place: Occupational LBP
Non • Heat application
Pharmacological
Mx
No evidence of • Cold application • Traction
benefit • Lumbar support: corsets, braces • Yoga
• Mattress recommendations • Prolong bed rest
• Spinal manipulation • Massage
• Exercise and physical therapy
LBP: Treatment (Chronic LBP)

• In general, improve activity tolerance is primary goal, while pain relief

is secondary

• Some patients of chronic LBP may experiences acute exacerbation -

managed as like as ALBP
LBP: Treatment (Chronic LBP)
Cont…
management:

 Non Pharmacological treatment

• Education
• Exercise
• Loss of excess weight
• Cognitive behavioral therapy

Pharmacologic therapy
• 1st line: NSAIDs (“as-needed”, lowest effective dose and frequency)
• 2nd line: Duloxetine, Tramadol (“as-needed” basis)
THERAPIES DO NOT ROUTINELY RECOMMEND

• Antidepressants – Other • Low-level laser therapy

than duloxetine • Ultrasound
• Benzodiazepines • Shortwave diathermy
• Antiepileptics • Transcutaneous electrical nerve
• Lumber supports stimulation (TENS)
• Traction • Percutaneous electrical nerve
• Interferential therapy stimulation (PENS)