Reginald Ajakwe, MD

Low back pain (LBP)is the fifth most common reason for all physician visits.

Second most common symptomatic reason (upper respiratory symptoms are the first)

50 to 80 percent of adults experience LBP LBP is the leading cause of disability and lost

production in the US, with associated direct and indirect costs of $50 billion per year

Despite the widespread opinion that 75-90% of patients with LBP recover within about 6 weeks, irrespective of treatment, pain may persist in up to 72%, and disability in up to 12% of patients one year after their first episode of LBP

Poor Physical Fitness and comobidity Social Class, occupation, and employment

status Increasing age Obesity Dimensions of the Spinal Canal Smoking Substance Abuse History Hard physical Labor

Radicular leg pain Poor self-rated health status A positive straight leg raised test Reduced Elasticity/Flexibility of the Back Poor Coping Strategies High Levels of distress, depression, and

somatization Lower activity level Anxiety

Mechanical Low Back Pain: It is defined as pain secondary to over use of a normal

anatomic structure (e.g. muscle strain) of pain secondary to trauma or deformity of an anatomic structure (e.g Herniated nucleus pulposus). This typically accounts for 90% of all LBP

The other 10% percent of adults typically have non-mechanical LBP. Typically the symptoms of LBP in the individuals are a manifestation of a systemic illness.

The challenge of the practicing physician is to separate individuals with mechanical disorders from those with systemic illness.

Usually, the patient’s symptoms and signs, along with radiographic and laboratory data designate specific disorders within these two major groups

Onset: Was there trauma or unusual period of strenous activity?

Duration and Frequency: Systemic disorders cause chronic LBP that is more persistent than episodic

Location and Radiation: These help identify the structures that are possible pain generators

Aggravating and Alleviating factors: Characterize the mechanical Quality of the disorder

The time of the day associated with maximum degree of pain is associated with certain disorder.

For example, inflammatory arthritis causes most symptoms in the morning versus mechanical disorders that are typically worse at the end of the day

Quality of the pain: can help separate musculoskeletal pain (aching) from neuropathic pain (burning)

The intensity of the pain is to help to document and determine improvement, but does not discriminate between mechanical and systemic disorders

Fever and Weight loss: These patients are more likely to have an infectious etiology as a cause of LBP.

Nocturnal Pain and Pain with Reccumbency: Tumors of the spinal column are of prime concern in these patients.

The mechanism of increased nocturnal pain with benign or malignant tumors is unknown.

Increased pressure associated with increased blood flow at night has been suggested as one possible cause.

Local Vertebral Column Pain: These patients usually have fractures of the vertebral body or expansion of the bone marrow space.

Some systemic processes can increase mineral loss from bone (eg osteoporosis, pagets disease)

Hypertrophy or replacement of bone marrow cells with inflammatory or neoplastic cells (multiple myeloma, hemoglobinopathy).

Both lead weaken the vertebral to the degree that fracture may occur spontaneously or with minimal impact

Prolonged morning stiffness: Morning stiffness lasting for more than one hour is a common symptom of spondyloarthropathy.

These include ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and enteropathic arthritis.

Visceral Pain Disorders of the Vascular, genitourinary, and gastrointestinal systems can cause stimulation of sensory nerves that results in the perception of pain in damaged areas and superficial tissues supplied by the same segments of the spinal cord

Detailed History and PEX identifying conditions that require immediate attention

For most patients, imaging and aggressive interventions should be delayed until the patient has undergone 4-6 weeks of non-operative care

Patients should be reassured that LBP only rarely leads to disability

Patients should be encouraged to return to normal activity and begin light aerobic exercises immediately while avoiding strenuous activities until symptoms resolve.

Over-the-counter analgesics, NSAIDS, and acetaminophen are first-line medications for pain relief

If symptoms have resolved or improving by 4-6 weeks, there is no need for further investigation

If symptoms progress or stabilize at an unacceptable level, clinical assessment and imaging are indicated

Plain radiographs initially. MRI follows and is considered the diagnostic imaging modality of choice

If there is bony pathology on plain radiographs or a history of trauma, CT scan is indicated

Usually, surgical intervention is an option only for patients with identifiable pathology on imaging studies that is consistent with their clinical presentation

Early surgical consideration is given to patients with neurologic deficit due to nerve root compression, incapacitating pain, or progressive neurologic deficits

Evidence of cauda equina syndrome with loss of bowel or bladder control is an indication for emergent imaging and surgical decompression

Lumbosacral Strain Lumbar Facet Arthropathy Lumbar Radicular Syndrome Sacroiliac joint Dysfunction Piriformis syndrome Spinal Stenosis Ichial-Gluteal bursitis

Pain is limited to a local area Pain often occurs simultaneously with

an injury Decreased ROM from reflex contraction

of the involved muscle and the surrounding muscles

Exacerbation of pain with motion that contracts the injured muscle

Muscular and ligamentous injuries Continuous mechanical stress from

poor posture Small tears in the annulus fibrosus

Any active motion of the involved muscle against resistance causes pain

Tenderness to palpation of the damaged muscle

Increased contraction and firmness compared with the surrounding muscle

Trigger points with “jump sign” Normal neurologic exam

Controlled Physical Activity Medications—NSAIDS, Centrally Acting

Muscle Relaxants The recommendation to maintain

activity as tolerated is important Trigger point Injections with or without

local anesthestic may be helpful

The axial spine rests on the sacrum, a triangular fusion of vertebrae arranged in a kyphotic curve and ending with attached coccyx in the upper buttocks. Iliac wings attach on either side forming a bowl with a high back and shallow front. Three joints arise from this union; the pubic symphosis in front, and the right and left SI joints in the back

It is diarthrodial joint: adjacent bones are lined by cartilage, joint cavity contains synovial fluid lined with a synovial membrane, reinforced by a fibrous capsule and ligaments, some degree of free movement.

The SI joint is innervated at its anterior and posterior aspects.

Posterior innervation is from the lateral branches of the posterior primary rami of L4 through S4.

Anterior innervation is from the ventral rami of L5 through S2 via branches of the sacral plexus

The incidence of SI joint pain in patients with back pain is 15 to 30 percent

Sources may be intra-articular or extra-articular sources.

Examples of intra-articular sources include infection and arthritis.

Examples of extra-articular sources include enthesopathy, fractures, and ligamentous injury.

Leg length discrepancy Gait abnormalities Prolonged vigorous exercise Scoliosis Trauma Pregnancy Spinal fusion to the sacrum.

Unfortunately, medical history, physical examination, and imaging studies perform very poorly in identifying the dysfunctional SI joint as a pain generator.

Unilateral pain (unless both joints are affected) localized predominantly below the L5 spinous process.

Point specific tenderness over the sacral sulcus and posterior sacroiliac spine is consistent physical finding

There are several SI joint pain provocation tests that have been developed to detect SI joint dysfunction.

Some of the more commonly used tests include FABER (also known as Patrick’s test), Gaenslen’s test, Yeoman’s test, and Pelvic rock

A combination of FABER (Flexion, Abduction and External Rotation), POSH (Posterior shear), and READ (Resisted Abduction) tests has a sensitivity of 70% to 80% and a specificity of 100%.

Degenerative changes of the joint on standard x-ray are uncommon and non-specific, as most patients with SI joints dysfunction have normal appearing joint on roentgenography.

Other imaging modalities such as CT scan, bone scintigraphy, and MRI also do not play a major role in the selection of patients with SI joint dysfunction.

Essentially, resolution of axial back pain following intra-articular injection of local anesthetic under fluoroscopic or CT guidance is the best available diagnostic tool.

Multimodal approach Medication: NSAIDS Physical Therapy SI joint injection with fluoroscopy using local

anesthetic and steroids Radiofrequency Ablation (RFA) of L4-L5

dorsal rami and S1 through S3 lateral branch nerves

Direct Denervation of the SI joint with RF

A Flat and pyramid –shaped muscle.

Originates anterior to the S2-S4 vertebrae, near the sacroiliac capsule and the upper margin of the greater sciatic foramen

It passes through the greater sciatic notch and inserts on the superior surface of the greater tronchanter of the femur.

As it courses through the sciatic notch it comes in close proximity to the sciatic nerve (SN)

Innervated by L5, S1, S2 nerve roots

There are developmental variations between the SN and piriformis muscle.

In 20% of the population, the belly is split by the SN.

In 10%, the tibial/peroneal are not enclosed in a common sheath.

6:1 female:male predominance In 50% of cases it is associated with direct trauma

to sciatic notch and gluteal region. Blunt injury causes hematoma formation and

subsequently scarring between the sciatic nerve and piriformis muscle

Other causes include prolonged sitting; prolonged combined hip flexion, adduction, and internal rotation

Certain sport activities like cyclists who ride for prolonged periods and tennis players who constantly internally rotate their hips

Deep aching pain in the buttocks of the affected side

Pain may radiate to hip, lower back, and posterior thigh, but rarely below the knee.

Squatting, climbing stairs, walking, and prolonged sitting (especially on hard surfaces) worsens pain

Pain is typically unilateral Often associated with a limp on the affected side. Freiberg test elicits pain on forced internal rotation

of the extended thigh The pace test elicits pain with resisted

abduction/internal rotation

Physical Therapy Piriformis stretch Standing hamstring

stretch Pelvic tilt Medication therapy

with NSAIDs Intramuscular

Piriformis injection with local anesthetic and steroid

Intramuscular injection with botulinum A toxin (100 units) Piriformis Muscle injection

This is pain originating from the facets joints Prevalance my be as high as 10 to 15% in

individuals with LBP With aging lumbar facet joint become weaker and

their orientation changes from coronal to saggital positioning

This predisposes them to injury from rotational stress

L3-4, L4-5, and L5-S1 are exposed to the most strain during lateral bending and forward flexion.

Thus they are more prone to repetitive strain, inflammation and joint hypertrophy.

Each facet joint is formed by the superior and inferior articular process of consecutive lumbar vertebra.

Each joint is named by the segmental number of vertebrae that form it.

Each facet joint has the typical structure of a synovial joint

The joints are innervated by the the medial branches of lumbar dorsi rami

Each joint receives innervation from the ipsilateral medial branch nerve, and from the medial branch above. Thus the L4-5 joint is innervated by the L3 and L4 medial branches

There are no discrete history and physical findings pathognomonic for lumbar facet arthropathy.

Some helpful indicators on PEX: 1. Pain not relieved when rising from forward flexion 2. Pain well relieved by recumbency 3. Pain not exacerbated by coughing 4. Pain not worsened by hyperextension Most often pain is referred to the region of the buttocks or

proximal thigh. Medial Branch nerve blocks with fluoroscopy is currently the

standard diagnostic test for establishing a diagnosis of zygopophyseal joint pain.

The correct target points for this block lies midway between two points: the notch between the Superior articular process and the transverse.

Multimodal treatment regimen including Medication therapy with NSAIDs, Cymbalta. Physical therapy for functional rehabilitation Radiofrequency Neurotomy: Done with

fluoroscopy. This is standard of care. It involves coagulating, percutaneously, the medial branch nerves that innervate nerves that innervate the joint.

Intraarticular steroid injection is rarely done for treatment of facet arthropathy.

Primarily caused by herniated disk and degenerative spinal disorders 98% of the time.

The incidence of radicular symptoms in patients with LBP ranges from 12 to 40%

Even though radicular pain can be a feature of radiculopathy, it is a separate condition from radiculopathy.

Radiculopathy implies numbness, weakness, or loss of DTR or any combination of the three.

The epidural presence of the herniated part of the disk can induce structural and functional changes in the adjacent nerves and sensitize the nerve roots to produce pain

Proposed mechanism for pain from herniated disc include neural compression with dysfunction, vascular compromise, inflammation and biochemical influences

Back pain can be the major symptom, especially in central herniated disks

Follows nerve root distribution The pain is described by patients as

sharp, shooting, superficial, lancinating, “like an electric shock”

Paresthesia may be present Worse with flexion

Better with extension Radiation below the knee May have sensory alterations Objective weakness possible Atrophy possibly present Positive root tension signs (SRL)

History and PEX, including a detailed neurologic examination

Diagnostic imaging Plain film to exclude systemic

pathology. Helps with demonstration of foraminal stenosis, tumors and infection

CT or MRI. Both offer greater resolution for identification of soft tissue

EMG and NCS

Treatment options depend on severity of the symptoms and patient’s preference. They include:

Conservative Management Interventional Management Surgical Management

Back school Muscle relaxants Exercise therapy Behavioural Therapy Traction Manual Therapy Athrosis—lumbar corcets TENS Acupuncture

NSAIDS– Not very effective in radicular pain Centrally acting muscle relaxants—helpful

with back pain but not with radicular pain Sytemic steroids-routinely used, but not yet

shown to be more effective than placebo Neuropathic pain medication: neurontin,

Lyrica, Cymbalta, Savella Opioids

Caudal epidural steroid injections Lumbar transforaminal epidural steroid

injection Lumbar interlaminar epidural steroid

injection Dorsal column stimulation with

epidurally placed spinal cord stimulator electrodes

L5-S1 Translaminar ESI

Right L5-S1 Transforaminal ESI

Spia

Inplantable Pulse Generator

Epidurally placed spinal cord electrodes

Typically reserved for cases where objective neurological deficits are present often with identifiable pathology on imaging studies that is consistent with clinical presentation.

Such deficits may include motor deficits, sensory deficits, severe intractable pain, urinary or bowel incontinence.

Evidence of cauda equina syndrome with loss of bowel or bladder control is an indication for emergent imaging and surgical decompression

The Evaluation of low back pain can be a daunting task The disease possibilities are numerous Diagnostic options are often complicated and expensive 90% of patients have a mechanical reason for their low back pain. The remaining 10% have back pain as a symptom of a systemic

illness. The practicing physician therefore has the challenge of separating

the patients with mechanical disorders from those with systemic illness.

The patient’s signs and symptoms often give clues for this differentiation.

Treatment ranges from conservative management, to interventional techniques, to surgery.

Despite the widespread opinion that 75-90% of patients with LBP recover within about 6 weeks, pain may persist in up to 72%, and disability in up to 12% of patients one year after their first episode of LBP