Low Back Pain

Question 1

List mechanical etiologies of low back pain

Answer 1

1. Musculoligamentous strain or sprain
2. Herniated disc
3. Foraminal stenosis causing symptoms from nerve root compression
4. Spinal canal stenosis causing neurogenic claudication or myelopathic symptoms
5. Facet joint dysfunction and arthropathy
6. Sacroiliac joint dysfunction and arthropathy
7. Myofascial pain syndrome
8. Degenerative disc disease, discogenic pain, internal disc disruption
9. Spondylolysthesis (displacement of a vertebral body compared to the adjacent)
10. Spondylolysis (defect in pars interarticularis without vertebral slippage)
11. Spinal instability (anomalous movement between the continguous vertebral bodies)
12. Spinal conditions causing misalignment such as kyphosis or scoliosis

Question 2

List nonmechanical etiologies of low back pain

Answer 2

1. Primary or metastatic neoplasm of the spine or its neural contents
2. Infections, such as osteomyelitis of the vertebral bodies, septic discitis, paraspinal or epidural abscess
3. Noninfectious inflammatory spinal disorders such as ankylosing spondylitis, Reiter syndrome, psoriatic spondylitis, inflammatory bowel disease
4. Traumatic or pathological fractures such as vertebral body compression fractures and dislocations
5. Metabolic disorders of the spine such as Paget disease
6. Miscellaneous conditions such as Scheuermann disease or osteochondrosis and hemangiomas

Question 3

List referred or visceral etiologies of low back pain

Answer 3

1. Pelvic visceral disorders such as prostatitis, endometriosis, or pelvic inflammatory disease
2. Renal disease such as nephrolithiasis, pyelonephritis, or perinephric abscess
3. Vascular disease such as abdominal aortic aneurysm
4. Gastrointestinal disease such as pancreatitis, cholecystokinin, or perforated bowel

Question 4

Symptom evaluation of patients with low back pain

Answer 4

1. Location and radiation of pain
2. Quality of pain
3. Natural history of the pain
4. Circumstances of onset of pain (h/o trauma)
5. Aggravating/relieving factors
6. Presence of constitutional symptoms (fever, malaise, weight loss)
7. “Red flag” features present
8. Neurologic symptoms (numbness, tingling, weakness)
9. Bowel or bladder dysfunction (retention/incontinence)
10. H/o previous treatments and efficacy
11. Age of patient
12. PMH/PSH
13. Contributing social and psychological factors
14. Impact of pain on activities of daily living, sleep

Question 5

“Red flag” features of low back pain

Answer 5

1. Age - <20 or >50
2. Duration of symptoms - <3 mos duration = more concerning
3. H/o trauma - significant traumatic injury or mild trauma in elderly or with a serious medical condition
4. Constitutional symptoms present - fever, chills, malaise, night sweats, unexplained weight loss
5. Systemic illness present - h/o cancer, recent bacterial infections, IV drug abuse, immunosuppressive, organ transplant, corticosteroid use
6. Unrelenting pain - not relieved by rest, supine position, analgesics, night pain
7. Cauda equina syndrome - caused by massive midline disc herniation or rarely by spinal metastases, hematoma, epidural abscess, traumatic compression, acute transverse myelitis, and abdominal aortic dissection. Symptoms include bilateral, but often unequal, lower extremity radicular pains and weakness, gait disturbances, abdominal discomfort and overflow incontinence. PE exhibits neurological dysfunction, saddle anesthesia, diminished anal sphincter tone, and urinary bladder retention. Diagnosis must be made by imaging the entire spine. Treatment is by urgent decompressive surgery

Question 6

Noninvasive treatment for low back pain

Answer 6

A. Rest (no longer than 1 week; return to activity to decrease risk of disability)
B. Pharmacological therapy: 1. Nonsteroidal antiinflammatory drugs, 2. Opioids, 3. Muscle relaxants, 4. Corticosteroids, 5. Calcitonin
C. Physical therapy: 1. Body mechanics, ergonomics, posture awareness, ADL training, 2. Strengthening and stretching, 3. Organized functional training programs, 4. Therapeutic massage, 5. Joint mobilizations and manipulations, 6. Mechanical traction, 7. Electrical muscle stimulations, 8. Transcutaneous electrical nerve stimulation (TENS), 9. Application of superficial and deep thermal modalities, 10. Cryotherapy, 11. Work hardening
D. Acupuncture
E. Spinal manipulation
F. Biofeedback

Question 7

Minimally invasive treatments for low back pain

Answer 7

A. Injection therapy: 1. Epidural steroid injections, 2. Facet joint injections, 3. Sacroiliac joint injections, 4. Trigger pain injections
B. Neuroablative procedures: 1. Radiofrequency ablation, 2. Chemical neurolysis, 3. Cryoablation
C. Intradiscal procedures: 1. Percutaneous disc decompression, 2. Intradiscal electrothermal therapy, 3. Intradiscal bioculoplasty, 4. Stem cell based therapies

Question 8

Surgical treatments for low back pain

Answer 8

A. Decompression surgery: 1. Discectomy, 2. Microdiscectomy, 3. Endoscopic discectomy, 4. Decompression for fixed osseous stenosis
B. Fusion: 1. Anterior fusion, 2. Posterior fusion, 3. Circumferential fusion, 4. Transformacional lumbar Inter body fusion
C. Disc arthroplasty: 1. SB Charite III, 2. ProDisc, 3. Maverick, 4. Flexcore

Question 9

Describe the typical characteristics of benign mechanical low back pain

Answer 9

1. Pain mainly with spinal movements such as sitting, bending, lifting, or twisting
2. Pain should improve while lying down and at night
3. Pain should diminish over the course of days to weeks

Question 10

What is the significance of identifying “red flags” when assessing low back pain?

Answer 10

Recognition of red flag clinical features signify the presence of conditions such as fractures, tumors, and infections that can pose significant threat to life or neurologic function, signaling necessity of further diagnostic work-up.