Low back pain

神經外科 溫崇熙
 Low back pain
● Common, no specific diagnosis in 85% of cases
● Detect potentially serious pathology, “red flags”
● Relief: Pain meds, spinal manipulation
● Bed rest: 2-3 days, return to work ASAP
● 80-90% of patients improve within 1 month
even without tx (including disc herniation)
 Low back pain
● 15% of all sick leave from work
● Lifetime prevalence: 60-90%
● Annual incidence: 5%
● Nerve-root symptoms: only 1%
● Lumbar disc herniation: 1-3%
 Definitions
● Radiculopathy: dysfunction of nerve root
– Pain in root distribution
– Sensory disturbance
– Weakness, hypoactive muscle stretch reflex
● Mechanical low back pain: musculoskeletal
– Most common form of LBP
– Strain of paraspinal muscles, ligaments, irritation of
facet joints…
 Intervertebral disc
● Permit stable motion of spine while supporting
and distributing loads under movement
 Intervertebral disc
● Annulus fibrosus
– Multilaminated ligament
– Attaches to end-plate cartilage/ring apophyseal bone
– Blends with nucleus pulposus
● Nucleus pulposus
– Central portion, remnant of notocord
● Capsule
– Combined fibers of annulus fibrosus and PLL
 Lumbar disc pathology
● Annular tears (annular fissures)
– Separations between annular fibers
– Avulsions of fibers from VB insertions
– Breaks through fibers
● Degeneration
– Desiccation, fibrosis, narrowing, diffuse bulging,
extensive fissuring, mucinous degeneration
– Defects/sclerosis of end-plates, osteophytes
 Lumbar disc pathology
● Degenerative disc disease (DDD)
– Degenerative changes in intervertebral disc
– Degenerative changes outside disc
● Bulging disc
– Generalized displacement of disc (>50% or 180°)
– Not a form of herniation
– May be a normal finding
– Not usually symptomatic
 Lumbar disc pathology
● Herniation: localized displacement (<50% or
180°)
– Focal: < 25% of disc circumference
– Broad-based: 25-50% of disc circumference
– Protrusion: no neck
– Extrusion: has a neck (narrower than fragment)
• Sequestration: free fragment
• Migration: displaced away
– Intravertebral herniation (Schmorl’s node)
 Other terms
● Vacuum disc
– Gas in disc space
– Disc degeneration, not infection
● Contained herniation
– Uninterrupted annulus or capsule
● Ruptured disc
– Equivalent to herniated disc
 Assessment of LBP
● Initial assessment: identifying serious underlying
conditions (fracture, tumor, infection, cauda
equina syndrome…)
● History
– Age
– History of cancer (prostate, breast, kidney, thyroid,
lung)
– Unexplained weight loss
 Assessment of LBP
● History
– Immunosuppression
– Prolonged use of steroids
– Duration of symptoms
– Responsiveness to previous therapy
– Pain worse at rest
– Skin infection: esp furuncle
– IV drug abuse
 Assessment of LBP
● History
– UTI or other infection
– Pain radiating below knee
– Persistent numbness/weakness in legs
– Significant trauma
• Young: MVA, fall from height, direct blow
• Old: minor falls, heavy lifting, severe cough
 Assessment of LBP
● History
– Findings of cauda equina syndrome
• Bladder dysfunction, fecal incontinence
• Saddle anesthesia
• Leg weakness or pain
– Psychological/socioeconomic factors
• Work status, job tasks, educational level, pending litigation,
compensation issues, failed previous treatments, substance
abuse, depression
 Assessment of LBP
● Physical examination
– Spinal infection
• Fever
• Vertebral tenderness
• Limited range of spinal motion
– Neurologic compromise
• Dorsiflexion strength of ankle and great toe: L5, some L4
dysfunction
• Achilles reflex: S1 dysfunction
 Assessment of LBP
● Physical examination
– Neurologic compromise
• Light touch sensation of the foot
• Straight leg raising test
 Assessment of LBP
● Further evaluation
– Electrodiagnostics: needle EMG, H-reflex, SSEPs,
NCVs
– Bone scan/SPECT: tumor, infection, occult fracture
– Plain x-rays
– MRI
– CT
– Myelography/discography
 Differential diagnosis of LBP
● Acute low back pain
● Subacute low back pain: 10%, > 6 weeks
● Chronic low back pain: 5%, > 3 months
 Acute low back pain
● Non-specific: 85%
– Lumbosacral sprain, strain of paraspinal muscles,
ligaments, irritation of facet joints…
● Neurogenic LBP: remain as still as possible,
possibly needing to change positions at intervals
● Aortic dissection: “tearing” pain
 Acute low back pain
● Unrelenting pain at rest
– Spinal tumor: pain > 1 month, weight loss, > 50 yrs,
nocturnal back pain
– Infection: IV drug abuse, DM, post surgery,
immunosuppression, pyelonephritis/UTI
– Sacroiliitis
• Bilateral & symmetric: AS, Reiter syndrome, Crohn’s dz
• Bilateral & asymmetric: psoriatic arthritis, RA
• Unilateral: gout, osteoarthritis, infection
 Acute low back pain
● Evolving neurologic deficit (CES)
– Spinal epidural abscess
– Spinal epidural hematoma
– Spinal tumor
– Massive central disc herniation
● Pathological fracture
– Lumbar compression fracture: osteoporosis, cancer
– Sacral insufficiency fracture: RA, steroids, no trauma
 Acute low back pain
● Coccydynia: pain & tenderness around coccyx
● Annular tears: may be asymptomatic
● SAH: irritation of roots
● Drug induced
– Statins: myalgia, weakness, rhabdomyolysis
– Phosphodiesterase type 5 (PDE5) inhibitors for
erectile dysfunction: most respond to simple
analgesics
 Subacute low back pain
● Causes of acute low back pain
● Spinal osteomyelitis: fever, elevated ESR
● Spinal tumor
● Spondylolisthesis
● Spinal osteophytes
● Lumbar stenosis
● Schmorl’s node/nodule
 Chronic low back pain
● Causes of acute and subacute low back pain
● Degenerative conditions: listhesis, stenosis…
● Spondyloarthropathies
– AS: sacroiliitis, HLA-B27
– Paget’s disease of spine
● Osteitis condensans ilii: usually asymptomatic
● Psychological overlay: financial, emotional…
 Treatment
● Nonsurgical management (conservative
treatment)
– Absence of “red flags”
– Except circumstances where urgent surgery indicated
• Cauda equina syndrome
• Progressive neurologic deficit
• Profound motor weakness
• Severe pain
 Nonsurgical management
● Activity restriction
– Bed rest
• Usually not required
• Option for radiculopathy
• 2-3 days maximum
– Activity modification
• Minimize disruption of daily activities
• Avoid heavy or repetitive lifting, total body vibration,
asymmetric postures, prolonged sitting/standing…
 Nonsurgical management
● Activity restriction
– Exercise
• Low-stress aerobic exercise: walking, bicycling, swimming
• Conditioning exercise for trunk muscles: after 2 weeks
● Analgesics
– Acetaminophen, NSAIDs
– Stronger analgesics (mostly opioids): severe pain,
radicular pain; not used > 2-3 weeks
 Nonsurgical management
● Muscle relaxants
– Probably more effective than placebo
– Potential for side effects: drowsiness (up to 30%), use
for < 2-3 weeks
● Education
– Positive reassurance
– Proper posture, sleeping positions, lifting techniques…
 Nonsurgical management
● Spinal manipulation therapy
● Epidural injections
– Option for short-term relief of radicular pain
– No evidence for LBP without radiculopathy
● Other treatments (usually not recommended)
– Steroids, colchicine, antidepressant
– TENS, traction, physical agents, corsets/belts
– Trigger point/facet joint injections, acupuncture
 Surgical treatment
● Indications for surgery for herniated lumbar disc
– Failure of non-surgical management after 5-8 weeks
– Emergent surgery
• Cauda equina syndrome (CES)
• Progressive motor deficit
• Severe pain
– Patient choice (potential surgical candidate)