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Low Back Pain
H Shraideh, MD, FAANS
Department of Neurosciences, JUST
Anatomy/ Spine
•Trijoint complex
•Anterior elements; 80% of
the load
Posterior elements; 20%
•static stability: Bony
elements and intervertebral
disk.
•Dynamic stability: muscular
and ligamentous supports Brad Bunney, MD
Anatomy
• Vertebra – body, neural arch, bony
process
• Ligaments & muscles = stability
• Cervical nerve roots pass above body
(All others pass below)
Brad Bunney, MD
Epidemiology
50-60% Life time incidence of LBP
15-30% prevalence among adults
1% of population are disabled because of LBP
15% of the sick leave
85% no specific diagnosis can be made
Highest prevalence 40-60 year of age
Overall incidence of LBP 45/1000 person per year
M=F
Brad Bunney, MD
Clinical presentation
LBP +/- radiculopathy
Pain exacerbated with physical stress and
relieved with bed rest
P/E differentiate mechanical (non-specific)
LBP from serious spinal conditions
(radiculopathy or cauda equina syndrome
caused by PID, tumors, infections…..)
Brad Bunney, MD
History / red flags
Hx of cancer (prostate, breast, kidney, thyroid,
lung)
Unexplained wt loss
Immunosuppression
Pain that worse at rest
psuedoclaudication
Pain not responding to conservative Rx
Skin or other systemic infection
Urine and fecal incontinence
Brad Bunney, MD
Examination / red flags
Fever
Spinal deformity
Tenderness & L.O.M
+ve SLR test
Motor and /or sensory deficits
Brad Bunney, MD
Recommendations
absent red flags
Bed rest
Activity modification
Analgesia
Reassurance
> 85 % show improvement within 4 weeks
without the need for diagnostic studies
Brad Bunney, MD
Diagnostic work / pts with red flags
Plain L.S Xray
L.S CT scan
L.S. MRI
L.S. Myelography
Brad Bunney, MD
Lower back pain + red flags
PID; Traumatic (Acute) vs degenerative
(gradual)
Spinal tumors (intradural vs extradural)
Spinal infections (osteomyelitis, epidural
abcess)
Brad Bunney, MD
PID
Displacement of disc material beyond confines of
the disc space
Pain start with back pain, which after days or
weeks produce radicular pain with reduction of the
back pain
Precipitating factors are identified < 20% of cases
Radicular pain is relieved by flexing the knee and
hip
Pain exacerbated by coughing and sneezing or
straining (cough effect)
Bladder symptoms (usually retention) < 5%
Brad Bunney, MD
PID
Physical signs (NL-sensory & motor loss)
Lesègue sign (slow leg raising test)
Brad Bunney, MD
PID
L3-L4 L4-L5 L5-S1
Compressed L4 L5 S1
root
% 5-10% 40-45% 40-45%
Reflex affected Knee - Ankle jerk
Motor Q. Femoris EHL & tibialis Gastrocnemiu
(knee ex) (foot drop) s
(plantarflexion)
Sensory M. maleolus Dorsum of L. maleolus
foot
Brad Bunney, MD
PID
Brad Bunney, MD
Disc Herniation
• L4-5, L5-S1 most common
• Cervical and thoracic do occur
• Thoracic: abrupt neuro deficits
- Narrow canal
• Postero-lateral aspect of the
disc Brad Bunney, MD
Disc Herniation
• Not necessary to have history of
strain or injury
• Unilateral radicular back pain with
nerve root impingement
Brad Bunney, MD
Disc Herniation
• X-ray only good if inter-vertebral
disc is narrow
• MRI is gold standard
• Electromyelography localizes the
specific nerve root
Brad Bunney, MD
Disc Herniation
Brad Bunney, MD
PID
Most common at
L4-L5 & L5-S1
Bulge, protrusion,
extrusion,
sequestered,
migrated
Midline or lateral
Brad Bunney, MD
PID
Brad Bunney, MD
Brad Bunney, MD
PID
-Traumatic
-Degenerative
Brad Bunney, MD
DDD
- Aging process
- Progressive dehydration of
the nucleus pulposus and
loss of disk volume
- Degenerative tear in the
annulus with herniation of
the nucleus pulposus
through this tear.
- Present with L.B.P and
L.O.M
Brad Bunney, MD
DDD
Three Phases:
- phase I, circumferential tears or fissures in
the outer annulus. +/- endplate separation or
failure, interrupting blood supply to the disk
and impairing nutritional supply and waste
removal. Such changes may be the result of
repetitive microtrauma.
Circumferential tears may coalesce to form
radial tears.
Brad Bunney, MD
Brad Bunney, MD
DDD
Phase II;
The unstable phase, loss of
mechanical integrity of the trijoint
complex. Internal disk disruption
(IDD), loss of disk-space height.
Concurrent changes in the facet
joints include cartilage. leading to
segmental instability
(Spondylolisthesis).
Brad Bunney, MD
DDD
Phase III;
Stabilization phase, characterized by further
disk resorption, disk-space narrowing, endplate
destruction, disk fibrosis, and osteophyte
formation
Brad Bunney, MD
DDD
Brad Bunney, MD
Disc Herniation
• Initial therapy is to decrease
pressure on the root
• Bed rest up to 4 weeks
• Non-steroid anti-inflammatory
• Muscle relaxants
Brad Bunney, MD
Disc Herniation
• Absolute indication for surgery
- Significant muscle weakness
- Progressive neurological deficit with
bed rest
- Bowel or bladder dysfunction
Brad Bunney, MD
Disc Herniation
• Relative indication for surgery
- Pain despite bed rest
- Recurrent episodes of severe pain
Brad Bunney, MD
PID / Discectomy
• Emergency surgery for:
- Progressive motor deficit
- Cauda equina syndrome
Brad Bunney, MD
PID / Discectomy
Brad Bunney, MD
PID / Discectomy
Brad Bunney, MD
Brad Bunney, MD
Discectomy / Complications
Infection (superficial vs deep)
Increased deficit (injury to neural structure)
Dural tear (CSF leak)
Complications of positioning
Failed surgery (incorrect dx, incomplete
surgery)
Vascular injury
Brad Bunney, MD
Thecal sac compression
• Malignant epidural spinal cord
compression (MESCC)
• Spinal epidural abscess (SEA)
• Spinal epidural hematoma
(SEH)
Brad Bunney, MD
Thecal sac compression
Factors
• Force of compression
• Direction of
compression
• Rate of compression
Brad Bunney, MD
MESCC
• Hematogenous spread
• Bone marrow
• Compress cord and vascular supply
• Edema, infarction
Brad Bunney, MD
MESCC
• Prostate
• Lung
• Breast
• Non-Hodgkin’s lymphoma
• Multiple myeloma
• Renal cell cancer
Brad Bunney, MD
MESCC
• Initial presentation in 20% of
malignancies
• Cervical, thoracic & lumbar by
proportion of vertebral body volume
• Thoracic is most common
Brad Bunney, MD
MESCC
• 95% have back pain
• Precedes other symptoms by 1-2
months
• Percussion tendencies, thoracic
location, worse lying down
Brad Bunney, MD
MESCC
• 75% have weakness by time of
diagnosis
• Weakness symmetric
• Ascending numbness
• Autonomic dysfunction, urinary
retention Brad Bunney, MD
MESCC
• Plain X-ray 10-17% false negative
• 30-50% of bone must be destroyed
for X-ray to be positive
• MRI, CT myelography are
standards
Brad Bunney, MD
MESCC
• Plain X-ray 10-17% false negative
• 30-50% of bone must be destroyed
for X-ray to be positive
• MRI, CT myelography are
standards
Brad Bunney, MD
MESCC
Brad Bunney, MD
MESCC
• Corticosteroids first line for edema
• Dexamethosone, 20-100 mg load,
4-24 mg 4 times/day
• Radiation therapy within 24 hours
Brad Bunney, MD
MESCC
• Surgery for:
- unresponsive to radiation therapy
- Acute neurological deteriorations
• Chemotherapy – Non-Hodgkin’s
lymphoma
Brad Bunney, MD
The Case
55 yo male with low back pain. The pain is sharp, right-sided,
worse with movement and non-radiating. He has no weakness,
numbness or incontinence. No hx of trauma.
Pmhx: HTN, irritable bowel syndrome, cervical disc herniation
Meds: none
Sochx: alcohol use
PE: afebrile, VSS
Back: mild tenderness right paraspinal area, L2-3
Neuro: normal
What do you want to do?
Brad Bunney, MD
The Case
He is given NSAI which makes him better and is sent
home. 5 days later he is at a new hospital with the
complaint of back pain, says it is the same as before, “I
ran out of my medicine”.
PE: Afebrile, VSS
Back: right paraspinal tenderness, worse with movement
Neuro: numbness anterior and med thigh
Brad Bunney, MD
What do you want to do?
The Case
He has an abdominal CT scan to R/O renal stone which was
normal. He is given a shot of paracetamol which makes him feel
better and is discharged with paracetamol and Valium. He returns
2 days later with worsening pain that radiates to the right foot and
left knee. He has numbness to the thighs and groin, and has been
incontinent of stool.
PE: Afebrile, VSS
Back: diffuse tenderness to lumbar spine palpation
Neuro: RLE- 3/5 strength, numbness anterior and med thigh,
decreased reflex. LLE- 4/5 strength.
What do you want to do? Brad Bunney, MD
The Case
Brad Bunney, MD
The Case
MRI is done which confirms a compressive lesion from
L2 to L4. WBC = 18,000. The patient is given antibiotics
and is admitted to neurosurgery. An L3-L4 laminectomy
is done and pus is drained.
Organism= Streptococcus and Stomatococcus
mucilaginosis
Patient was discharged to a rehab facility on hospital
day 13 for 6 weeks of Vancomycin therapy. At the time
of discharge he was continent, but could only ambulate
Brad Bunney, MD
with assisted use of a walker.
Conclusion
• Back pain is common in the ED
• Radicular pain requires diligence to find
the cause
• The severity of spinal cord compression
is related to force, duration and rate
• Emergent therapy is necessary
“Spinal Cord Attack”
Brad Bunney, MD
•
SEA
Risk Factor
• IVDA
• Diabetes
• Trauma
• Prior spinal surgery or nerve blocks
• Immune compromised host
Brad Bunney, MD
SEA
Presenting Complaints
• Back pain
• Paresthesias
• Motor deficits
• Fever
Brad Bunney, MD
SEA
Diagnosis
• WBC
• Sedimentation Rate
• MRI = gold standard
Brad Bunney, MD
SEA
Organisms
• Staphylococcus aureus
- Methicillin resistant – 15%
• Streptococcus
• Escherichia coli
• Pseudomonas
• Klebsiella
Brad Bunney, MD
• Mycobacterium Tuberculosis
SEA
Treatment
• Surgery – depending on
- severity of neuro deficits
- Extent of spine involved
- Infecting organism
• Antibiotics
Brad Bunney, MD
SEA
Non-Operative Indications
• Panspinal involvement
• Lumbosacral SEA and normal neuro
exam
• Fixed neuro deficit for > 48 hours
Brad Bunney, MD
SEA
Antibiotics
• Start immediately
• Vancomycin
• Aminoglycoside or 3rd generation
cephalosporin
• 4 to 6 weeks
Brad Bunney, MD
Vertebral Osteomyelitis
-IVDA
-D.M
-Hemodialysis
-Elderly
-Immune compromised patients
-Postoperative
-Lumbar spine, Thoracic, Cervical, Sacrum
-Neurological findings develop late
(delayed Dx)
-Vertebral body collapse, Kyphotic
deformity
-Staph. Aureus
-Medical vs. Surgical Brad Bunney, MD
VO / Epidural abcess
Brad Bunney, MD
Spinal Epidural Hematoma (SEH)
Risk Factors
• Coagulapathy
• Trauma
• Vascular lesion
• Surgery
• Epidural catheterization
Brad Bunney, MD
SEH
Diagnosis
• Back pain, neuro deficit
• Symptom onset to max. neuro deficit = 13
hours
• All segments of spinal cord
• MRI = gold standard
• Plain X-ray or CT scan for fractures or
Brad Bunney, MD
dislocation
SEH
Treatment
• Surgical evacuation
• Immediate surgery within 12 hours
of presentation had better outcome
than later surgery
Brad Bunney, MD
LBP
Spinal stenosis
Ankylosing spondylitis
Spinal tumors
Brad Bunney, MD
First line of therapy for epidural spinal
cord compression from metastatic cancer
is:
A. Radiation therapy
B. Surgery
C. Corticosteroids
D. Chemotherapy
Brad Bunney, MD
The most common site of epidural spinal
cord compression from metastatic cancer
is:
A. Cervical spine
B. Thoracic spine
C. Lumbar spine
D. Sacral spine
Brad Bunney, MD
All of the following are indications for non-
operative treatment of spinal epidural
abscesses except:
A. Pan-spinal involvement
B. Lumbosacral SEA and normal neurological
exam
C. Fixed neurological deficits for greater than 48
hrs
D. Urinary incontinence and sensory deficit
Brad Bunney, MD
All of the following contribute to the
severity of spinal cord compression
except:
A. Force of compression
B. Length of spinal cord compressed
C. Duration of compression
D. Rate of compression
Brad Bunney, MD
The most common organism cultured in
spinal epidural abscesses is:
A. Streptococcus
B. Pseudomonas
C. Staphylococcus aureus
D. Klebsiella
E. Mycobacterium
tuberculosis
Brad Bunney, MD
Objectives
• Discuss the different types of LBP
• Review anatomical principles
• Review nontraumatic etiologies for LBP
• Treatment options for patients with LBP
Brad Bunney, MD
Nerve Root Diagnosis
L4
• Pain = lateral back, antero-lateral
thigh, anterior calf
• Numbness = anterior thigh
• Weakness = quadriceps
• Diminished knee jerk
Brad Bunney, MD
• Squat and rise
Nerve Root Diagnosis
L5
• Pain = hip, groin, postero-lateral
thigh, lateral calf and dorsum of foot
• Numbness = lateral calf
• Weakness = dorsiflex great toe
• Heel walking
Brad Bunney, MD
Nerve Root Diagnosis
S1
• Pain = mid-gluteal region, posterior
thigh, posterior calf to heel & sole
• Numbness = posterior calf
• Weakness = plantar flex great toe
• Diminished ankle jerk
• Walk on toes Brad Bunney, MD
PID / Discectomy
Brad Bunney, MD
