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 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