Low backache is an extremely common malady afflicting the human race across the globe cutting the geographical boundaries race, culture, etc. Eighty to ninety percent of the human population will suffer from some form of backache, mild or severe in their lifetime. It is of interest to know the historical background regarding low back pain.
Causes of low backache
Common causes (80%)
*Back muscle strain and ligament sprain
*Prolapsed lumbar intervertebral disk
*Obesity
*Poor posture
*Facet joint arthritis
*Unaccustomed activities
*Occupational causes Uncommon causes (20%)
*Congenital causes
*Scoliosis
*Spondylolisthesis
*Spina bifida
*Spondylolysis
*Infective conditions
*Osteomyelitis Tuberculosis
* Brucellosis, etc.
*Traumatic causes
"Vertebral body injuries, posterior arch fracture *Muscle sprain/strain
*Prolapsed disk
*Inflammatory causes
*Rheumatoid arthritis
*Ankylosing spondylitis
*Neoplasms
*Benign-Osteoid osteoma
*Malignant-Secondaries, multiple myeloma, et
*Metabolic causes
*Osteoporosis
*Osteomalacia
*Degenerative conditions
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*Osteoarthritis
*Lumbar spondylosis
*Referred pain from
*Gynecological diseases Genitourinary diseases
*Gastrointestinal conditions, etc.
.Nature of pain
Is it sudden (trauma) or gradual (spondylosis)? Was it preceded by weight lifting, sudden bending, etc? Is there remissions and exacerbations (disk disease) or is it continuous (tumors)? Is there history of night cries (e.g. TB spine)? Is it relieved by rest? Does it radiate to the lower limbs? Etc.
Site Is the pain in the middle of the spine or Para vertebral muscles? Is it in the dorsolumbar spine (trauma or tumor) or in the lumbar spine (disk disease)?
Sciatic pain Here pain radiates along the course of the sciatic nerve (see causes for sciatica). Common cause is disk prolapse.
Sciatica and its causes Sciatica is defined as a radiating pain along the course of the sciatic nerve and is felt in the back, buttocks, posterior of the thigh, legs and the foot. It is commonly due to disk prolapse. The other causes are: Spondylolisthesis.
Sacroiliac joint arthritis.
*Affliction of the nerve root by herpex simplex virus can cause radicular pain.
Tuberculoma causing cord compression.
*Lymphomas and pelvic malignancy. Incurled thickened ligamentum flavum.
Cysts of the sacral nerve root.
*Intraspinal neurofibromas and other tumors.
*Hemorrhage in the ependymoma can cause sudden and gross neurological deficit, mimicking acute disk prolapse.
*Diabetic neuropathy, etc.
*Neurogenic Claudication
*This is a feature of spinal stenosis (see page 300).
Neurological Symptoms
*These consist of paraesthesia, muscle weakness, disturbance of sphincters, cauda equina syndrome, etc.
Presenting Complaints
Age
*Backache is more common in middle-aged and elderly people (usually degenerative). In young adults it is due to trauma and in children it is usually due to organic lesions.
Sex
*Osteoporosis, rheumatoid arthritis, etc. are more common in females. Ankylosing spondylitis, trauma, secondary, etc. are more common in males.
Occupation
*People with sedentary jobs and heavy manual laborers are frequently prone for backache.
Pain
*Over 90 percent of the patients complain of pain in the back.
-Other Complaints
There may be history of stiffness, pain in other joints (e.g. rheumatoid arthritis), constitutional symptoms (e.g. tuberculosis, malignancy, etc.), genitourinary complaints etc.
Physical Signs
*Stance and gait Does the patient stand with a normal stance or has deformities like scoliosis, kyphosis, lordosis or pelvic tilt. Is the gait normal or altered?
Spasm
*This is seen in acute painful conditions of the spine. The patient complains of pain in the Para vertebral muscles and painful restriction of all the spine movements.
Movements
*There may be restriction of the spine movements due to the organic lesions affecting the back.
Swelling
*Swelling due to cold abscesses may be present.
Tenderness
*It may be present over the spinous process, in between the spinous processes, over muscles, ligaments, facet joints, etc.
Neurological Examination
*This consists of examinations of the various dermatomes for sen sations, myotomes for muscle power and reflexes.
SLRT and tension signs
*This is to know the effects of disk lapse on the sciatic nerve.
Other Examinations
*Other examinations include examinations of the adjacent joints, peripheral pulses, abdominal, rectal or pervaginal examina tions.
Investigations
*Blood tests these are useful in detecting metabolic, hormonal, infective and malignant conditions.
Radiology
* Routine plain radiographs of the lumbar spine are advised. Both anterioposterior and lateral views are usually required. Oblique views are helpful in detecting the fracture of pars. Though X-rays are not very helpful in detecting the disk prolapse, it is of value in diagnosing metabolic, degenerative, inflammatory, malignant conditions affecting the spine.
Myelography
*This procedure is not routinely used any more because of its complications. However, it has a role in demonstrating blocks due to disk prolapse.
CT scan
*It is a noninvasive proese and helps to identify the bone and soft tissue problems with greater accuracy.
MRI scan
*This is the gold standard in the investigations of the spine. It is noninvasive and is better than CT scan in diagnosing the bone and soft tissue problems around the spine. However, its high cost is prohibitive and is available only in major cities and centers
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Treatment plan of backache
Conservative
• Absolute bed-rest
• Traction
• NSAIDs
• Epidural steroids
• Belts
For sub acute and chronic cases
• Long-acting steroids + Local anesthetics
• Reduces dependence on narcotics Effect lasts for 3 weeks
Surgery
• Done in proper indications
Open or microscopic lumbar discectomy
Chemonucleolysis
Same indications as for surgery
• Limited only to lumbar spine
Drug used is chymopapain
Physiotherapy
• Recurrence
• Active and passive physiotherapy
• Flexion or extension exercises
• Back education
Proper postural habits
Back exercises
. Avoid all sports
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