Back Pain: An Approach

Dr.Bishnu Babu Thapa

Asst.Prof.
Orthopaedic Spine surgeon
 Lower back is commonly defined as
the area bounded by the bottom of
the rib cage and the buttock creases.
 Acute low back pain is the back pain
of less than 6 weeks duration.
If the duration of pain is 6-12 weeks,
it is subacute low back pain.
Chronic low back pain is the back
pain of >12 weeks duration.
 Low back pain is benign condition. More
than 80% will get low back pain once in
their lifetime.

95% of patient return to their job within 3

months of onset of symptoms.

Probability of returning to work fall as the

increasing duration of disability.(6months-
50% : 2 years-<2%)
 Aetiology
Non infective inflammatory
Mechanical back pain disease
Degenerative Ankylosing spondylitis
PIVD Seronegative spondyloarthropathies
Spondylolisthesis
Spinal stenosis
Spinal infection Metabolic Bone disease
Tuberculosis
Pyogenic osteomyelities
Osteoporosis,osteomalacia
Discitis
Spinal deformity Non spinal causes
Scoliosis
Kyphosis Genitourinary ,gynaecological
Neoplasia
Benign(Osteoid osteoma,
Malignant(Multiple myeloma,secondaries) Psychological
Postoperative backach
 History
Age:
Children: uncommon
Adolescents: Postural,Traumatic
Adults: Ankylosing Spondylitis,Disc prolapse
Elderly: Degenerative.Osteoporosis,Metastatic

Sex:
F>M(Several pregnancy,Lack of
exercise,Overweight)

Occupation:
Sedentary jobs
 History(Cont.)
Pain:
Location:Lower lumbar: Disc prolapse, Degenerative
Dorsolumbar:Infection,Trauma
Onset:
Localization of pain:
Localised(Muscle,Tendon)
Diffuse(Deeper structure pain)
Referred (Nerve root entrapment)
Progress of pain:
Trauma,Disc prolapse: Pain is maximum at onset
Spondylytic: Constant & aggravated by activity
Tumour,Infection: Progressive course
Relieving and aggravating factor:
Ankylosing spondylitis: Worse after rest
Spinal stenosis: Pain initiated on walking or standing and relieved by
rest.
Benign tumour: Pain at night responds to Aspirin.
 History(Cont.)
Stiffness:AS(Chest
expansion&Lumbar excursion).
Pain in other joint: large and small
joint
Neurological symptoms:
Motor,Sensory and reflex
Extra skeletal symptoms:
Psychological status:
 Waddells criteria
Waddel determined 5 findings on physical examination which correlated with non
organic LBP known as the 5 Waddell criteria;
Most patients with documented organic LBP had one or none of Waddell criteria, and
that patients who had 3/5 Waddell criteria were much more likely have non organic
LBP.

1) Tenderness
superficial (light pinch)
non anatomic (tender to palpation over LS, Pelvis, and TS)

2)Simulation
Axial Loading (should not cause LBP)
Rotation

3)Distraction
SLRT

4)Regional
Weakness
Sensory

5)Overreation
 Physical Examination
Standing Position:
Position
Spasm
Tenderness
Swelling
Range of movement
Wall Test
 Phy.Exa.(Cont.)
Lying down position
Straight leg raising test
Neurological examination
Peripheral pulses
Adjacent joints
Abdominal,Rectal,Per vaginal
Examination
Investigation
X-ray

Two View
Two region
Two occasion
Two site
 Selective indication for X-ray in low back
pain
Age >50 yrs
Significant trauma
Neuromuscular deficits
Unexplained weight loss
Suspicion of AS
Drug or alcohol abuse
History of cancer
Use of corticosteroids
Temperature>100o F
Recent visit (within month)
Patients seeking compensation
 Investigation(Cont.)
Other radiological parameter
CT Scan
MRI

Blood investigation:
TC,DC,ESR,PSA,CA,P,Alk Phosphatase

Electromyography

Bone scan
 Treatment
For specific
pathology(Trauma,Infection,Tumours), treat
accordingly.
For Non specific Category:
Physiotherapy
Back school programme
Drugs
Rest
Traction
Lumbar corset
 Failed back syndrome
FBS or Post laminectomy syndrome is persistent
back or leg pain following back (spinal) surgeries.
Cause of failure
Patients related factor
Nutrition,smoking,diabetes,drug.
Psycosocial problem
Surgeon related factors
Pre-op: Error in diagnosis,
Intra-op: surgical timing, wrong
approach,improper fusion level, peri operative
events(infection,durotomy,pseudomeningocele,he
matoma.
Post-op: Improper or inadequate rehabilitation.
1.Ennumerate the cause of Back pain.
2.Describe Waddells Criteria.
3.Failed back syndrome:
Define,Aetiology,Treatment
 THANK
YOU