~ Approach to Low Back Pain

~ Lumbosacral Strain
Lee Zu Ying 1001129316

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Causes of Low Back Pain
Types Examples

Physiological Pregnancy, faulty posture, etc.

Traumatic Prolapsed intervertebral disc, lumbar strain, vertebral #

Infective Spinal tuberculosis, osteomyelitis

Inflammatory Rheumatoid arthritis, ankylosing spondylitis

Neoplastic Primary and secondary tumors*

Congenital Spina bifida, transitional vertebrae, hemivertebrae, fused vertebrae

Metabolic Osteoporosis, osteomalacia, hyperparathyroidism

Degenerative Spondylosis, spinal stenosis

Spinal deformity Kyphosis, Scoliosis, Spondylolisthesis

Referred pain Pancreatitis, cholecystitis, AAA, peptic ulcer, pyelonopehritis, pelvic

inflammatory disorder, gynaecological tumour, uterine prolapse, etc. 2
History

Age Sex Occupation

Past Features of Associated

History pain Symptoms
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Age
Children: uncommon, usually due to organic disease
Adolescents: postural and traumatic back pain, infection,
spondylolisthesis
Adults: ankylosing spondylitis, disc prolapse
Elderly: degenerative arthritis, osteoporosis (compression #),
metastatic bone disease, multiple myeloma

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Sex
Back pain is commoner in women:
Pregnancies (multiparity, excessive weight gain)
Lack of exercise leading to poor muscle tone
Nutritional osteomalacia

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Occupation Past History
Common in : History of spinal disease:
Sedentary jobs Trauma
Surgeons Inflammatory disease
Dentists
Miners
Truck drivers

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Features of pain
Site:
Thoracolumbar spine: infection, trauma (compression #)
Lower lumbar spine: Disc prolapse, degenerative spondylitis
Lumbosacral: Spinal stenosis
Onset:
Spontaneous
Trauma/heavy lifting (Significant/subtle)
Localisation of pain:
Tendon/muscle: localised
Deeper structure: diffuse
Nerve root entrapment :Pain referred to a dermatome +
neurological signs pertaining to a particular root
Sciatica: Pain radiating down the back of thigh and calf,
following distribution of sciatic nerve, aggravated by
coughing or straining, often accompanied by symptoms of
nerve root compression (paresthesia, numbness in the foot),
more intense than a referred low back pain
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 Progress of pain:
Acute disc prolapse: Maximum at onset,
gradually subsides, with periods of remissions
and exacerbations
Arthritic/spondylitic pain: More constant,
aggravated by activity
Infection/ tumour: Progressively worsen

Relieving/aggravating factors:
Back Pain Causes Aggravating Factors Relieving Factors Neurological claudication/
pseudoclaudication:
Most back pains Activity Rest Pain radiating down the lower
Ankylosing spondylitis Rest Activity limbs on walking and is
Osteoid osteoma Night pain Aspirin relieved by rest for a few
minutes
Spinal stenosis Walking/standing Rest *Bending forwards or walking
Gynaecological pathology Menstruation uphill may also relieve the
pain. 8
Associated Symptoms
Stiffness: Extraskeletal symptoms:
Ankylosing spondylitis: early Abdominal, urogenital,
morning stiffness, limited chest gynaecological causes of back pain
expansion
Mental status:
Pain and swelling in other Psychological causes of back pain
joints: (hysteria, malingering)
Rheumatoid arthritis
Neurological symptoms:
Paraesthesia, numbness,
weakness in disc prolapse
Cauda equina syndrome

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 The main purpose of
clinical assessment is
to differentiate the
self-limiting disorder
of acute mechanical
back pain from serious
spinal pathology.

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Physical Examination- Standing
Look
Deformities, swelling (cold abscess), scar, sinus, muscle spasm (acute back pain), pigmentation
Standing with one knee bent- nerve root tension
Bend forward- to exclude postural scoliosis
Wall test- Ankylosing spondylitis
Gait
Feel
Temperature
Tenderness at spinous process, interspinous ligmaments, paravertebral muscles and ligaments, iliac
crest
Stepping
Move
Flexion, extension, lateral flexion, rotation (hands support pelvis)
Measure
Schobers test
Chest expansion
Limb length 11
Physical Examination- Lying
Supine
Limb muscle wasting
Special tests:
Straight leg raising test
Crossed sciatic tension
Sciatic stretch test
Bowstring test
FABER test*
Neurovascular- power, sensation, reflex*, clonus, Babinski sign (spinal cord compression),
peripheral pulses (to exclude vascular claudication)
Prone
Gluteal muscle wasting
Femoral stretch test
Neurovascular- gluteus maximus power, hamstring muscle power (knee flexion), sensation
(saddle area S3,4), peripheral pulses

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Spine X-ray

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Spine X-ray
AP and lateral views of spine
Extra: Oblique view of spine, Pelvis x-ray AP view, Sacroiliac joints AP view

AP view:
Spine should be perfectly straight
Look for scoliosis
Soft tissue shadows should outline the normal muscle planes
Paravertebral abscess- bulging of psoas muscle or loss of psoas shadow
Individual vertebrae- asymmetry, collapse
Outlines of pedicles
Infection, neurofibroma, metastatic disease- missing or misshapen pedicle
Disc space

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Lateral view:
Normal: regular thoracic kyphosis (up to 40) and lumbar lordosis
Vertebral bodies
Spondylolisthesis- anterior shift of an upper segment upon lower, defects in
posterior arch (best shown in oblique view)
Normal- rectangular shape
Osteoporosis- wedged/ biconcave, bone density and trabecular markings
View in flexion and extension
To reveal excessive intervertebral movement
Intervertebral spaces
Disc degeneration- edged by bone spurs
Ankylosing spondylitis- bridged by fine bony syndesmophytes

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 Strains are defined as tears,
either partial or complete, of
the muscle-tendon unit.

Sprains are ligamentous

injuries.

Lumbosacral Strain/Sprain
Due to musculoligamentous injuries
The posterior ligaments are more prone to injury. The posterior longitudinal ligament, for example,
is the biggest of this group of ligaments and is less developed than its anterior counterpart.
The lumbar spine and the hips are responsible for the mobility of the trunk. The L4-5 and L5-S1
areas bear the highest loads and tend to undergo the most motion. Consequently, these areas are
found to sustain the most spinal strain or sprain injuries. 17
Lumbosacral strain/sprain
Can be acute or chronic
Common in:
Athletes
Tall and thin people
Those in a job requiring standing for long hours/ working in bad postures
Sedentary workers
Women after pregnancy
Preexisting structural deformities, such as scoliosis, spondylolysis, or spinal
fusions
Acute sprain may occur while lifting a heavy weight, sudden
straightening from bent position, pushing etc.

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History
The mechanism of injury, with an exact description of the event
leading to the pain
The exact localization and duration of the pain
Typical: Pain and spasm at the posterior lumbar spinal muscle bellies (lateral
to spinous process/ muscle insertion site at the iliac crest)
Any pain radiation
Movements that aggravate or minimize the pain

*Usually structural deformities, generalized midback pain indicating

disc involvement, and neurologic symptoms should be absent.

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Physical Examination
Look on standing position:
Evaluate for obvious deformities, changes in alignment,
or difficulties in achieving changes in position or full
ROM -> Muscle spasms/ loss of lumbar lordosis
Palpation of painful area:
In prone position
A point-specific midline back pain between the spinous
processes indicates a ligamentous injury.
Neurological examination: to rule out disc
involvement

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Investigations- Imaging
Standard anteroposterior and lateral radiographs of the lumbar spine
should be routinely obtained to:
exclude a fracture, rheumatic disease, or a tumor growth
evaluate degenerative joint disease as well as overall spinal alignment.
If an individual does not respond to conservative treatment and
develops neurologic signs:
CT scan or MRI may be considered to evaluate for disc herniation and
involvement of the nerve roots.

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Management Pain would usually subside
within 6 weeks.

Pharmacological Non-pharmacological Prevention

Muscle relaxants Lumbosacral corset Proper warm-up

Methocarbamol Physical therapy exercises
(Oral/IM) Cold therapy Correct weight-lifting
NSAIDs Electrical techniques
Diclofenac stimulation Correct posture
Ibuprofen Ultrasound
Muscle stretching
Should not exceed 6 and strengthening
weeks

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References
"Lumbosacral Spine Sprain/Strain Injuries: Background, Epidemiology,
Functional Anatomy". Emedicine.medscape.com. N.p., 2017. Web. 22
Feb. 2017.
Solomon, L., Warwick, D. & Nayagan, S. (2010). Apleys System Of
Orthopaedics And Fractures (9th ed.). London, UK: Hodder Arnold.
Maheshwari, J., Mhaskar, V. A. (2015) Essential Orthopaedics (5th
ed.). New Delhi, India: Jaypee.

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SEMINAR / Academic Activities

Active participation / Performance Date: 10/5/2017

Topic Musculoskeletal Tumours

No Contents Full marks Marks

awarded
1 Introduction 1

2 Content: 5
1. Applied anatomy
2. Epidemiology
3. Pathophysiology
4. Clinical features
5. Specific clinical tests
6. Differential diagnosis
7. Investigation
8. Principle of management
9. Rehabilitation
10. Complications
3 Arrangement of presentation 1

4 Literature Review/ References 2

5 Presentation skill 1

Total 10 8

Name of lecturer/Specialist: Dr Thit Lwin 25