CHAPTER Practical Approach to a Person with Low Backache

33 Pradeep Kumar Maheshwari, Anjana Pandey, Rosmy Jose

Backache is a price we pay for our upright posture. It f. Obesity affects about 60-80% of world population1. Most patients g. Psychosocial risk factors like job dissatisfaction, with acute low , with or without radicular unhealthy relations result into fear/avoidance symptoms, have musculoskeletal or degenerative behaviour and reduced activity levels, excessive disorders that do not require specific treatment and are reliance on aids and appliances, depressed mood, often self-limited. Approximately 85% of patients with withdrawal from social interaction and various cannot be given a definitive diagnosis. somatisation disorders particularly low back pain.3 However, the possibility of more serious abnormalities that require specific treatment should always be excluded. NON MECHANICAL CAUSES4,6,7 Although there is no evidence that back pain prevalence Infection (#) has increased, reported disability and absence from work 1. Osteomyelitis due to back pain have increasedg. significantly in the last 30 years2. 2. Septic RISK FACTORS h. Psychosocial risk factors 3.like jobParaspinous dissatisfaction, abscess unhealthy a. Older age 4. Epidural abscess b. Heavy labour (in particularrelations jobs requiring result liftinginto infear/avoidance 5. Shingles behaviour and reduced an awkward position). activity levels, excessive Inflammatory(*)reliance on aids and appliances, c. Long-distance driving and whole-body vibration 1. Ankylosing such as experienced by a lorry driver depressed mood, withdrawal2. Rheumatoidfrom social arthritis interaction and d. Lower education and income 3. Psoriatic arthritis e. Smoking 3 various somatisation disorder4. s particularlyReiters low back pain.

4 CLASSIFICATION

MECHANICAL (97%) NON MECHANICAL (1) % VISCERAL (2%)

1) Lumbosacral strain / 1)infection (#) 2) Lumbar canal 2)inflammatory(* ) stenosis 3)neoplastic(×) 3) Traumatic 4) Diskogenic pain 4)metabolic(ₓ) 5) Bony deformity

(/)

PELVIC RENAL GIT a) prostatitis a) pyelonephritis a) penetrating ulcer b) endometriosis b) perinephric abscess b) cholecystitis

5 c) chronic pelvic inflammatory disease(40%) c) nephrolithiasis c) pancreatitis 559dddisease 40(40%disease(40%)

CHAPTER 33 175 . Superficial, non anatomic tenderness to Superficial, non anatomic tenderness light touch loading on a standing patient’s Vertical skull produces low back pain and pelvis rotation of shoulders Passive in same plane causes low back pain findings on sitting Discrepancy between and supine straight leg raising tests weakness “Cogwheel” (give-way) Non dermatomal sensory loss Disproportionate facial expression, or tremor during verbalization examination Waddell Test Waddell Tenderness Simulation Axial loading Rotation Distraction Regional disturbances Weakness Sensory Overreaction Three or more inappropriate responses suggest complicating or more inappropriate suggest Three responses psychosocial issues in patients with low back pain group from 20-55 years. According to etiology the pain various postures. on attaining or improve may vary 4 Symptoms and Signs and Symptoms muscle spasm. back with paraspinal to lower pain confined Post traumatic of present. Features muscle spasm and paraspinal trauma, point tenderness History of present. with rest. relieved Pain back pain (Pseudoclaudication). buttock and low History of in the low back only or of spinal flexion. The pain is located History of limitation Features of radiculopathy are of leg,back of thigh and buttock. referred to the back equina syndrome signifies Cauda by maneuvers. All symptoms exaggerated present. the spinal canal distal to the roots within lumbosacral nerve an injury of multiple and areflexia in the weakness spinal cord at L1-2. Low back pain, termination of the occur. or loss of bladder function may ankle, saddle anesthesia, primary pain worsens on movement; with other constitutional symptoms, Fever can be often associated. source of infection males below age 45 years. has young onset,patients are often This spinal disease with morning back low back and buttock pain accompanied Insidious onset of exercise. Loss by rest but improving with stiffness, nocturnal pain, pain unrelieved as of thoracic kyphosis develop of the normal lumbar and exaggeration restricted movements spondylitis, the disease progresses. Similar to ankylosing syndrome), Psoriatic as Reiter’s arthritis (formerly known may accompany reactive disease. bowel arthritis, and chronic inflammatory on rest. with no improvement constant dull in character worsened at night Pain Neurologic deficits may be seen. (localized or radicular)Pain are seen on radiological and compression fractures which Precipitating factors like steroid abuse, imaging and are often asymptomatic. may be present. immobilization, thyroid disorders etc. the organ. spinal segments that innervates Referred pain particularly to the posterior on movements. Local signs are absent with little pain lesions on exhaustive vague pain with no anatomical Nonspecific chronic cause is poor posture or malingering. Most common investigations. 6,7 Acute (1 day - <6 weeks) - ≤12 weeks) Subacute (6 weeks Chronic (> 12 weeks) Metastatic malignancy Lymphoma/ leukemia Multiple myeloma Spinal cord and retroperitoneal tumours. disease of bone Paget’s Inflammatory bowel disease Inflammatory bowel Table 1: Table causes Mechanical sprain/strain Lumbosacral fracture Vertebral stenosis Lumbar canal disease Lumbosacral disc Non mechanical causes Infection Inflammatory Neoplastic Metabolic causes Visceral organs Renal, Pelvic GIT, Postural back pain CLINICAL FEATURES CLASSIFICATION (BASIS OF DURATION ) DURATION OF (BASIS CLASSIFICATION B. C. Low backache is definedwith or without ribs and gluteal folds lower between as pain relatednon neuropathic leg pain. It can be a symptom in any age to the area A. 2. 3. 4. Metabolic (x) 1. 2. Osteomalacia 3. Neoplastic(×) 1. 5. RHEUMATOLOGY 176 C. B. v. iv. iii. ii. i. A. visceral causeifpresent. thorough examination ofabdomenandrectumtoruleout any includes examination Complete thoroughly. and vascular systemexaminationshouldalsobedone reflexes) tendon deep and tone (especially neurological patient. Apart from musculoskeletal system examination, entire spinalcurvature, lower limbs and the gaitof the Examination of the spine begins withinspection of the etiology ofthedisease. is mustandinvestigations arenecessarytopinpointthe and clinicalexamination and sleepcycleofthepatient) A completeandthoroughhistory(withemphasisonmood systematically. nerves5 minifitisdone accomplished in lessthan canbe A good examination ofthelumbarspineandrelevant 6. 5. 4. 3. 2. 1. backache. issues playanimportantroleinthepersistenceoflow physical aroutine examination toidentifypatientsinwhom non organic during performed maneuvers five cause is highly likely. The Waddell tests is a setof If thedistributionofpainis nonanatomic, a psychogenic INSPECTION DIAGNOSIS RED FLAG SIGNS ASSOCIATED WITH LOW BACKACHE PSYCHOGENIC LOW BACK PAIN Nerve Root L4 L5 S1 shortening) is measured from ASIS (anterior and true). Truelength discrepancy(lengthening Look for limb length discrepancy (apparent or Recumbent posture Sitting posture:lookfor asymmetry ofpelvis Abnormal hairgrowthinthe area. Muscle atrophy Spinal deformities, Asymmetry ofskinfolds, Any exaggeratedorflattenedspinalcurvatures, Standing posture Motor, sensoryorreflexsigns. Signs ofradiculopathy Saddle anaesthesia Faecal incontinence Gait disturbances Progressive motorweakness 3,6,7,9 Pain medial calf Antero lateralthighand buttocks Lateral calf,dorsalfoot, Buttocks, posterior thigh, calf 8 Sensory Medial partleg Dorsum offoot Sole andlateralborderfoot 7 pain andsymmetry inmotionshouldbenoted. Range of motion atthehipjointalso to beexamined. Hip pressure, asitcouldexacerbatethepatient’ssymptoms. applying when taken be to Care motion. of passiverange patient, gentlepressure to beapplied check for a further upright. If full rangeof active motion is achieved by the At lumbarspinethisis evaluated with thepatientstanding Range ofmotion and behindthepatient. Should beevaluated whilestandinginfront,totheside Gait reproduction ofsymptomsinthisposition. there’s if positive is test The foot. the dorsiflex passively disappear. While holding the leginthislowered position, symptoms radicular until or 5˚-10˚ lowered slowly is leg test. Once a complaint of painortightnessis achieved, the performed inthesamefashion asthestraightlegraise It isalsousedtoevaluate lumbarnerveIt is irritation. herniation. and indicatescentrallumbardisc raise test leg straight produced inthecontralateralleg.Thisistermedascrossed the straightlegraisetest,sometimes symptoms may be patient’s symptoms can bereproduced. While performing held inextendedposition.Itissaidtobepositive if knee with hip at flexed passively is limb lower test this It is used to evaluate forlumbarnerve rootirritation.In bones shouldbepalpated. superior iliacspine,anteriorinferiorandpubic is instructedtoliesupine,andtheanterior The patient be appreciated. which arepositioneddeeptoparaspinalmuscles,canalso points orspasms. In thisposition,thetransverse processes, spinous processes should also be palpatedfortender the to lateral just Muscles deformity. for and tenderness Palpation alongthemidlineisusedtocheckforbony ii. i. Purpose ofpalpationthelumbarspine— LASEGUE TEST STRAIGHT LEG RAISING TEST PALPATION tibial tuberosityormedialmalleolus. like landmark fixed distal a to spine) iliac superior the inspection. in demonstrated previously findings confirm To To locatetenderareas Motor Knee extensors,hipadductors and hipabductors Foot evertors, foot dorsiflexors plantar flexion Hip extensors,toeflexors,foot Reflex Knee Ankle CHAPTER 33 177 10 Is associated with neurological symptoms or signs. or symptoms neurological with Is associated CT SCAN when the study It is diagnostic and spinal bony pathology are clear and levels neurological is suspected. CT scan is superior to routine x-rays involving posterior of fractures for the detection and craniothoracic craniocervical spine structures, junctions, C1 and C2 vertebrae, or misalignment within the spinal canal, bone fragments MRI OR CT soft of intraspinal and adjacent exquisite views Myelography: Spine MRI’s tissue anatomy. yield are when the exact and neurologic levels spinal unclear, or of the spinal cord condition when a pathological soft tissues is suspected, disc herniation is possible, or when postoperative cause neoplastic or an underlying infectious when is suspected. Non pharmacological Surgical TREATMENT PHARMACOLOGICAL NON e. 2. 3. scenarios - It is useful in following i. ii. iii. iv. CT Myelography is useful with previous pathology, particularly in patients in identifying nerve lumbar spinal surgery or root with a metal fixation device in or compression place. It provides elucidation of neural been have spinal operations when several arachnoiditis spinal and foramina the treatment of for undertaken and canal stenosis. RADIONUCLIDE technetium-99m is helpful in conditions characterized by BONE These include bone metastases, increased bone turnover. SCINTIGRAPHY binds Gallium-67 infections. and disease, Paget’s fracture, with can be to polymorphonuclear leucocytes and helpful in and sacroiliac osteomyelitis of vertebral the evaluation in are negative septic arthritis. Typically, bone scans which is characterized patients with multiple myeloma by lytic lesions. Neurophysiological studies are rarely indicated except in patients in whom it is difficult to distinguish between a neuropathy, radiculopathy, or plexopathy. Fibrillations and common are the most muscles in the para spinous earliest findings seen in radiculopathy. Their foramen and indicates a lesion proximal to the vertebral presence excludes a plexopathy. The H reflex noted on is used to an from distinguish to radiculopathy or S1 an for evaluate L5 radiculopathy. A. B. Pharmacological C. latest teaching however previously, advised was rest Bed if allowing early mobilization with back strengthening Spinal X-rays are required associated only with if certain the ‘red signs, which indicate a high risk of more serious pain flag’ symptoms is or underlying problems: Starts before the age of 20 or after 50 years. Is persistent and a serious cause is suspected. Is worse at night or in the morning, when an spondylitis), ankylosing (e.g. arthritis inflammatory infection or a spinal tumour may be the cause. weight or fever illness, with a systemic Is associated loss. CBC with ESR: The sedimentation rate is the most of having suspected test in patients useful blood to 80 per in up spinal infection since it is elevated cent of cases. Neutrophilia anaemia are also and and with neoplasia patients in seen commonly infection. RA factor/ CRP. HLA B-27. Urine routine microscopy. etc.). Markers for malignancy (PSA, CEA, of patients with osteoporosis Laboratory evaluation serum include and/or pathological fractures should calcium, phosphorus, alkaline phosphatase as well as serum and urine. RADIOLOGICAL INVESTIGATIONS RADIOLOGICAL LABORATORY EVALUATION LABORATORY VASCULAR SYSTEM SYSTEM VASCULAR NEUROLOGICAL EXAMINATION NEUROLOGICAL PATRICK TEST TEST PATRICK a. b. c. d. In general, imaging procedures are not required for patients with uncomplicated neck or back pain of less than 1 month’s duration 1. II. III. IV. V. VI. Biochemical Investigations I. Check peripheral pulses of should be compared tibialis posterior artery. The character dorsalis pedis artery and bilaterally. The neurological examination is an important part in examination is an important part The neurological the and cord spinal The evaluation. the lumbar spine pain. The lumbar can contribute to or cause roots nerve motor, of 3 elements: consists neurological examination sensory, and reflex. The test is used to evaluate for pathology of the sacroiliac of the sacroiliac for pathology evaluate to is used The test on the supine lies The patient joint. and hip joint table examination foot on the asked to place one and is opposite knee by placing the hip with one the pelvis rotation. While supporting external in flexion abduction hand, the physician presses firmly down anterior at the opposite pelvis supporting the knee while on flexed the test is when pain in the A positive superior iliac spine. is a the leg can be demonstrated. It sacroiliac joint of in inflammatory arthritis. common finding RHEUMATOLOGY 178 III. II. I. invasive andinvasive techniques. Surgical procedures can further be classified as minimally and mayeven worsenbackpain. should not be operated on, since surgery is rarely effective by backpainthanneurologicalclaudicationprobably Patients withspinal stenosis who are more incapacitated with attempts all conservative managementhave failed. after only but stenosis, spinal to due be indicated in patientswithneurological claudication neurological deficit whilst on treatment. Surgery may also management, and/orsevere orprogressive worsening and/or legpaindespite2to3monthsofconservative Indications for surgery include persistent disabling buttock sedation isavery commonanddisturbingsideeffect. metaxalone provide symptomatic relief. However methocarbamol, carisoprodol, Skeletal musclerelaxantslikecyclobenzapramine, as benefitinanxiety. mediated mechanisms provide muscle relaxation as well NSAID clonazepam like are Benzodiazepines used and preexisting comorbidities. of renal commonly risk gastrointestinal toxicityisincreased in patientswith The are effective. are (acetaminophen) that Drugs for surgery. ofepidural short-term afford improvement in leg painbuttheydo not reduce the need may role They unclear. The remains steroids drugs. anti-inflammatory and analgesics, rest, limited with significantly improve will with aherniatedlumbardisc About 90percentofpatients the otheravailable options. Spinal manipulation,massageaccupuntureandTENSare reduce potentialconcernsaboutLBP. and active, staying in assist self-management, encourage pain and disease per say.These interventions often helping includes that regarding thinking and modifyhis/her to identify patients therapy behavioural Cognitive found toeffective alternative totheseexerciseregimens. symptoms.Yogain alleviating initsmanyformshasbeen effective be to found been has exercise physical intense exercises, aerobics and stretching exercises. Supervised MINIMAL INVASIVEMINIMAL TECHNIQUES SURGICAL PHARMACOLOGICAL method forpainalleviation. It requires minimal Transforaminal corticosteroid injectionsis another used tomanage chroniclowbackache. interventionalendoscopy isanother technique Percutaneous adhesiolysis with orwithout spinal tissues, therebyimproving thepain. shrinkage of collagen fibers and coagulation neural to thermomodulation.The proposed mechanism is invasive techniquewheretheannulusis subjected Intradiskal electrothermaltherapyaminimally 3,11,12 6 chlorzoxazone,and prts i GABA- via operates

demonstrated inallcases. cannot be is doubtfulbecausesegmentalinstability are also being performed.The need for such procedure Apart from these methods, procedure like spinal fusions V. IV. if nocontraindicationexists. activeis staying stone oftreatment andearlymobilization exercises, back definitive diagnosis is not possible in majority of cases.The corner as graded therapies behavioural cognitive and like yoga modifications lifestyle modalities. Majority of patients can be treated by offering examination andjudicioususeofavailableinvestigatory to elicitadetailedhistory,conductingmeticulous the physician’sawareness aboutthissymptom,hisability The art of diagnosing and treating thiscondition lies in be ignorednorover zealouslyinvestigated andtreated. Backache, thoughacommon complaint shouldneither 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. CONCLUSION REFERENCES 2007; 6:198. Spine A randomized controlledclinicaltrial.JNeurosurg fusion: allograft compared with cervical diskarthroplasty Mummaneni PV et al: Clinical and radiographic analysis of trial andcost-effectiveness analysis.Lancet2010;375:916. controlled randomised A care: primary in pain low-back Lamb SEetal:Groupcognitive behaviouraltreatment for 147:492-504. therapies Nonpharmacological Med 2007; Intern pain. Ann for acuteandchroniclowback LH; Huffman R1, Chou Society. AnnInternMed Painthe American and Physicians of College the American of lowbackpain: A jointclinicalpracticeguidelinefrom Qaseem R, V,Chou Snow treatment A, and Diagnosis al. et Nonorganic physical signsinlow-backpain.Spine1980;5:117–25. al. et E, Kummel JA, McCulloch G, Waddell Davidson’s Principle&Practiceofmedicine,22ndedition. Harrison’s PrinciplesofInternalMedicine,19thedition. 784.[PubMed]. 1985-2001. States United visits, ambulatory dischargesand hospital pelvic disease al.Trendsin inflammatory et A, M,Zaida Strenberg MY, Sutton EULAR Textbook onrheumaticdiseases,2ndedition. Kumar &Clark:clinicalmedicine,8thedition. Goldman: CecilMedicine,25thedition. 81. of lowbackpain.BestPract Res ClinRheumatol 2010; 24:769- Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology alleviation. Kyphoplasty isanothersimilartechniqueforpain lessens thedeformity,andreduces associated pain. cement is injected tostrengthenthestructures, into afracturedvertebral body,andthenbone involves theplacementofaneedle(orneedles) Vertebroplastyis apercutaneoustechniquethat placement neartheinvolved nerve root. Epidural injectionshavewidely usedindirect been site. volume ofdrugtobeinjectedintothepathological 2007;147:478-491. 2005; 32:778- Dis 2005; Sex Trans