Non-Mechanical Disorders of the Lumbar Spine: Pathology

Non-mechanical disorders of the lumbar spine: pathology

CHAPTER CONTENTS to slip forwards. The condition occurs four times as Disorders ...... e217 frequently in females than in males and nearly always at the fourth lumbar level (Cyriax:3 p. 288; Rosenberg4). The Spondylolisthesis ...... e217 slip is never severe. This condition has been discussed in Osseous disorders ...... e219 Chapter 35 on the stenotic concept. Rheumatological disorders ...... e223 • Traumatic spondylolisthesis results from a fracture of a Infections ...... e224 posterior element other than the pars interarticularis. Intraspinal lesions ...... e226 • Pathological spondylolisthesis develops as the result of Pain referred to the back ...... e228 weakness caused by a local or generalized bone disease. In this chapter we discuss only the spondylolytic spondylolistheses.

Disorders Aetiology

Isthmic spondylolisthesis has been defined as ‘a condition in Spondylolisthesis which fibrous defects are present in the pars interarticularis, which permit forward displacement of the upper vertebrae and In 1782, the Belgian gynaecologist Herbiniaux described a separation of the anterior aspects of the vertebra from its severe case of lumbosacral luxation, which he considered as a neural arch’ (Fig. 1).5 The aetiology of this bony defect (spond- potential obstetrical problem.1 ylolysis) has been discussed for decades but it is now widely A precise definition of spondylolisthesis was first given by accepted to be the result of a congenital weakness. The defect Kilian in 18542 – a spinal condition in which all or a part of a itself is not present at birth, however, but develops in child- vertebra (spondylo) has slipped (olisthy) on another. hood, probably as the result of repeated stress and trauma.6–8 Wiltse et al9 described five major types: Stress fractures form in the weakened pars interarticularis; • Dysplastic spondylolisthesis is secondary to a congenital fibrous tissue fills the gap, and further tension enlarges the 9 defect of the first sacral–fifth lumbar facet joints, with defect. Forward slipping of the vertebral body therefore gradual slipping of the fifth lumbar vertebra. occurs most frequently between the ages of 10 and 15 years, and progression is unlikely after adolescence.10,11 The reported • Isthmic or spondylolisthetic spondylolisthesis is the most 12–14 common type of spondylolisthesis. The basic lesion is in incidence of spondylolisthesis is between 4 and 7%, although a higher incidence has been reported among Eskimos the pars interarticularis. The vertebra above can slip as the 15,16 result of a lytic process, an elongation without lysis or an (18–56%). acute fracture (subtypes a, b and c). If a defect in the pars interarticularis can be identified, but no slip has Grading occurred, the condition is called a ‘spondylolysis’. • In degenerative spondylolisthesis an advanced degeneration Spondylolysis is visualized by an oblique view of the lumbar of the facet joints and a progressive change in the spine which shows the well-known ‘collar on the Scottie dog’s direction of the articular processes allow the vertebra neck’ (Fig. 2).

Superior articular facet

Transverse process

Inferior articular facet

Superior facet Defect

Transverse process

Inferior facet

Fig 1 • Spondylolisthetic spondylolisthesis: fibrous defects in the pars interarticularis permit forward displacement of the upper vertebra and separation of the anterior part of the vertebra from its neural arch. Facet joint

Spinous process

Forward slipping is best visualized on a lateral radiograph Fig 2 • The defect in the pars interarticularis is best visualized in an and the amount of listhesis is graded by the Meyerding’s oblique view (‘Scottie dog with collar’). From Magee 2008 Orthopedic th system (Fig. 3):17 the upper sacrum is divided into four parallel Physical Assessment, 5 edn, Saunders, St Louis. Reproduced by kind quarters and the degree of slipping is calculated from the dis- permission. tance that the posterior edge of the fifth lumbar vertebra has shifted on the posterior edge of the sacrum in relation to the total width of the upper sacrum. Grade I is a shift of less than Spondylolisthesis .with .secondary .disc .lesion 25%, grade II between 25 and 50%, grade III between 50 and 75% and grade IV more than 75%. As early as 1945, Key stated that symptoms in spondylolisthe- Some authors emphasize that there is a significant differ- sis were far more often caused by a disc lesion than by slip- ence in measurements when the radiographs are taken with page of the vertebra.22 The clinical features are exactly the the patient in a recumbent rather than erect position.18 same as in patients without spondylolisthesis, and nothing in the history or clinical examination arouses suspicion, except some irregularity of the spinous processes on examination. Clinical findings Radiographs carried out in the erect posture disclose the slip. It is obvious that the management of disc lesions occurring It should be emphasized that most cases of spondylolisthesis in spondylolisthetic spines is exactly the same as in those are asymptomatic. Even severe displacements may be present without bony defects. The only difference is probably the in very active patients, without the slightest discomfort. liability to recurrence of acute or chronic discodural conflicts. In a radiological study of 996 adult patients with low back As in other forms of lumbar instability, sclerosing injections pain, MacNab found spondylolisthesis in only 7.6%, which is can have a good preventive outcome after reduction has taken not significantly higher than in the population as a whole place. (4–6%).19 Therefore caution must be taken before ascribing back pain or sciatica to spondylolisthesis and the radiological demonstration of a defect in a patient with back pain does Spondylolisthesis .of .itself .causing .symptoms not always indicate that the source of the symptoms has been Spondylolisthesis can cause both backache and sciatica. The discovered.20,21 former has postural ligamentous characteristics: the ache is Spondylolisthesis can produce backache or sciatica in two central, sometimes with vague and bilateral radiation over the ways: spondylolisthesis as the basis of a secondary disc lesion lower back. The discomfort is associated more with maintain- and the spondylolisthesis itself causing symptoms. ing a particular position than with exertion. Dural symptoms

Normal Grade 1 Grade 2 Grade 3 Grade 4

Fig 3 • Grades of spondylolisthesis (from Meyerding).17

are absent. There are no articular signs or symptoms; lumbar both spondylolisthesis and a disc lesion the displacement will mobility is full and painless. Root signs are also absent. The reappear. In these instances, sclerosing injections are used as a only clinical finding is a bony irregularity palpated over the prophylactic measure. spinous processes. Treatment is that for ligamentous backache Spondylolisthesis which of itself causes lumbar pain should and consists of sclerosing injections (see p. 579). always be treated non-surgically. Sclerosing injections to the Spondylolitic sciatica very much resembles a bilateral lateral ligaments often give good results. recess stenosis but the patient is much younger. Increasing pain If leg pain is a significant problem, nerve root infiltrations and paraesthesia appear in the standing position and may force can often abolish it. The patient can also be advised to wear a the patient to sit or lie down, which causes the symptoms to corset during occasional strenuous activity. If root pain cannot disappear. Dural symptoms are absent. Clinical examination be abolished by these conservative measures, surgery should reveals little: there is a normal range of movement without be considered. Surgical intervention can also be considered if pain. Root signs, such as positive straight leg raising, weakness the listhesis is progressive or the patient presents with a or sensory loss are not found (J. Cyriax, personal communica- Meyerding grade III or IV. The gold standard of surgical treat- tion, 1983; Calliauw and Van23). ment is fusion in situ.26 The different techniques for fusion The cause of sciatic pain in spondylolisthesis is unknown. have mixed and variable results27–29, and the possibility of com- The different hypotheses are: plications.30 Recently, reduction of the listhesis and stabiliza- • The forward movement of the listhetic vertebra drags on tion, whether by bilateral lateral fusion or interbody fusion, has 31,32 the nerve roots, which engage painfully against the shelf been recommended. formed by the stable vertebra below (Cyriax:3 pp. It should be remembered, however, that even in grade III 287–290). and IV listhesis, good results have been described after non- 33 34 • A fibrocartilaginous mass, with or without small ossicles, surgical treatment. Apel et al. reported on the long-term may form at the defect in the pars interarticularis. results (40 years) after surgical and non-surgical treatment of Adhesions around the nerve root and compression grade I and grade II spondylolisthesis. Of the conservatively result.24 managed patients, all functioned well. Among those undergo- ing surgery, poor results were confined to those patients in • With the forwards and downwards drop of the vertebral whom the fusion failed, and a pseudarthrosis developed (40%). body, the pedicles descend on the nerve roots and kink Frennered et al35 stated that operative treatment for low-grade them as they emerge through the foramen.19 spondylolisthesis does not seem to give better results than • A forwards slipping of the vertebral body moves the conservative treatment. More recent prospective studies, transverse processes in a forwards and downwards however, conclude that surgical management of adult isthmic direction, allowing the L5 roots to be pinched spondylolisthesis improves function and relieves pain more between the sacrum and transverse process efficiently than an exercise programme.36,37 (the ‘far-out’ 25).

Treatment Osseous disorders

Patients with an accidentally detected spondylolisthesis do not need treatment. If the pain is caused by a secondary disc lesion, Osteoporosis the patient is treated by the normal procedures used in dis codural or discoradicular problems: manipulation, traction or Osteoporosis is a metabolic disease, related to several different epidural anaesthesia. The liability to recurrences after success- disorders. It is characterized by a reduction of bone mass which ful treatment, however, is much increased and in patients with occurs predominantly in the axial skeleton, the femoral neck

© Copyright 2013 Elsevier, Ltd. All rights reserved. e219 The Lumbar Spine and the pelvis. By radiographic criteria, 18% of men and 29% • the pain is usually located in the upper lumbar area: of women between the ages of 45 and 79 years of age have pathological fractures occur more often in the ‘forbidden evidence of osteoporosis and more sensitive methods for deter- area’ mining vertebral bone mineral density show that 50% of • dural signs are absent: although the patient describes an women past the age of 65 have asymptomatic osteoporosis.38 intense backache, coughing does not hurt The radiographic appearances are changes in bone porosity, • inspection reveals an angular kyphosis trabecular pattern and vertebral body shape (the so-called 39 • examination shows a capsular pattern, with symmetric biconcave fishmouth vertebrae). It is a common mistake to limitation of lateral flexion believe that these changes account for patients’ backache. It • there are no dural signs: straight leg raising is normal, should be remembered that uncomplicated osteoporosis does which is always suspicious in a case of acute lumbago. not cause any symptom except some loss of height of the spine. Thus the major explanation for long-standing back pain in the The girdle pain lasts a week or two, whereafter a localized bone elderly does not appear to be related to spinal osteoporosis and, pain remains. After 3 months the fracture will have united and if a radiograph shows uncomplicated osteoporosis in a symp- symptoms have ceased. Although a wedged vertebra results in tomatic patient, other sources for the pain should be sought.40 lasting malalignment of the related posterior joints, usually Osteoporosis may, however, lead to a pathological fracture. If little ligametous pain results. Any continuous pain after the this takes place, a sudden pain in a girdle distribution will fracture has healed is from a coincident disc lesion. Indeed, result. any force sufficient to break bone will also threaten disc tissue and it is not hard to imagine that, after a crush fracture of a vertebral body, the disc above or below the lesion may Paget’s disease also be damaged. The possibility of a coincident disc displacement should therefore be considered in a case with persistent Osteitis deformans or Paget’s disease of bone41 is a localized pain. Because of the permanent kyphosis and the possible disorder characterized by a remarkable hyperactivity of osteo- elongation of supra- and interspinous ligaments, the protrusion clasts and subsequent increase of osteoblastic bone deposition. may be very unstable and difficult to treat. Although manipula- As a result, the normal bone architecture is completely dis- tion usually affords excellent results, the improvement is turbed.42 In a vertebral body this can result in softening, broad- not lasting unless sclerosing injections are given to stabilize ening and collapse of the bone. The disease is reported to occur the joint. in approximately 4% of individuals over the age of 40.43 In the majority, the disease is restricted to a few bones. It must be emphasized that most patients with Paget’s Spondylolysis 44 disease are asymptomatic. The main problem for the clinician Isthmic spondylolysis is considered to represent a fatigue frac- therefore is not the discovery of the Paget’s disease but the ture of the pars interarticularis of the neural arch. There is a association of the back symptoms with the Pagetoid lesion. relatively high incidence of radiographically identified spondy- Back pain and the associated angular kyphosis arise as the result lolysis in the general population, but the vast majority of these of collapse of the vertebral body. Sometimes new bone growth lesions probably occur without associated symptoms.6,47,48 The in the vertebral arch may compress nerve roots, resulting in a incidence of spondylolysis in the young athletic population 45,46 spinal stenosis or a lateral recess stenosis. shows an almost fivefold increase compared to the general population,49 with the highest rates in weight lifters,50 gym- 51 52 Fractures nasts and football players. Given this high incidence of asymptomatic lesions, the relation between unilateral or bilateral back pain and a fatigue fracture of the pars interarticularis Crush .fracture .of .the .vertebral .body remains unclear.53 This causes a wedge deformity. It usually occurs at the upper However, recent histological studies could identify a well- lumbar or at the thoracolumbar level and usually results from developed ligamentous structure covering the defect (‘the axial trauma or from flexion injuries (see online chapter Dis- spondylolysis ligament’) and containing thin unmyelinated orders of the thoracic spine: non-disc lesions – disorders and nerves.54,55 Infiltration of bupivacaine hydrochloride (Marcain) their treatment). Wedging of a vertebral body may also result into the pars defect produced temporary symptom relief, from a pathological fracture which is the consequence of senile which proves the existence of symptomatic lesions.56 osteoporosis, tumour, Paget’s disease or tuberculous caries. Symptomatic lesions appear to be particularly a clinical Immediate post-traumatic pain is referred bilaterally in the problem in adolescents, especially adolescent athletes. appropriate dermatome. The diagnosis is not missed if back- Although clinical features of active spondylolysis do not dif- ache follows a gross trauma. In a pathological fracture, however, ferentiate this condition from other causes of low back pain,57 the patient probably does not recall an injury that can be suspicion may arise when an adolescent athlete presents with related to the onset of the symptoms. Nothing in the history unlilateral backache without dural signs nor symptoms, and then warns the examiner of the possibility of a crushed verte- pain is provoked by full extension.58,59 bra. However, if the history is taken carefully, and compared On plain radiography, the defect in isthmic spondylolysis is with the clinical findings, some unlikelihoods will immediately visualized as lucency in the region of the pars interarticularis. become obvious. They are: The lesion is commonly described as having the appearance of

© Copyright 2013 Elsevier, Ltd. All rights reserved. e220 Non-mechanical disorders of the lumbar spine: pathology a collar on the ‘Scotty dog’ seen in lateral oblique radiographs Benign .tumours (see Fig. 2). Plain radiography has limited sensitivity, however, Benign tumours of the vertebrae predominantly affect patients and nowadays bone scintigraphy with single photon emission under the age of 30 years and are mostly localized in the pos- computed tomography (SPECT) is considered as the gold 60,61 terior wall. Chronic localized backache that is not dependent standard of investigation. on posture and movement and does not ease with recumbency Conservative treatment consists of relative rest and the 62 is the main characteristic of a benign tumour. Clinical examina- avoidance of activities associated with increased pain. tion may show a limited range of flexion due to a muscle spasm. If the lesion compresses nerve roots, slowly progressing sciatica will supervene. Early detection of the lesion on the Fractures .of .the .transverse .processes radiograph is not always easy. These may occur after direct trauma to the back. Alternatively they result from gross muscular effort, frequently a resisted Osteoid osteoma rotation strain; lumbar manipulation is a rare cause of This constitutes about 12% of all benign tumours (Dahlin and fracture. Unni:70 pp. 88–101) and appears mostly in children and adults The patient complains of post-traumatic and localized uni- below the age of 30 years. The pain is frequently exacerbated lateral pain. Clinical examination reveals a partial articular at night and is often relieved by small doses of aspirin.71 Treat- pattern, with pain during side flexion away from the affected ment consists of local excision of the tumour. side. However, there is also pain during resisted movements: resisted side flexion to the painful side and resisted extension in the prone-lying position are both positive. The lesion may Osteoblastoma appear insignificant on radiograph. This is a rare benign neoplasma of bone but has a predilection Pain usually ceases after a fortnight. If pain persists, a co for the spine: approximately 40% of all osteoblastomas are 72 incident disc lesion should be suspected. Alternatively, an found in the posterior elements of the spine and sacrum. The emotionally unstable patient may capitalize on radiological tumour is seen most frequently in males under the age of 30 73 evidence of a ‘fractured spine’. years. The back pain is localized, insidious in onset, with a duration of months or years and not as severe as in osteoid osteoma. Clinical examination may reveal muscle spasm Stress .fractures .of .the .lumbar .pedicle and localized tenderness. Because of the expansive nature of the tumour, slowly progressive compression of nerve root(s), Stress fractures of the contralateral pedicle in patients 63,64 with radicular pain and evidence of neurological deficit, may with unilateral spondylolysis has recently been reported occur. and termed ‘pediculolysis’.65 The development of a unilateral spondylolysis probably leads to a redistribution of forces, resulting in a stress fracture of the contralateral pedicle. Alter- Haemangiomas natively, not a fracture but a compensatory sclerosis and hyper- These account for less than 1% of symptomatic primary bone 74 trophy of the contralateral pedicle develop.66,67 To date, it is tumours (Mirra: pp. 492–497), although postmortem studies not clear if the lesions are responsible for particular clinical have demonstrated that asymptomatic lesions exist in 12% of syndromes.68 all vertebral columns. This implies that most of these lesions remain asymptomatic throughout life. The thoracic spine is the location for 65%, the cervical spine 25% and the lumbar Tumours for only 10%. Patients with symptomatic haemangiomas are usually between 40 and 50 years of age.75 The main complaint Classically, neoplastic lesions in the lumbar spine are classified is localized pain. Clinical examination may show limitation of as benign or malignant lesions. The latter are subdivided into movement from muscle spasm and localized tenderness. Increased weakening may result in a pathological fracture, primary malignancies and metastases. Benign and primary 76 malignant neoplasms are rare in the lumbar spine, whereas which in turn may cause neurological symptoms. Since secondary deposits are common. Although the diagnosis of vertebral haemangiomas are usually asymptomatic and have tumours of the lumbar spine is largely dependent on radiologi- a benign course, treatment is expectant. Radiation seems to afford a good outcome in patients with constant, cal examinations, it must be remembered that 30% of the 77 osseous mass of bone must be destroyed before a lesion is disabling pain. radiologically evident.69 Therefore radiographs do not reveal early disease and too much reliance on radiographic appear- Eosinophylic granuloma ances can give both the patient and the physician a false feeling This is a rare bone lesion characterized by the infiltration of of security. Therefore, in the diagnosis of neoplastic lesions, bone with histiocytes, mononuclear phagocytic cells and eosi- the history and clinical examination remain vital. Special atten- nophils. It was first described by Jaffe and Lichtenstein in tion must be paid to warning signs. When routine radiographs 1944.78 It occurs most commonly in children and adolescents79 fail to support the clinical impression, a radioisotope scan must and only 10% of the lesions are localized in the spine. Local be obtained, in order to demonstrate the presence of a malig- and constant back pain is the first symptom. Clinical examina- nant lesion and the extent of the spinal involvement. tion shows muscle spasm and local tenderness. If the lesion

© Copyright 2013 Elsevier, Ltd. All rights reserved. e221 The Lumbar Spine affects a vertebral body, a flattening – vertebra plana – will bone destructions with calcified foci and a pre-sacral soft result. This spontaneous collapse of the vertebral body in chil- tissue mass.91,92 dren was first described by Calvé in 192580 and was thought Patients with chordomas of the lumbar spine may present to be a manifestation of osteochondritis juvenilis.79 It seems with localized central lumbar pain sometimes radiating bilater- that the collapse of the vertebra induces spontaneous healing ally. Involvement of nerve roots may induce bilateral sciatica. of the granuloma, in that symptoms usually cease after the Clinical examination then shows muscle spasm and bilateral body has collapsed.81,82 weakness.93 Treatment consists of total resection of the tumour, which Aneurysmal bone cyst usually presents a major problem. Often partial resection, fol- This is a benign, cystic vascular lesion of bone. The majority lowed by radiation therapy, is the only option.94 Chemotherapy of aneurysmal bone cysts occur in the long bones of the is ineffective.95 extremities of young adults.83 The lumbar spine is affected in only 10% of cases.84 The clinical presentation is lumbar pain Chondrosarcoma that usually has an acute onset and increases in severity over a This is a malignant tumour that forms in cartilaginous tissue. short period of time. Depending on the location and size of The tumour is frequently located in the pelvis and lumbar the lesion, the other clinical manifestations vary. If the lesion spine and grows extremely slowly. The usual age of onset is is at the spinous or transverse processes, the pain remains between 40 and 60 years (Dahlin and Unni:70 pp. 227–259). local.85 If the vertebral body is affected, the lesion may expand, The tumour may be symptomless over many years. Local pain which can result in weakening of the bone, pathological frac- is very suggestive of actively growing tumour. When neural tures and serious neurological deficits. Although aneurysmal elements are compressed by the tumour, abnormalities are bone cysts are benign lesions, they may cause severe damage found on neurological examination. The treatment of choice is because of their expansive characteristics. The lesion therefore total resection of the tumour. must be diagnosed early and treatment instituted without delay in order to keep disability to a minimum. Treatment is Myeloma by surgery, radiotherapy or cryotherapy. This is a malignant tumour of plasma cells and is the most common primary tumour of bone; the spine is almost always involved. The disseminated form is multiple myeloma and Malignant .tumours accounts for 45% of all malignant bone tumours (Dahlin and Malignant tumours of the spine predominantly affect patients Unni:70 pp. 193–207). The patients are usually in an older age over the age of 50 and are mostly localized in the anterior spine group, in that the disease is rare below the age of 50 years. elements. Metastatic lesions of the axial skeleton are much Plasmacytoma is the solitary form and affects the spine in more common than primary malignant lesions (chordoma, about 50% of patients.96 myeloma and chondrosarcoma), the overall ratio being 25 : 1 The most common complaint is of back pain, which does (Francis and Hutter;86 Mirra:74 pp. 448–454). not vary with exertion, although initially may be relieved some- what by bed rest. Malignant disease is suggested by steady Chordoma worsening of the backache which eventually becomes continu- This is a slowly developing malignant tumour that originates ous, irrespective of posture or movement. As the backache from the remnants of notochordal tissue and therefore occurs becomes more severe, sciatica, which is often bilateral, exclusively in the midline of the axial skeleton. It has a predi- appears.97 The fact that the backache does not cease after the lection for either end of the spinal column: 50% of cases occur root pain comes on and that the root pain is bilateral, imme- in the sacrum and 38% in the skull base.87 The lesion is rarely diately draws attention to the possibility of an expanding reported below the age of 30 years and most tumours become lesion. Alternatively, the backache is sudden as the result of a evident between the ages of 40 and 70.88 Chordomas are slow- pathological fracture. growing tumours with a locally invasive and destructive Findings on clinical examination depend on the extent character. of the disease. In the early stage, there is usually only lumbar The common sacral tumours may be difficult to detect. The muscle spasm and localized tenderness. In later stages, angular patient initially presents with localized pain in the sacral area kyphosis and signs of nerve root compression at different levels or with coccygodynia. The pain is dull, constant and not can be seen. Finally, signs of generalized illness, such as fever, relieved by recumbency. Often it is of long duration and only weight loss and pallor, become prominent. moderate, so that it does not force the patient to seek treat- Radiographically, multiple myeloma is characterized by the ment.89 Chordomas of the sacrum extend anteriorly into the presence of round lytic defects in the bone without any sur- pelvis. Because the dural sleeve is not involved, presacral inva- rounding reactive sclerosis. Occasionally, lytic defects may not sion of the nerve roots does not provoke radicular pain. Straight be obvious, and the radiograph shows nothing more than a leg raising is also not limited. However, gross muscular weak- diffuse osteopenia.98 In such circumstances the differential ness of one or both legs, together with considerable sensory diagnosis must be made by laboratory examinations,99 which deficit is detected. Sometimes the patient presents with consistently reveal an elevated erythrocyte sedimentation rate urinary or bowel incontinence as well.90 Such a gross paresis – seldom less than 100 mm/h. Characteristically, abnormal in the absence of root pain always suggests a tumour. A Bence-Jones proteins can be demonstrated in the urine.100 The radiograph of the lumbar spine and sacrum discloses lytic most important test is serum protein electrophoresis, which

© Copyright 2013 Elsevier, Ltd. All rights reserved. e222 Non-mechanical disorders of the lumbar spine: pathology identifies a monoclonal spike in more than 75% of patients and Cure is seldom possible and treatment of metastatic depos- hypogammaglobulinaemia in 9%.101 its in the spine is palliative: it includes radiation therapy, cor- The usual course of multiple myeloma is one of gradual ticosteroids and decompressive laminectomy. progression. Systemic therapy with melphalan and cortisone may improve clinical symptoms, but the average survival seldom exceeds 5 years.102 Rheumatological disorders

Metastatic tumours Ankylosing spondylitis The most common malignant tumour in the spine is metastatic cancer. The prevalence of metastases increases with increasing This disease usually affects the sacroiliac joints initially, and age, and patients who are aged 50 years or older are the popula- then appears in the thoracolumbar area. Thereafter, the lower tion at greatest risk. Neoplasms frequently associated with 103 lumbar, the thoracic and the cervical spine also become spinal metastases are of prostate, breast, lung, thyroid and 111 104 affected (see Ch. 43). Although the lesion invariably starts colon. Up to 70% of patients with a primary neoplasm will at the sacroiliac joints, it is possible that this does not cause sooner or later develop metastases in the thoracolumbar 105 any symptoms and the first complaint is then of backache. spine. The predilection of metastases for the lumbar spine Backache in ankylosing spondylitis is typically intermittent; may be explained by the functioning of Batson’s plexus. This it comes and goes irrespective of exertion or rest. However, is a venous network, located in the epidural space between the the pain and the stiffness are greatest in the morning and bony spinal column and the dura mater. Because this plexus usually improve with movement. Several segments at the has no valves to control blood flow, metastatic cells may easily upper lumbar and thoracolumbar level become involved at enter it and lodge in the connected sinusoidal systems of the 112 106 about the same time. Because the pain is usually limited red bone marrow of the vertebral bodies. to the central part of the spine and does not refer laterally, Some suspicion may arise when, for the first time, a patient the patient complains of vertical distribution (Fig. 4a). over the age of 50 presents with an attack of low back pain. This contrasts with the more or less horizontal, gluteal and Especially if the pain has a gradual onset and increases in inten- asymmetrical reference of dural pain in a lumbar disc disorder sity over time, the patient should be suspected of suffering (Fig. 4b). from a malignant disease. The concern should be even greater if there is a prior history of malignancy. In the beginning the pain is localized but very soon it spreads down the leg in a distribution not corresponding to a single root. Sometimes (a) (b) there is bilateral sciatica and the lumbar pain does not ease but becomes even worse when the sciatica appears. Because the tumour often extends into the epidural space, dural symptoms may be present. However, not all skeletal metastases cause pain: symptoms may occur only when the lesion is complicated by a pathological fracture.107 Results of the clinical examination depend on the stage; at first, there will be muscle spasm, markedly limiting- move ments, especially side flexions. Localized tenderness, particularly at the ‘forbidden’ upper lumbar area causes more suspicion. Later, distinctive neurological signs will immediately draw attention to the possible existence of a spinal neoplasm: • Bilateral weakness • Weakness of the psoas muscle • Signs of involvement of two or three consecutive roots, or non-adjacent roots • Discrepancy between pain and weakness • A warm foot on the affected side. It is important to stress that radiographs may be normal and are not reliable early in the course of a metastatic lesion. Clini- cal symptoms and even signs of gross muscular weakness may appear before the radiograph shows erosion or collapse of bone.108 If the clinical features of metastasis are present but the radiographic examination remains negative a bone scan may be necessary to establish the diagnosis.109 MRI examination is a quite sensitive complementary tech- Fig 4 • Localization of pain affecting the upper lumbar level in nique and appears to be more specific for metastasis in certain ankylosing spondylitis (a), dural reference of low back pain in a locations of the spine.110 lumbar disc disorder (b).

Inspection usually shows a flat lumbar spine, together with Ankylosing hyperostosis the beginning of an upper thoracic kyphosis. The motion of the spine is impaired in a symmetrical way, which is best demon- This disease is also known as the vertebral hyperostosis of strated by a gross limitation of side flexion in both directions. Forestier.119 More recently ‘diffuse idiopathic skeletal hyperos- There is also upper lumbar tenderness and the end-feel during tosis’ (DISH) has been suggested, in recognition of the fre- a downwards thrust on the prone spine is hard. quent combination of both spinal and extraspinal foci.120 Sometimes an acute increase in pain caused by a sprain of According to autopsy findings, it seems to be a common entity the stiffened lumbar joints can simulate an attack of lumbago. in the eldery.121 The patient then states that lifting something heavy caused Despite the impressive anatomical abnormalities, most immediate and agonizing pain at the upper lumbar level. patients rarely have significant disability from the illness, the Although the history probably suggests a disc protrusion, there principal complaint being increasing stiffness. Some patients is a complete absence of dural signs, which is rather unusual develop a vague and local ache in the entire trunk.122 Clinical in such an acute case. Furthermore, there is a symmetrical examination shows marked limitation of movement at every limitation of side flexion and the pain on the palpation is upper spinal joint. Dural and radicular signs are of course absent. lumbar, in the ‘forbidden area’. Laboratory parameters are normal and the diagnosis of Diagnosis is confirmed by radiography of the sacroiliac DISH is a radiographic one. The criteria are a flowing calcifica- joints. Because lumbar manifestations occur some years after tion along the anterolateral aspect of four contiguous vertebral sacroiliac manifestations, plain radiographs of the latter will bodies, preservation of the normal intervertebral disc height almost certainly reveal the typical narrowed joint spaces and and absence of apophyseal arthrosis or sclerosis.123 surrounding sclerosis. In later stages, radiographic abnormali- Treatment is seldom necessary, in that the complaints are ties also appear in the lumbar and thoracolumbar spines. First rather minor. there are signs of osteitis of the anterior corners of the vertebral bodies. This results in the typical ‘squaring’ of the vertebrae. Healing of the inflammation leads to a reactive sclerosis in the anterior portions of the vertebral bodies. Later on, thin, Infections vertically orientated calcifications of the annulus fibrosus and anterior and posterior longitudinal ligaments appear. These Infections of the spine are rare. However, it is important to growing ‘syndesmophytes’ can enclose the whole axial skele- remember them as a potential source of backache. An early ton, which is then called a ‘bamboo spine’.113 diagnosis is vital, because the prognosis of infections of the vertebral column is excellent if the disease is recognized early. Infections involving the lumbar spine include vertebral osteo- Rheumatoid arthritis myelitis, intervertebral discitis and herpes zoster, and viral infection of the dorsal root ganglia. Rhematoid arthritis, a systemic chronic inflammatory disease which involves synovial joints, may affect the facet joints of the lumbar spine, although it is found more frequently in the Vertebral osteomyelitis cervical articulations. The disease does not affect the sacroiliac joints.114 Those who develop low back pain secondary to rheu- Pyogenic .vertebral .osteomyelitis matoid arthritis usually have a long-standing history of disease This occurs as the result of haematogenous spread through the in the joints usually affected by the illness.115 blood stream. Pelvic lesions, such as urinary tract or rectosig- Pain stems from the facet joints and therefore its reference moid infections, preferentially spread to the vertebral column does not spread beyond the hips.116 The symptoms are inflam- through the venous plexus of Batson.124 During recent decades matory in nature, with pain and stiffness increasing with rest, the clinical features of vertebral osteomyelitis have changed.125 greater in severity in the morning and improving during activ- Before the antibiotic era, it used to be a disease of children ity. Clinical examination reveals limitation of movement in a and adolescents, with a rapid evolution and in most cases capsular way and localized tenderness. The diagnosis is based caused by Staphylococcus aureus. Now, the mean age of patients upon the typical history, the clinical appearances of the periph- reported with osteomyelitis is 50 years, the onset is insidious eral joints and the characteristic laboratory findings. and the development is slow.126 The diagnosis of vertebral osteomyelitis is frequently missed because the patient’s symp- Reiter’s syndrome toms are ascribed to mechanical problems. Onset of back pain is insidious and it becomes more and This is a triad of urethritis, arthritis and conjunctivitis.117 It is more severe. The central ache is usually constant, although it the most common cause of arthritis in young men and prima- is sometimes increased by exertion. If the lesion becomes more rily affects the joints of the lower extremity. The disease invasive, the patient will find it difficult to stand or sit upright. results from the interaction of a specific infection and a geneti- In a later stage, the infection may extend beyond the bone and cally predisposed host. Although back pain is a frequent can produce a psoas abscess: the patient may then present with symptom of patients with Reiter’s syndrome, pain usually an abdominal syndrome or with hip pain.127 Should the infec- stems from the sacroiliac joint and lesions of the lumbar spine tion drain into the spinal canal, an epidural abscess or menin- area118 (see Ch. 43). gitis will result.128

In the early stage, the signs may be insignificant, with only destruction of vertebral bodies. Investigation by CT seems to slight limitation of movement. As a rule, side flexions are sym- be the best way of searching for abscess formation.140 metrically limited. Local tenderness at the affected level can Treatment consists of antituberculous drugs and immobiliza- be detected during passive forcing of extension in the prone- tion. Surgery must be considered if, despite antituberculous lying position.129 Because the first and second lumbar vertebrae therapy, abscesses progress. are the levels in the axial skeleton most commonly affected,130 the discovery of pain at the ‘forbidden area’ during selective Intervertebral disc space infections examination will alert the examiner. As the pain worsens, side flexions become more and more Infections of the intervertebral disc can develop secondary to limited and muscle spasm limits flexion. Because of severe haematogenous invasion via the blood stream. The primary pain, the patient finds it more and more difficult to remain lesion is usually an infectious endocarditis or a urinary tract upright. This could suggest an attack of lumbago but when it infection.140 The most common cause for spondylodiscitis, comes to further clinical examination, straight leg raising is however, is a direct complication of disc surgery.141–143 found to be of full range and completely painless. The clinical picture is that of an acute lumbago which Patients with psoas muscle irritation also present with appears 1 week to 2 months after the discectomy. The pain decreased hip motion and a painful weakness of hip flexion. It radiates in a dural manner to the gluteal region, groin and is important to notice that, in most cases, fever and signs of limbs, is exacerbated by movement and is relieved by absolute general illness only appear if an abscess forms.131 rest. Dural symptoms are present. Radiographic evidence of the disease follows the sympto- There are dural and articular signs. Fever is rarely present matic onset by 1–2 months. Bone scintigraphy usually demon- but the erythrocyte sedimentation level is usually elevated.144 strates abnormalities at an earlier stage of disease, although it Since the condition closely resembles a discodural conflict, should be remembered that false positives and negatives do nothing except the previous disc surgery will draw attention to occur. Computed tomography may also show bony changes the possibility of an infection. It is therefore wise to consider before their appearance on routine radiographs.132 every case of ‘acute lumbago’ occurring in the first months after Treatment includes antibiotics and bed rest. The choice of discectomy as a discitis until the reverse is demonstrated. antibiotic is dependent on the identification of the organism Radiographs do not show abnormality during the first few causing the infection.133 Surgical interventions such as laminec- weeks. The earliest change is a decrease in the height of the tomy, discectomy or vertebral fusion may be indicated in case affected intervertebral disc space. Later, relative sclerosis and of neurological compromise or mechanical instability.134 irregularity at the vertebral endplates will be noted. If a disc infection is suspected, a bone scintillation scan is indicated and Tuberculous .vertebral .osteomyelitis identifies an area of increased bone activity in the adjacent vertebrae.145 During the last decade, MRI has become the This has a clinical course that can be distinguished from pyo- radiological method of choice for establishing the diagnosis of genic infections. Before the antibiotic era, it was a disease of spondylodiscitis, in particular with regard to differentiating children but nowadays patients with spinal tuberculosis have between cases with and without abscess formation.146,147 an average age between 40 and 50 years.135 Alcoholics and drug Treatment includes antibiotics and immobilization. addicts are at greatest risk of developing the disease.136 The childhood form of discitis develops in children between Tuberculous spondylitis occurs as the result of haematoge- 2 and 6 years old. The patient presents with antalgic posture, nous spread from foci in either the lungs or the genitourinary muscular defence, unexplained fever and increased erythro- tract. The lesion begins under the bony endplate and, although cyte sedimentation rate.148,149 initially only the vertebral body is affected, in a later stage the infection can spread to disc, soft tissues and spinal cord. Abscess formation is present in about 50% of the cases.137 The Herpes zoster disease is very insidious, and the time elapsing before a diagnosis is made may be as long as 3 years.138 This is a sequela of previous infection with chickenpox. After Initially there is a vague and localized backache. Later the the termination of the illness, the virus remains dormant in the pain can spread to the buttock. A careful history also reveals posterior spinal sensory ganglia. During a period of low host the existence of constitutional problems such as anorexia, resistance, the virus multiplies, which results in pain and skin weight loss, intermittent fever and night sweats. lesions.150 Herpes (shingles) occurs more frequently in the Limitation of movement in a capsular way and muscle elderly and in patients with impaired immune function. spasm, together with localized tenderness over the involved The patient complains of segmental pain which is burning vertebra, are the main clinical findings in the early stage. Later or shooting in character. Since the pain antedates the appear- there is localized bony deformity, resulting from vertebral col- ance of the vesicles by 4–7 days, the early diagnosis can be lapse or neurological abnormalities. Because of the insidious missed and the patient may be mistakenly regarded as suffering nature of the disease and the insignificant and local symptoms, from sciatic pain, although examination of the lumbar spine the onset of paraplegia is sometimes the first manifestation of and the neurological examination of the limbs are normal.149 tuberculous spondylitis.139 Sometimes, however, dysaesthesia in the area of skin supplied Because the disease has a slow development, patients by the affected nerve root can be detected. Once the skin with tuberculous spondylitis usually present with identifiable lesions develop in a segmental distribution, the diagnosis will

© Copyright 2013 Elsevier, Ltd. All rights reserved. e225 The Lumbar Spine be obvious. Sometimes patients with herpes zoster may also and as a complication of haemorrhages or meningitis.158 The demonstrate a mild and temporary paresis in the motor nerve patient complains of diffuse and constant back pain, sometimes that corresponds to the affected level. radiating to both legs. Paraesthesia and dysaesthesia may be Treatment is directed at controlling the pain. present. The prognosis is poor and there is no effective treatment. Intraspinal lesions Neurofibromas .and .meningomas Pathological processes may affect tissues inside the spinal Meningomas and neurofibromas are slowly growing benign column (Fig. 5). In the lumbar area they can be extradural or tumours, arising from meninges and spinal nerves. They are intradural. rarer at the lumbar spine than at the cervical level. As intradural spinal tumours can compress the dura mater, the nerve Extradural lesions roots and the nerve root sleeves, dural and radicular symptoms and signs will be present and the clinical picture usually mimics a herniated disc – between 0.8 and 1.0% of patients presenting Extradural .neoplasms with symptoms consistent with disc herniation have intraspinal These are metastatic lesions that have invaded the intraspinal tumours.159,160 If the tumour involves the nerve roots of the space from contiguous structures. They usually remain extra- first or second level, diagnosis is not very difficult because first dural because the dura is resistant to invasion by the and second lumbar disc lesions are extremely rare. At the lower neoplasm. lumbar levels, however, neuromas are very difficult to detect, which explains the considerable delay in diagnosis.161, 162 Epidural .abscesses .and .epidural .haematomas The patient presents with back pain and/or root pain. Some- times the pain increases at night or in the supine position. These present as acute backache with severe dural signs and Dural symptoms, such as pain during coughing and sneezing, symptoms. There is a rapid progression to bilateral sciatica and 151–154 are always present – a neuroma is unlikely if a cough does not neurological weakness. hurt. Unlike a disc lesion, coughing usually hurts in the limb rather than in the back. Intraspinal .synovial .cysts Clinical examination shows limitation of spinal movements Cysts arising from the synovium-lined facet joints can exert and straight leg raising. Motor and sensory deficit together with pressure on the nerve root sleeve and cause unilateral sciat- reflex disturbances can be present. Differential diagnosis of ica.155 Cauda equina compression has also been reported.156 neuromas and lumbar disc lesions is almost impossible if only Diagnosis is made by CT or MRI and the treatment is the actual symptoms and signs are considered. However, when surgical.157 the duration and evolution of the symptoms are analysed, certain features should arouse suspicion. The evolution of radicular pain in neuroma is that of a slowly progressive lesion. Intradural lesions This is completely different from the evolution in discoradicular interactions, in which the sciatica becomes rapidly worse Arachnoiditis .and .arachnoid .cysts and reaches a peak within 1–2 months; severe symptoms may Inflammatory changes to the arachnoid space (arachnoiditis) then persist for a certain length of time, which seldom exceeds develop after myelography with iophendylate, in spinal injuries 2 months. Although primary posterolateral protrusion in young patients can have a slower and more gradual onset, the evolution usually does not take more than 6 months. Hence any case of root pain that is getting worse at the end of 18 months is suspect (Cyriax:3 p. 293). Also, increasing backache after root 1 pain has set in must alert the examiner. The range of straight 2 2 leg raising is not much help in the differential diagnosis: if the lesion lies upwards in the canal, straight leg raising may be 2 1 normal, but if the neuroma lies near the intervertebral foramen it will be markedly and often bilaterally restricted.163 Palsies affecting two non-adjacent roots may suggest a neuroma, and bilateral sciatica should also alert the clinician to the possibility 3 of a cauda equina tumour (Fig. 6).165,166 Late manifestations are 2 marked motor deficit, with drop foot or widespread weakness 1 and muscle atrophy. Bladder dysfunction also tends to be a late manifestation, although urinary and rectal incontinence sometimes appear early in the evolution.167,168 Sometimes the diagnosis of a neuroma is suggested by the Fig 5 • Intraspinal lesions: 1, extraspinal, osseous lesions; unusual response to a sacral, epidural anaesthesia. Although the 2, intraspinal, extradural lesions; 3, intraspinal, intradural lesions. introduction of the fluid creates considerable and sometimes

Discoradicular interaction Neuroma

Symptoms Backache ceases when root pain comes on Backache increases Root stabilizes after 2–4 months Root pain continues to worsen after 8 months Recovery of root pain after 1 year Persisting or increasing root pain after 1 year A cough sometimes hurts in the back A cough always hurts, mostly in the limb

Backache Backache

Pain Root pain Pain Root pain

0 3 6 9 12 0 3 6 9 12 Months Months

Signs Root signs evolve in the course of 1–4 weeks Root signs appear insidiously They continue unchanged for 6–8 months Progression is very slow, month by month Recovery may be expected within 1 year after onset No spontaneous recovery, but steadily increasing weakness Palsy is uniradicular or involves two adjacent roots Triple palsies, a palsy affecting two non-adjacent (L4–L5 or L5–S1) roots or a bilateral palsy are all possible

Straight leg raising may be positive or negative in both cases and is therefore no help in differential diagnosis

Fig 6 • Differential diagnosis of discoradicular conflict and neuroma in the lower lumbar area.164

unbearable root pain, it has no immediate effect on the symp- Craig et al172 summarized this in 1952 when they stated: ‘It is toms or on the range of straight leg raising because the fluid not unusual at this clinic to remove a spinal cord tumor from cannot touch the neuroma, which is intradural. Had the root a patient who has had a previous operation for protruding disc pain been caused by an inflammation of the dural sheath, the without relief of symptoms’. injection would have created some anaesthesia immediately Treatment consists of laminectomy and total excision of the afterwards. No improvement of straight leg raising after the tumour, which gives excellent results, provided there is not too epidural injection thus strongly suggests the possibility of a much neurological dysfunction. neuroma and the patient should be referred for further Differential diagnosis investigation. MRI is the most useful method for the differentiation of The following conditions may resemble a neuroma. spinal tumour from lumbar disc herniation.167 In MRI imaging, Adherent nerve root schwannomas commonly appear isointense on T1-weighted There are rare cases of root adherence to the posterior aspect images and markedly hyperintense on T2-weighted images.169 of the intervertebral joint, which occur after the herniation has Computed tomography is not the technique of choice because shrivelled away as the result of the natural course of the disc a lesion higher up in the spinal canal will always be missed. In lesion. The patient’s sciatica slowly subsides and after 2 years addition, as disc protrusions are often asymptomatic,170 the the pain may have gone. However, the patient continues to clinical picture may be wrongly ascribed to such a cause, surgi- find that they cannot bend forwards, and examination shows cal opinion sought and an exploration of the disc undertaken.171 about 45° limitation of straight leg raising on the affected side.

Attempted trunk flexion causes pain in the back and the leg. Lesions of the aorta Apart from that, there are no other complaints and the sciatic pain is slight. The pain also does not increase; there is no An arterial aneurysm is a localized or diffuse enlargement of appreciable neurological deficit and certainly not an increasing an artery. In the abdominal aorta it occurs most commonly in one. The condition thus presents as sciatica, usually in a young men over the age of 50 years.173 The majority of patients with man in whom the symptoms have abated but the signs con- a stable abdominal aneurysm are asymptomatic, and pain is tinue. As in neuroma epidural local anaesthesia does not alter only associated with enlargement or rupture. Most frequently the range of straight leg raising. the pain is abdominal, dull and steady. Sometimes the main Increasing protrusion on an atrophied root symptom is severe and increasing backache, accompanied by The patient has suffered from severe sciatica some years ago. L3 pain in the left leg.174 Increasing back pain and L3 pain in There is sudden loss of pain, together with considerable weak- an elderly patient with a negative functional examination ness of one or two roots, which indicates that root atrophy has should therefore always arouse suspicion. The patient should taken place. There is no recovery from the palsy; however, one be referred immediately for ultrasonography and CT of the day, without pain, the patient notices increased weakness and abdomen. These methods are non-invasive and very reliable in numbness. This can be explained by a further protrusion of identifying the location of the lesion.175 disc substance at the original level. Because it impinges against Acute occlusion of the abdominal aorta presents as acute the atrophied nerve root there is no pain, but there is further and severe low back pain and abdominal pain together with loss of sensory and motor conduction. acute claudication of the lower extremities.176 A second disc protrusion The patient is suffering from sciatica, which is improving (as expected) after some months. After a while, a new disc lesion Genitourinary diseases develops at an adjacent level, impinging against an adjacent or a contralateral root. Of course, weakness extending to another The colic and excruciating pain caused by a kidney or ureteral level after some months’ sciatica is suspect, but the differential stone is well known. The pain is sudden, sharp and has a spas- diagnosis will easily be made on a myelogram. modic character. It is upper lumbar and radiates to the lateral Neuralgic amyotrophy (Cyriax:3 p. 300) flank and along the course of the ureter into the ipsilateral flank This uncommon parenchymatous disorder of the peripheral and along the course of the ureter into the ispilateral testicle nerves usually afffects three to four consecutive roots at the (men) or labium (women). same side. The origin is unknown but the disease has a spon- Renal infarction causes a sudden and sharp pain in the cos- taneous and complete recovery within a year. tovertebral angle. Renal cancers may present as increasing The patient, usually a man aged between 50 and 70 years, upper lumbar and flank pain, which is constant and 177dull. experiences a sudden and severe ache in one leg. The pain is Clinical examination reveals a limitation of the side flexion considerable and not altered by position or motion. There is away from the painful side as the only finding. This warning no pain on coughing or sneezing. After about 3 months the sign should always prompt the physician to refer the patient symptoms slowly ease, and 6 months after the onset they have for further internal examination. disappeared. Diseases of the bladder and the prostate rarely cause lum- Examination shows a full range of movement and full bosacral pain. Lesions of the testis, however, often cause back- and painless straight leg raising. Considerable muscle weakness ache and back pain may be a presenting symptom in 10–21% is detected where the muscles are innervated by two to of patients with testicular carcinoma.178 Patients may even three different roots. An important differential diagnostic present with back pain in the absence of any testicular finding is that the palsy is maximal from the first onsetand symptoms.179 In testicular carcinoma, the pain is dull and per- does not increase or spread to the other limb. There is no sistent, localized over the lumbosacral and paravertebral region. sensory loss. Functional lumbar examination is completely negative, but There is no treatment for this condition. As the pain ceases, examination of the testicles reveals a testicular mass together so the muscles gradually recover. The disorder completely with diffuse induration. resolves 1 year after its onset. In women, referred pain from the genital organs (uterus, fallopian tubes or ovaries) is possible, although backache from gynaecological causes should not be overestimated. For instance malposition of the uterus in times past was regarded as a main Pain referred to the back source of backache in women, but this certainly does not cause any back trouble.180 In contrast, endometriosis, a disease asso- It should be remembered that back pain occurs not only due ciated with the presence of endometrial tissue outside the to lesions of bones, discs and ligaments, but also as referred uterine cavity, is often associated with intermittent back pain. from intra-abdominal or pelvic lesions. The prominent feature The pain is lower lumbar and often irradiates to the buttocks will then be the complete absence of articular, dural and radic- or thighs. The symptoms characteristically increase at the time ular signs during routine clinical examination. Lesions of the of menstruation and persist throughout the entire period of aorta and genitourinary or gastrointestinal diseases should be bleeding. Other symptoms associated with the disease are dys- suspected in such circumstances. pareunia, infertility and menorrhagia.181

It is a well-known fact that women complain more often exertion but appears during eating. The only finding during of low back pain during pregnancy. The incidence reported clinical examination is central discomfort during extension. varies between 24 and 49%.182–185 The increase in backache The combination of pain influenced by posture and abdominal during pregnancy is not very well understood. Hormonally visceral function brings the diagnosis to mind, and the diagnosis induced laxity probably allows increased biomechanical stress is confirmed by gastroscopy. on the pelvis and spine, which results in more postural A peptic ulceration of the posterior duodenal wall can also ligamentous pain.181,186 But there are several studies indicat- cause low back pain. Again the pain is localized to the L2–L3 ing that pregnancy is also a risk factor for lumbar disc lumbar level, but appears 1–3 hours after the meal, and is herniations.182,183 relieved by further intake of food. The pain has no relation to Pelvic inflammatory disease, an acute or chronic infection physical activity.187 Sometimes there is tenderness at the upper of the fallopian tubes, is also associated with pain at the lower lumbar (‘forbidden’) area. back, radiating into the buttocks. The chief clinical symptoms, Pain from chronic pancreatitis or carcinoma of the pancreas however, will be lower abdominal and pelvic pain, with a is felt in the epigastrium and is referred to the upper lumbar feeling of pelvic pressure.183 area.188 Disease processes that affect the head of the pancreas cause pain to the right of the spine, while lesions of the tail are felt at the left side. Gastrointestinal diseases Lesions of the colon – both diverticulitis and carcinoma – can be associated with low back and flank pain.189 Patients with Diseases of the pancreas, stomach, duodenum and colon may a rectal carcinoma often complain of sacral pain. Invasion of be associated with low back pain. The gallbladder has a T5–T9 the nerve roots at the front of the sacrum gives rise to gross origin and pain is therefore felt in the thoracic region. weakness of the muscles in both legs. As the dural sleeve is not Cyriax described cases of gastric ulcer adherent to the affected here, the lesion does not provoke pain and the weak- lumbar spine. The back symptoms are connected both with ness often remains silent. Similar back pain may be the first eating and with posture. The pain is upper lumbar, with radia- sign of recurrence after apparently successful excision of a tion into one or other iliac fossa. It is not brought on by rectal cancer.

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