Lumbar Spine: Back Pain and Radiculopathy

Question 1

Bony anatomy of the lumbar vertebrae?

Answer 1

Vertebral body

Just posterior is the pedicle, which connects the body to the rest of the vertebrae

Transverse process is an anatomical landmark that is very useful in surgery

Facet joints - between the superior and inferior articular processes of 2 adjacent vertebrae

Laminae join to create the spinous process

Question 2

Causes of lower back pain?

Answer 2

• Trauma
• Inflammatory
• Infections
• Degenerative
• Tumours
• Referred pain

Question 3

Occurrence of lower back pain?

Answer 3

THIS IS A SYMPTOM, not a condition

It is the 2nd most common reason for which people seek medical help

Question 4

Classifications of lower back pain?

Answer 4

Acute - 10% continue having pain for 6 weeks (turns into sub-acute); 5% have pain for >3 months (turns into chronic)

Sub-acute - >6 weeks

Chronic - >3 months

Question 5

Types of traumatic lower back pain?

Answer 5

Musculoligamentous - MAJORITY of cases

Lumbosacral junction (transition between mobile segment of lumbar spine and fixed sacroiliac degment); L5/L6 is the most commonly affected and the one that most commonly slips

Osteoporosis - requires minimal trauma; often occurs in elderly women

Traumatic spondyloisthesis

Post-operative pain - often in patients who are operated on at a young age

Question 6

Causes of degenerative lumbar spine disease and lower back pain?

Answer 6

VERY COMMON cause, esp. as life expectancy is increasing

DISC DEGENERATION (very common) - protrusion of disc onto nerve root, causing radicular pain and sciatica

Spondyloisthesis -
degeneration of facet joints, allowing slippage of vertebrae over one another

Spinal stenosis - combination of an element of instability, a spinal canal that is already congenitally narrowed and thickening of ligaments; clinically, this causes neurogenic claudication

Facet joint arthritis - typically causes pain in paramedian area

Scoliosis and structural issues - there are congenital, developmental and degenerative types; mainly treated conservatively by orthopaedics

Question 7

Types of infections of the lumbar spine, causing lower back pain?

Answer 7

Discitis - occurs within disc material itself

Vertebral OM - extension of infection into bone

Epidural abscess - occur in epidural space

Paraspinal abscess - can be seen in TB; also, may occur as a secondary phenomenon when pus extends anteriorly from the vertebral column OR disc

Question 8

Types of tumours of the lumbar spine?

Answer 8

2 types of spinal tumours:
• Primary (may arise from bony structures themselves, OR from the bone marrow, as in myeloma)
• Metastatic - may spread haematogenously, e.g: from lung, breast, OR there can be local spread, e.g: lung cancers near the paravertebral gutter

Extradural tumours:
• Lymphoma

Intradural - there are 2 types:
• Extra-medullary tumours (meningioma, neurofibroma) - located outside the spinal cord but inside the dural sheath
• Intra-medullary (ependymoma, astrocytoma) - arise from cells within the spinal cord

Question 9

Causes of inflammatory disease in the lumbar spine?

Answer 9

Sacroiliitis

Ankylosing spondylitis

Any rheumatological condition affecting the spine

Arachnoiditis, e.g: post-meningitis, post-epidural injections

Question 10

Causes of referred pain to the lumbar spine?

Answer 10

Aortic dissection

Retroperitoneal disease (any tissue) e.g: of the pancreas (pancreatitis, pancreatic cancer)

Peri-spinal disease, e.g: tumours and abscesses

Ovarian / gynaecological causes, e.g: ovarian cysts

Question 11

Non-organic causes of lower back pain?

Answer 11

This is a diagnosis of exclusion and organic causes should be investigated and ruled out

Psychiatric

Malingering (financial, emotional, etc)

Substance abuse

Question 12

Observations on meeting a patient with lower back pain?

Answer 12

Gait

Posture:
• Standing all the time
• Unable to stand
• Stiff back

Constitution

Affect

Question 13

Questions about back pain?

Answer 13

When, where and how it started? How bad was it at the start? (can use the visual analogue scale here)?

Where and how bad is the pain now? Exacerbating and relieving factors?

How does the pain affect the QoL?, e.g: sleep, work, mobility

Question 14

Other symptoms to inquire about with back pain?

Answer 14

Weight loss

Fever, night sweats

Neck / arms (could this be coming for a higher up) / legs

Bladder / bowel (to check for cauda equina)

Cold extremities and non-healing ulcers (vascular system)

Question 15

Red flags with lower back pain?

Answer 15

Acute, rapidly progressive worsening

Constitutional symptoms, e.g: weight loss, fever, night sweats, fatigue

Hx / FH of malignancy

Bladder / bowel symptoms (part. of recent onset)

Bilateral pain / weakness

Pain on lying flat

1st time presentation, part. in a young patient

Question 16

3 clinical syndromes inv. the lumbar spine?

Answer 16

Sciatica (a type of radiculopathy)

Spinal stenosis

Cauda equine syndrome - compression of cauda equina occurs, usually, due to a large disc prolapse

Question 17

Clinical features of sciatica?

Answer 17

Leg pain MUCH WORSE than back pain; the pain is sharp, shooting and travels down the affected dermatome, i.e: radicular pain

Worse on stretching / standing and better on lying with knee bent

Painful urinary retention

NOTE - constipation occurs in those with chronic analgesic use

Question 18

Clinical features of spinal stenosis?

Answer 18

Back pain is WORSE than leg pain

Symptoms begin with WALKING and their is a claudication distance, i.e: they will have to stop due to pain / weakness in the lower limbs (usually bilateral)

If severe, they may gradually develop chronic bladder / bowel symptoms

+/- radicular pain; as many patients are elderly, their may be osteophytes placing pressure on nerve roots, resulting in an element of radicular pain

Question 19

Clinical features of cauda equina syndrome?

Answer 19

Presents with both back and leg pain, although leg pain is usually more severe

Look for BILATERAL SCIATICA and BILATERAL LEG WEAKNESS with ACUTE BLADDER / BOWEL involvment

Urinary retention is a late presenting feature; usually, deficit may still be reversible

Painless urinary retention is more significant than painful retention

Perineal numbness; assess anal tone and perineum (used as a predictor of urgency and treatment outcome)

Question 20

PMH and surgical history of note in lower back pain?

Answer 20

Trauma, inc. surgery (even if they were young or at birthing period)

Tumour (not just spine but any part of the body)

Rheumatology

Drugs, esp. steroids

Gynaelogical factors in females

Question 21

SH of note in lower back pain?

Answer 21

Smoking and alcohol (poor bone density and poor healing)

Drugs use, part. IV drug use as higher risk of spinal infections

Occupation (what does it involve?) and leisure activities

Family, travel, housing

Finances (may influence when surgery occur, as many symptoms improve over time and surgery may not be required in the end)

Question 22

Purpose of examining the lumbar spine?

Answer 22

Targeted (to confirm a diagnosis that is suspected from the Hx)

Rule out important negatives:
• C-spine pathology

Question 23

Steps in examination of a patient with lower back pain?

Answer 23

Walk (assess gait)

Stand still and then on:
• Heel / tip toes
• Stand on one leg
• Rhomberg’s test

Inspect back:
• Loss of lordosis
• Scoliosis

Palpate back

Bend (look for deviation that may suggest a scoliosis)

Check active movements of lower limb, starting with the normal side

Compare tone, power and sensation of upper and lower limbs

Check sensory levels, where appropriate; when doing this, compare it to a region that is unaffected (check the CNs)

Sitting - makes it easier to examine reflexes:
• Lift foot / leg up
• Knee and ankle jerks

NOTE - do not forget hip and vascular examination

Question 24

Describe the lumbar lordosis

Answer 24

Loss of the lumbar lordosis may result in weight being distributed anteriorly and too much P being placed on the anterior part of the spine; this can cause issues with the anterior parts of discs and degeneration

Question 25

Describe a lumbar scoliosis

Answer 25

Weight is not distributed in a normal place; stress occurs, part. in the convexities of the curve and this leads to degeneration

Question 26

Ix in lumbar back issues?

Answer 26

X-ray - can be done in a standing and sitting position, so spine can be checked with load on it CT scan (better bony detail and can be used in patients unfit for an MRI scan) MR scan (better soft tissue detail) - Ix of choice in those with RADICULAR PAIN: • T1 sequence is better for looking at anatomy • T2 sequence is better for looking at CSF • STIR is better for looking for oedema and injury

Question 27

Important consideration when Ix lower back pain?

Answer 27

There are many incidental findings, both spinal and non-spinal Elderly patients often have multiple issues A pathology that is found may NOT be responsible or fully responsible for the symptoms Psychological effects of doing Ix Some patients, e.g: with genetic conditions like NF1, may require multiple Ix, as screening devices, over a long period; this can be a period of heightened anxiety for the patient

Question 28

Effects of lower back pain treatment?

Answer 28

Immediate effect, e.g: pain Intermediate effect, e.g: loss of work, addiction Long-term effect (given age), e.g: spinal instability, stress-riser with surgical fusion

Question 29

Pharmacological treatment of lower back pain?

Answer 29

PARACETAMOL IS NOT EFFECTIVE FOR BACK PAIN Anti-inflammatories for inflammatory pathology Muscle relaxants, e.g: diazepamn, work in a synergistic fashion with NSAIDs, on the level of the pathology Amitriptyline / gabapentin is useful for nerve / radicular pain For acute lower back pain, opiates and derivatives are used; use must be monitored

Question 30

Advice to patients with lower back pain?

Answer 30

Proper sitting technique - hips should be flexed, legs should not be extended and back should not be overly arched Maximum sitting period of 30 minutes, esp. important for those with a sedentary life Proper lifting - back should stay erect and knees should be bent; the weight being lifted should be kept close to the body

Question 31

Other management options for patients with lower back pain?

Answer 31

Aim to maintain flexibility, free nerve roots, muscle tone and restore core paraspinal muscles (reduces strain on intervertebral discs and facet joints) Self-exercises: • Sit-ups and crunches • Pelvic tilts (flatten back against floor) • Hip lifts (from lying on back position) • Back extension (to 90 degrees) • Psoas and hamstring stretches (bring knees to chest) Physiotherapy

Question 32

Injectable options for treatment of lower back pain?

Answer 32

Long-acting anaesthetic / steroids Facet joint infections Peri-root infections

Question 33

Surgery for lower back pain?

Answer 33

Given TIME, most lower back pain will resolve Conservative Mx is usually the preferred method Early surgery may be more useful in patients who have financial commitments that they must return to

Question 34

Types of surgery for lower back pain?

Answer 34

``` • For spinal canal stenosis - lumbar laminectomy (removal of lamina to reveal the thecal sac and nerve root) ``` * For focal disc protrusion - microdiscectomy * Intervertebral fusion- indicated with spinal instability, secondary to injury, or a dynamic slip * Vertebroplasty, e.g: in vertebral body collapse; the cement that is inserted heats up and ablates the painful nerve endings, providing an element of pain control * Decompression procedures are used for focal nerve root compression, e.g: radicular compression by a prolapsed disc, or multi-level thecal sac compression