Specific Low Back Pain


 Original Editor - Michelle Lee

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Introduction[edit | edit source]

Specific low back pain accounts for a small proportion of the back pain populations. In the CSAG report 1994 nerve root pain accounted for only <5% of the population with only <1% having a serious spinal pathology.[1] 

Serious or systemic pathology[edit | edit source]

Serious spinal conditions are very rare but it is important to know about these conditions so that we can adequately screen for them as recommended in international back pain guidelines[2].  These conditions are identified by Red Flags, a list of prognostic variables for serious pathology such as:

Malignancy[edit | edit source]

There are 3 main types of tumors:

  1. Primary Tumors – located in either the disc or the bony structures of the spine such as myeloma.
  2. Metastatic Tumors – these are secondary tumors which have spread from a primary tumor located elsewhere. Most commonly breast, prostate or lung.
  3. Intra and extramedullary Tumors – these are located in (intramedullary) or in the cells surrounding (extramedullary) the spinal cord.

Symptoms can include: unremitting pain which is uninfluenced by analgesia, severe night pain, neurological deficits, lack of co-ordination of limbs, accompanied with decreased appetite and weight loss.[3][4]

Systemic inflammatory disorders[edit | edit source]

These include a number of conditions such as: arthritis, rheumatoid arthritis, infections and Ankylosing Spondylitis (AS). Some of these conditions can be quite challenging to diagnose but can be debilitating, such as AS, in which some parts of the vertebrae can become fused together. This results in progressive stiffness as a by-product of inflammation. [5][6]

Infections[edit | edit source]

Infections of the bone include osteomyelitis, discitis or infections in the epidural space (infection in the vertebrae / disc). The most common location for a spinal infection is in the lumbar region (50%), and this has been linked to urinary tract infections. Other links have been made to the following: diabetes, post cardiac / urinary catheterization, drug addiction and post-spinal surgery. Infections affecting the disc have been shown to have a 40% chance of causing paraplegia. This figure can range as high as 75-100% for infections involving the epidural space. Although there is low risk of developing an infection, it is essential that appropriate treatment is given. Some of the signs and symptoms are pain and those associated with infections. To accurately diagnose infections of the bone, blood cultures are completed to assess inflammatory markers, including Erythrocyte Sedimentation Rate (ESR), C-reactive Protein (CRP) and White Cell Count (WCC). Alongside these blood tests, appropriate radiography is utilized, such as magnetic resonance imaging (MRI).[7][8][9]

Fractures[edit | edit source]

Fractures of the vertebra can occur for a number of reasons, including osteoporosis, tumors and trauma. Tumors which are growing near and around the spine can lead to compression fractures due to the fragility of the bones. Patients who are diagnosed with certain types of tumors (such as multiple myeloma and lymphoma) are monitored regularly for spinal fractures. Trauma and osteoporosis are other mechanisms for fractures

Osteoporosis is the largest cause for a fracture. It usually occurs in the lower thoracic / upper lumbar regions, due to a reduction in bone density. This can be caused from minor trauma such as lifting or even coughing. Compression fractures can lead to a wedging of the vertebrae on the anterior aspect, and this can lead to spinal deformities such as kyphosis. Common treatments for fractures include conservative methods such as physiotherapy, analgesia and bracing. Other treatments include balloon kyphoplasty and fusions to stabilise. [10][11][12]

Cauda equina syndrome [edit | edit source]

Cauda Equina Syndrome Incomplete (CESI) is a very serious pathology which needs to be identified as soon as possible. The spinal cord terminates at the level of L1 (1st Lumbar Vertebrae) and forms the cauda equina (lumbosacral nerves). These lumbosacral nerves supply function to the legs, genitalia, bladder and bowels. Compression of these nerves is most commonly caused by a herniated disc which will present with normal radiculopathy symptoms (dermatomal and myotomal changes) and commonly one or more of the following red flags: perineal numbness / saddle anaesthesia, loss of urinary sensation, urinary retention / incontinence, poor anal tone and fecal soiling / incontinence. It has been advised that urgent surgical intervention (within 24-48 hours from onset) will enable the best possible outcome in preventing long-term damage. Spinal stenosis can also be a cause of CESI, but this presentation is a much slower one as this change happens over time.[13][14][15]


LBP with significant neurological deficits[edit | edit source]

Lumbar radiculopathy[edit | edit source]

Radiculopathy is the whole complex of symptoms that can rise from nerve root pathology, including anaesthesia, paresthesia, hypoesthesia, motor loss and pain. Lumbar radiculopathy occurs in the lower back and causes symptoms in the legs. It is caused by damage to the lower spine which causes compression of the nerve roots which exit the spine. The compressed nerve roots can cause pain, numbness, tingling, or weakness along the course of the nerve. Radiculopathy is not a synonym for “radicular pain” or “nerve root pain,” but patients with radiculopathy commonly have nerve root pain. Radicular pain and nerve root pain specifically apply to a single symptom (pain) that can arise from one or more spinal nerve roots.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

A variety of conditions can lead to compression of the nerve roots, which means that there are several different approaches to the treatment and management of lumbar radiculopathy. These are the conditions that we should look out for:

Symptomatic disc [edit | edit source]

The nucleus of the disc can protrude out (herniated intervertebral lumbar disc) and compress the nerve roots giving the symptoms of a radiculopathy. These can produce dermatomal / myotomal pain, paraesthesia / anasthesia, weakness and altered reflexes. Inflammation and chemical changes around the disc can also cause irritation to the nerve root simulating a radiculopathy. Conservative treatment involves analgesia accompanied with a neuropathic analgesic (for the radiculopathy symptoms) and physiotherapy. Surgical / medical interventions can include micro / discectomy, nerve root and caudal epidural injections. [16][17]

Spinal stenosis[edit | edit source]

Spinal stenosis is a condition in which the spinal canal narrows and the nerve roots and spinal cord become compressed. Because not all patients with spinal narrowing develop symptoms, the term "spinal stenosis" actually refers to the symptoms of pain and not to the narrowing itself. [18][19][20]

Depending on where the narrowing takes place, patients may feel pain, cramping, weakness or numbness in the lower back and legs.[18][19][20] Patients commonly present with an insidious history of back pain with gradual onset of radiating pain into the buttocks and extremities. Neurogenic claudication (or pseudoclaudication) is the most common presenting symptom. It is characterized by bilateral pain or weakness in the buttocks, thighs and calves, is initiated by prolonged standing and walking and relieved by sitting or bending forward. Pain may vary from dull and aching to dysesthetic or sharp and truly radicular. Less commonly, symptoms present unilaterally. [21][22][23]

Spondylolisthesis[edit | edit source]

Spondylolisthesis is defined as a translation of one vertebra over the adjacent caudal vertebra. This can be a translation in the anterior (anterolisthesis) or posterior direction (retrolysthesis) or, in more serious cases, anterior-caudal direction.[24][25] It is classified on the basis of etiology into the following five types by Wiltse: dysplastic (congenital), isthmic, degenerative, traumatic, and pathologic spondylolisthesis.[24]

Symptoms and findings in spondylolisthesis are: low back pain; pain in the legs; dull pain, typically situated in the lumbosacral region after exercise, especially with an extension of the lumbar spine; diminished range of motion (spine); and neurological symptoms (possible evolution towards cauda equine syndrome). Patients usually report that their symptoms vary in function of mechanical loads (such as in going from supine to erect position) and pain frequently worsens over the course of the day (Figure 3). Radiation into the posterolateral thighs is also common and is independent of neurologic signs and symptoms. The pain could be diffuse in the lower extremities, involving the L5 and/or L4 roots unilaterally or bilaterally. [26]

Spinal Masqueraders
[edit | edit source]

When discussing screening for conditions that fall outside the category non-specific low back pain it is worth mentioning spinal masqueraders. These are conditions which present as lower back pain but are actually caused by non-mechanical referred pain from a visceral structure.

Spinal masqueraders are examples of when red herrings can sometimes lead to misdiagnosis[27]. Patients will present with lower back pain but the source is not a mechanical structure[28]. Although the percentage of patients seen by Physiotherapists with these conditions is small it is important to be able to recognise the red flags that could point towards these conditions.

Some of the sources of visceral pain include:

  • Inflammation - eg. Appendicitis
  • Distention - eg. Bowel Obstruction
  • Ischemia - eg. a tumour blocking blood supply

The blood supply to internal organs is in close proximity to the sympathetic nerve system so changes to the blood supply from ischemia, distention of inflammation can directly affect the nerve innervation[29].

Summary[edit | edit source]

We must screen for these serious pathologies and specific conditions that lead to neurological deficit in the assessment of an individual with low back pain to direct appropriate management.  It is also worth paying attention to spinal the possibility of spinal masqueraders.

90% of people will have no clear pathoanatomical diagnosis and an absence of red flags, these people have Nonspecific LBP.

Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. ↑ Report of Clinical Standards Advisory Group (CSAG) on Back Pain. HMSO: London, 1994
  2. ↑ Anthony Delitto, Steven Z. George, Linda Van Dillen, Julie M. Whitman, Gwendolyn Sowa, Paul Shekelle, Thomas R. Denninger, Joseph J. Godges. Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic and Sports Physical Therapy, 2012, 42(4)
  3. ↑ Greenhalgh S, Selfe J. Red Flags - A Guide to Identifying Serious Pathology of the Spine. Edinburgh: Churchill Livingstone, 2006.
  4. ↑ Spine Health - Trusted Information for Back Pain. Types of Spinal Tumors. http://www.spine-health.com/conditions/spinal-tumor/types-spinal-tumors (accessed 6 October 2015)
  5. ↑ Spine Health - Trusted Information for Back Pain. Ankylosing Spondylitis. http://www.spine-health.com/conditions/arthritis/ankylosing-spondylitis (accessed 8 October 2015)
  6. ↑ Columbia Neurosurgeons. Spinal Inflammatory Disorders. http://www.columbianeurosurgery.org/conditions/spinal-inflammatory-disorders/ (accessed 8 October 2015)
  7. ↑ Greenhalgh S, Selfe J, Red Flags - A Guide to Identifying Serious Pathology of the Spine. Edinburgh: Churchill Livingston, 2006
  8. ↑ Spine Health - Trusted Information for Back Pain. Osteomylitis Diagnosis. http://www.spine-health.com/conditions/lower-back-pain/osteomyelitis-diagnosis (accessed 9 October 2015)
  9. ↑ American Association of Neurological Surgeons. Spinal Infection. http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments/Spinal%20Infections.aspx (accessed 9 October 2015)
  10. ↑ MKSpine Mr Manoj Khatri. Balloon Kyphoplasty. http://www.mkspine.co.uk/balloon-kyphoplasty.html (accessed 9 October 2015)
  11. ↑ Columbia Neurosurgeons. Spinal Compression Fractures. http://www.columbianeurosurgery.org/conditions/spinal-compression-fractures/ (accessed 9 October 2015)
  12. ↑ Eurospine. Osteoporosis of the Thorocolumbar and Lumbar Spine. http://www.eurospine.org/osteoporosis-of-the-thoracolumbar-and-lumbar-spine.htm?action=confirmbox (accessed 9 October 2015)
  13. ↑ Greenhalgh S. Selfe J. Red Flags A Guide to Identifying Serious Pathology of the Spine. Edinburgh: Churchill Livingston, 2006
  14. ↑ Cauda Equina Syndrome Association. Cauda Equina Syndrome. http://www.cesassociation.org.uk/gp-resource/jon-raynard-document/ (accessed 9 October 2015)
  15. ↑ American Academy of Orthopaedic Surgeons. Cauda Equina Syndrome. http://orthoinfo.aaos.org/topic.cfm?topic=A00362 (accessed 9 October 2015)
  16. ↑ Eurospin. Lumbar Spine. http://www.eurospine.org/lumbar-spine.htm (accessed 9 October 2015)
  17. ↑ American Academy of Orthopaedic Surgeons. Sciatica. http://orthoinfo.aaos.org/topic.cfm?topic=A00351 (accessed 9 October 2015)
  18. ↑ 18.0 18.1 Wise C., Spinal stenosis, American College of Rheumatology, 2013.
  19. ↑ 19.0 19.1 Ogiela D., Spinal stenosis, National Library of Medecin, 2012.
  20. ↑ 20.0 20.1 Cluett J., M.D, Spinal stenosis, Orthopedics, 2010.
  21. ↑ Hall S, Bartleson JD, Onofrio BM, et al. Lumbar spinal stenosis. Clinical features, diagnostic procedures, and results of surgical treatment in 68 patients. Ann Intern Med 1985;103(2):271–5.
  22. ↑ Blau JN, Logue V. Intermittent claudication of the cauda equina. Lancet 1961;1:1081–6.
  23. ↑ Katz JN, Dalgas M, Stucki G, et al. Degenerative lumbar spinal stenosis: diagnostic value of the history and physical examination. Arthritis Rheum 1995;38(9):1236–41.
  24. ↑ 24.0 24.1 http://emedicine.medscape.com/article/1266860-overview: Amir Vokshoor et al., Spondylolisthesis, Spondylolysis, and Spondylosis. Medscape, updated Sep 10, 2014, Consulted on Oct 20, 2014
  25. ↑ Tebet, M.A. (2014). Currents concepts on the sagittal balance and classification of spondylolysis and spondylolisthesis. Revista Brasileira de Ortopedia, 49 (1), 3-12.
  26. ↑ Frymoyer, J.W. (1992). Degenerative spondylolisthesis. In: Andersson GBJ, McNeill TW (eds) Lumbar spinal stenosis. Mosby Year Book, St Louis. (Level of Evidence: 5)
  27. ↑ Walcott BP, Coumans JV, Kahle KT. Diagnostic pitfalls in spine surgery: masqueraders of surgical spine disease. Neurosurg Focus. 2011 Oct;31(4):E1.
  28. ↑ Walcott B, Coumans J, Kahle K. Diagnostic pitfalls in spine surgery: masqueraders of surgical spine disease. Neurosurgical Focus. 2011;31(4).
  29. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named Eveleigh
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