Low back pain

Low back ache

                          Low back ache is the second most common disease that human come across. About eighty percentage of the population complain at same time in their life. Most of them may subside automatically or after resting. In about 78% men 89 % of women the cause is unspecific. The anatomy of spine and modern lifestyle had added a high range of susceptibility for disease. Mostly bad posture of office working population, working with computers for hours has increased the incidence. Other traumas during road traffic accidents too cause a similar problem just after the event or later in life. A wide range of etiologies are noted as cause of low back pain starting from minor trauma to carcinogenic conditions.

Etiology

                 The causes of low back ache can grossly be divided into primary and secondary etiologies. The cause directly associated with the lower back structure i.e. lumbo-secral vertebrae, ligaments, muscles etc. can be classified under primary cause, where as a radiating pain from nearer viscera’s like intestine, uterus, bladder etc. can be classified under the second.

The most common causes of low back ache are – back muscle strain, IVDP, obesity, bad posture, facet joint arthritis, occupational causes. The mechanical causes are the chief factors. The basic etiology as Ayurveda emphasizes the nidana parivarjana chikitsa of importance.

The first two columns include primary causes & the third column of table includes the secondary causes.

Mechanical (97%)	Non-mechanical (1%)	Visceral organ disease ( 2%)
Strain, sprain lumber (70%) Degenerative disc & facet (10%) Disc herniation (4%) Spinal stenosis (3%) Osteoporotic compression fracture (4%) Spondylolisthesis (2%) Traumatic fracture (<1 o:p="">

Congenital disorders

(<1 o:p="">

Neoplasia (0.7%)

Infection (0.01%)

Osteomyelitis

Epidural abscess

Paraspinal abscess

Pott’s  disease

Inflammatory

Arthritis (0.3%)

Ankylosing  spondylitis

Psoriatic spondylitis

Reiter’s syndrome

Paget’s disease

Disease of the pelvic organs (prostatitis endometriosis)

Renal disease (nephrolithiasis, pyelonephritis,

Perinephric abscess )

Aortic aneurysm

Gastrointestinal disease (pancreatitis,cholelithiasis)

  

Examination

 A proper history may be importance aid to determine the cause. A previous history of noticed or unnoticed trauma in the back may later proceed to the disease.

Age

In children it is generally due to organic causes. Low back ache middle aged and elderly people. In adults disc prolapse is seen commonly. Spondylolisthesis is more common fourth and fifth decades of life. Ankylosing spondylitis is more prevalent in young adults from 15-35 years of age. Degenerative conditions and canal stenosis is often found in old age above 40 years

Sex

Osteoporosis, rheumatoid arthritis, psychogenic LBA, osteomalacia and ligamentous strain are more common in females. Women having multiple pregnancies are also more prone to it. Ankylosing spondylitis, IVDP, osteoarthritis are more prevalent in males.

 Occupation

People with sedentary job are more vulnerable to LBA. Back pain in surgeons, dentists, compu ter professionals, miners, trunks drivers etc.

Duration of Symptoms

Back pain is classified into three categories based on the duration of symptoms. Acute back pain is arbitrarily defined as pain that has been present for six weeks or less. Sub-acute back pain has 6 to 12 week duration and chronic back pain lasts longer than 12 weeks.

Using these three categories, one can make predictions about prognosis. At least 60 percent of patients with acute low back pain return to work within one month, and 90 percent return within three months. With minimal intervention, most patients improve in the first few weeks.

Table-8

Clinical clues of Low Back Pain

Condition	Clinical clues
Nonspecific back pain (mechanical back pain, facet joint pain, osteoarthritis, muscle sprains, spasms)	No nerve root compromise, localized pain over lumbosacral
Sciatica (herniated disc)	Back-related lower extremity symptoms and spasm in radicular pattern, positive straight leg raising test
Spine fracture (compression fracture)	History of trauma, osteoporosis, localized pain over spine
Spondylolysis	Affects young athletes (gymnastics, football, weight lifting); pain with spine extension; oblique radiographs show defect of pars inter-articularis
Malignant disease (multiple myeloma), metastatic disease	Unexplained weight loss, fever, abnormal serum protein electrophoresis pattern, history of malignant disease
Connective tissue disease (systemic lupus erythematous)	Fever, increased erythrocyte sedimentation rate, positive for antinuclear antibodies, scleroderma, rheumatoid arthritis
Infection (disc space, spinal tuberculosis)	Fever, parenteral drug abuse, history of tuberculosis or positive tuberculin test
Abdominal aortic aneurysm	Inability to find position of comfort, back pain not relieved by rest, pulsatile mass in abdomen
Cauda equina syndrome (spinal stenosis)	Urinary retention, bladder or bowel incontinence, saddle anaesthesia, severe and progressive weakness of lower extremities
Hyperparathyroidism	Insidious, associated with hypercalcemia, renal stones, constipation
Ankylosing spondylitis (morning stiffness)	Mostly men in their early 20s, positive family history, increased erythrocyte sedimentation rate
Nephrolithiasis	Colicky flank pain radiating to groin, haematuria, inability to find position of comfort

Clinical Categories of Low Back Pain

Low back pain can be caused by many conditions, both serious and benign. Because of this, the Agency for Health Care Policy and Research (AHCPR) has grouped back pain into three categories:

1.      Potentially serious spinal conditions

2.      Sciatica

3.      Nonspecific back symptoms

1.      Potentially Serious Spinal Conditions:

Spinal tumor, infection, fracture and the cauda equina syndrome are potentially serious causes of acute low back pain. These conditions are suggested by characteristic findings from the history and physical examination. Immediate further treatments are usually needed.

2.      Sciatica:

The word Sciatica is defined in Taber’s Medical Dictionary as “pain along the course of the sciatic nerve of different aetiology”. Sciatica is thus a non-specific term that means radiating pain in the leg and foot. The Back-related lower extremity symptoms suggest nerve root conciliation. Sciatica is often debilitating but, in most cases, the pain abates with conservative therapy.

3.      Nonspecific Back Symptoms:

Some patients have symptoms primarily in the back that suggest neither nerve root compromise nor a serious underlying condition. Mechanical low back pain is in this category. These patients also usually improve with conservative treatment.

With this clinical classification, the examiner can use the history and physical findings to specify the type of back pain affecting the patient and properly treat patients who have potentially serious spinal conditions.

Table-9

Differential Diagnosis of Low Back Ache

Primary Mechanical Derangements-	Ligamentous strain, muscle strain or spasm, facet joint disruption or degeneration, intervertebral disc degeneration or herniation, vertebral compression fracture, vertebral end-plate micro fractures, spondylolisthesis, spinal stenosis, diffuse idiopathic skeletal hyperostosis etc.
Infection-	Epidural abscess, vertebral osteomyelitis, septic discitis, Pott’s disease (tuberculosis) etc.
Neoplasia-	Epidural or vertebral carcinomatous metastases, multiple myeloma, lymphoma, primary epidural or intra-dural tumours etc.
Metabolic disease-	Osteoporosis, osteomalacia, hemochromatosis etc.
Inflammatory Rheumatologic Disorders-	Ankylosing spondylitis, reactive spondyloarthropathies (including Reiter's syndrome), psoriatic arthropathy, polymyalgia rheumatic etc.
Referred pain-	Abdominal or retroperitoneal visceral process, retroperitoneal vascular process, retroperitoneal malignancy, herpes zoster etc.
Other-	Paget's disease of bone, primary fibromyalgia, psychogenic pain etc.