HISTORY
The diagnosis of low back pain requires a careful history to determine whether the causes are mechanical or secondary and more threatening. Mechanical causes of acute low back pain include dysfunction of the musculoskeletal and ligamentous structures. Pain can originate from the disc, annulus, facet joints and muscle fibres. Mechanical low back pain generally has a favourable outcome, but back pain with a secondary cause requires treatment for the underlying condition.
The secondary causes of low back pain are much less frequent than mechanical causes. An important consideration in the patient's history is age. Patients, who are older than 50 and younger than 20, are more likely to have secondary causes.
Less common secondary causes of acute low back pain include metabolic diseases, inflammatory rheumatologic disorders, and referred pain from other sources, Paget's disease, fibromyalgia and psychogenic pain.
Red flag: Red flag means warning factors in a patient’s case history and from clinical findings relating to possible serious underlying pathology e.g. fracture, tumour or infection. The symptoms under the category of Red flags in low back pain are-
Ø Age under 20 or above 55 years
Ø Constant pain, possibly increasing over time; pain whilst at rest
Ø Thoracic pain
Ø General feeling of illness and /or loss of weight
Ø Injury, cancer, use of steroids or immunosuppressant, drug abuse
Ø Widespread neurological signs
Ø Deformity of the spine
Ø High ESR, declared morning stiffness that lasts for more than one hour
PHYSICAL EXAMINATION
The physical examination is not as important as the history in identifying secondary causes of acute low back pain. Nevertheless, certain aspects of the physical examination are considered important
Gait and Posture:
Observation of the patient's walk and overall posture is suggested for all patients with low back pain. Scoliosis may be functional and may indicate underlying muscle spasm or neurogenic involvement.
Range of Motion:
The examiner should record the patient's forward flexion, extension, lateral flexion and lateral rotation of the upper torso. Pain with forward flexion is the most common response and usually reflects mechanical causes. If pain is induced by back extension, spinal stenosis should be considered. Unfortunately, the evaluation of spinal range of motion has limited diagnostic use, although it may be helpful in planning and monitoring treatment.
Straight Leg Raising Test:
Bending the knee while maintaining hip flexion should relieve the pain, and pressure in the popliteal region should worsen it (popliteal compression test). If placing the knee back in full extension during straight leg raising and dorsi-flexing the ankle also increase the pain (Lasègue's sign), nerve root and sciatic nerve irritation is likely.
The result of straight leg raising is positive in 95 per cent of patients with a proven herniated disc, but it is also positive in 80 to 90 per cent of patients without any form of disc protrusion. In contrast, crossed straight leg raising is less sensitive but much more specific for disc herniation. In the crossed straight leg raising test, the contralateral, uninvolved leg is raised. The test result is positive when pain is produced (Figure- 11).
Palpation or Percussion of the Spine:
Point tenderness over the spine with palpation or percussion may indicate fracture or an infection involving the spine. Palpating the paraspinous region may help delineate tender areas or muscle spasm.
Heel-Toe Walk and Squat and Rise:
A patient unable to walk heel to toe, and squat and rise may have severe cauda equina syndrome or neurologic compromise.
Palpation of the Sciatic Notch:
Tenderness over the sciatic notch with radiation to the leg often indicates irritation of the sciatic nerve or nerve roots.
EXAMINATION OF SPINE
Lumbo-Sacral Spine Flexion:
The forward bending of lumbo-sacral region is a combination of spinal and hip flexion. The normal range of movement is 800 angles from the vertebrae prominence and if patients can bend up to ground, concern as normal. Patients with an acute disc protrusion may find it difficult to reach even to the knees. It was assessed with the help of measuring tape (Figure- 12).
Lumbo-Sacral Spine Extension:
Ask the patient to bend backwards, supporting the shoulders. An assessment of extension is highly subjective, but not gets an impression of loss of extension, to a third or two-thirds of the normal range. The normal range of flexion is 400 angles with the line between the sacrum and vertebrae prominence (Figure- 12).
Lumbo-Sacral Spine Lateral Flexion:
Lumbo-Sacral Spinal Rotation:
The normal range of movement of rotation is 400 angles with the medial line (Figure- 12).
Reflexes and Motor and Sensory Testing:
Testing knee and ankle reflexes in patients with radicular symptoms often helps determine the level of spinal cord compromise. An altered knee or ankle reflex alone does not suggest the need for invasive management because this finding is generally transient and fully reversible. Weakness with dorsiflexion of the great toes and ankle may indicate L5 and some L4 root dysfunction. Sensory testing of the medial (L4), dorsal (L5) and lateral (S1) aspects of the foot may also detect nerve root dysfunction.
Limited Neurologic Testing:
In the primary care of patients with low back pain and leg symptoms, the neurologic examination can be limited to just a few tests. These include the testing of dorsiflexion strength of the ankle and great toe, ankle reflexes and light touch over aspects of the foot, as well as the straight leg raising test. This abbreviated neurologic examination of the lower extremities allows the detection of most clinically important radiculopathy related to lumbar disc herniation. If patients with abnormal findings on these tests do not show improvement by one month, further diagnostic work-up or referral to a specialist is necessary. The patients with progressive symptoms should undergo further evaluation without delay.
LABORATORY TESTS
Laboratory tests generally are not necessary in the initial evaluation of acute low back pain. If tumour or infection is suspected, a complete blood cell count and erythrocyte sedimentation rate should be obtained. Other blood studies, such as testing for HLA-B27 antigen (present in ankylosing spondylitis) and serum protein electrophoresis (results abnormal in multiple myeloma), are not recommended unless clinically warranted. Additional laboratory tests, such as urinalysis, should be tailored to the possible diagnoses suggested by the history and physical findings.
Plane x-ray of the spine-
Plane x-ray of the spine can also reveal fracture, malignancy, infection and inflammation as causes of back pain, but MRI is more sensitive in these conditions. Plane x-ray of the spine should be primary examination if spondylolysis, spondylolisthesis and pathological mobility are suspected, and may be necessary preoperatively to avoid surgery at the wrong level (especially relevant if there is an extra sacro-lumbar vertebra that can be difficult to recognise with CT and MRI).
Computerized Tomography (CT)-
Figure- 14
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Magnetic resonance imaging (MRI)-
Since ionising radiation is not being used, the method is
without any known harmful effects unless the patient has any of the following: a pacemaker, vascular clips, suspected metal object in the eye or cochlea implant.
Myelography-
Figure- 16
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MRI- Myelography-
A representation of the nerve root with the help of MRI (MRI-myelography) will in the future probably be increasingly used as a replacement for traditional myelography.
Discography-
Punctuation of the disk with the injection of x-ray contrast is maintained by some to be useful for the determination of the correct level prior to spinal fusions, but seems to have little relevance to diagnostics .
TREATMENT
Most patients require only symptomatic treatment for acute low back pain. In fact, about 60 per cent of patients with low back pain report improvement in seven days with conservative therapy, and most improvement noted within four weeks. Patients should be instructed to watch for worsening symptoms such as an increasing loss of motor or sensory functions, increasing pain and the loss of bladder or bowel function. If any of these occur, the patient should be undergone further evaluation and treatment immediately, with weekly follow-up.
Patients should gradually return to their normal activities, as tolerated. It is being noticed that continuing ordinary activities within the limits permitted by pain leads to a more rapid recovery than either bed rest or back-mobilizing exercises.
Patients with acute low back problems benefit from exercise programs, if started early and if the exercises cause minimal mechanical stress on the back. The goal of an exercise program is, first, to prevent debilitation related to inactivity and, second, to improve activity tolerance and return patients to their highest level of functioning as soon as possible.
Medications commonly used for the treatment of acute low back pain include aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen and, muscle relaxants. Patients taking opioid analgesic drugs, often used in the first few days after the development of acute low back pain, do not return to full activity sooner than patients taking NSAIDs or acetaminophen. Muscle relaxants are more effective than placebo but no better than NSAIDs in relieving acute low back pain. Oral corticosteroids and antidepressants do not appear to be effective in patients with acute low back pain, and their use is not recommended. Gupta et al have reported good results using epidural steroids and lignocaine in low backache patients.
Spinal manipulation has been shown in several randomized trials to be beneficial. Shoe insoles over-the-counter foam or rubber inserts and custom-made orthotics may also be beneficial in some patients. Spinal traction, transcutaneous electrical nerve stimulation, biofeedback, trigger-point injections, facet joint injections and acupuncture are usually not helpful in the management of acute low back pain. Surgery may be indicated in selected patients who are not helped by conservative treatment and who have debilitating symptoms after one month of therapy. Patients with “red flags” noted at the initial evaluation may be applicants for immediate surgery.
When back pain does not respond to more conventional approaches, patients may consider the following options:
Acupuncture involves the insertion of needles the width of a human hair along precise points throughout the body. Practitioners believe this process triggers the release of naturally occurring painkilling molecules called peptides and keeps the body’s normal flow of energy unblocked. Clinical studies are measuring the effectiveness of acupuncture in comparison to more conventional procedures in the treatment of acute low back pain.
Biofeedback is used to treat many acute pain problems, most notably back pain and headache. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature (by controlling local blood flow patterns). The patient can then learn to effect a change in his or her response to pain, for example, by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects.
Interventional therapy can ease chronic pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anaesthetics, steroids, or narcotics into affected soft tissues, joints, or nerve roots to more complex nerve blocks and spinal cord stimulation. When extreme pain is involved, low doses of drugs may be administered by catheter directly into the spinal cord. Chronic use of steroid injections may lead to increased functional impairment.
Traction involves the use of weights to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Traction is not recommended for treating acute low back symptoms.
Transcutaneous electrical nerve stimulation (TENS) is administered by a battery-powered device that sends mild electric pulses along nerve fibres to block pain signals to the brain. Small electrodes placed on the skin at or near the site of pain generate nerve impulses that block incoming pain signals from the peripheral nerves. TENS may also help stimulate the brain’s production of endorphins (chemicals that have pain-relieving properties).
Ultrasound is a non-invasive therapy used to warm the body’s internal tissues, which causes muscles to relax. Sound waves pass through the skin and into the injured muscles and other soft tissues.
Minimally invasive outpatient treatments to seal fractures of the vertebrae caused by osteoporosis include vertebraplasty and kyphoplasty.
Vertebroplasty uses three-dimensional imaging to help a doctor guide a fine needle into the vertebral body. A glue-like epoxy is injected, which quickly hardens to stabilize and strengthen the bone and provide immediate pain relief.
In Kyphoplasty, prior to injecting the epoxy, a special balloon is inserted and gently inflated to restore height to the bone and reduce spinal deformity.
In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by back problems or serious musculoskeletal injuries. Since invasive back surgery is not always successful, it should be performed only in patients with progressive neurologic disease or damage to the peripheral nerves. Some of the surgical interventions are:
• Discectomy is one of the more common ways to remove pressure on a nerve root from a bulging disc or bone spur. During the procedure the surgeon takes out a small piece of the lamina (the arched bony roof of the spinal canal) to remove the obstruction below.
• Foraminotomy is an operation that “cleans out” or enlarges the bony whole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve the pressure on the nerve.
• Intra-Discal Electrothermal Therapy (IDET) uses thermal energy to treat pain resulting from a cracked or bulging spinal disc. A special needle is inserted via a catheter into the disc and heated to a high temperature for up to 20 minutes. The heat thickens and seals the disc wall and reduces inner disc bulge and irritation of the spinal nerve.
• Nucleoplasty uses radiofrequency energy to treat patients with low back pain from contained, or mildly herniated, discs. Guided by x-ray imaging, a wand-like instrument is inserted through a needle into the disc to create a channel that allows inner disc material to be removed. The wand then heats and shrinks the tissue, sealing the disc wall. Several channels are made depending on how much disc material needs to be removed.
• Spinal fusion is used to strengthen the spine and prevent painful movements. The spinal disc(s) between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together.
• Spinal laminectomy (also known as spinal decompression) involves the removal of the lamina (usually both sides) to increase the size of the spinal canal and relieve pressure on the spinal cord and nerve roots.
Other surgical procedures to relieve severe chronic pain include rhizotomy, in which the nerve root close to where it enters the spinal cord is cut to block nerve transmission and all senses from the area of the body experiencing pain; cordotomy, where bundles of nerve fibres on one or both sides of the spinal cord are intentionally severed to stop the transmission of pain signals to the brain; and Dorsal Root Entry Zone Operation (or DREZ), in which spinal neurons transmitting the patient’s pain are destroyed surgically.
DIETARIES FOR BACK PAIN
The diet of those suffering from backache should consist of a salad of raw vegetables such as tomato, carrot, cabbage, cucumber, radish, lettuce, and, at least two steamed or lightly cooked vegetables such as cauliflower, cabbage, carrot, spinach, and plenty of fruits, except bananas. The patient should have four meals daily. Fruit and milk are advised for breakfast, steamed vegetables and whole wheat Chapati for lunch; fresh fruit or fruit juice in the evening; and a bowl of raw salad and sprouts during dinner. The patient should avoid fatty, spicy, and fried foods, curd, excess sugar, tea and coffee. Foods that have been processed for preservation should also be eliminated from the diet. Smoking or taking tobacco in any from should be given up completely.
