LOWER BACK PAIN

Dr Robert Ramcharan
MBBS, FRCSEd, DM (Neurosurgery)
Neurosurgeon
 Epidemiology

• 60-80% lifetime incidence of low back pain

in the general population

• Most frequent cause of activity limitation in

people below the age of 45 years
 Epidemiology
• second most frequent reason for physicians' visits
• fifth most frequent cause for hospitalization
• third-ranking for surgical procedures.
– loss of 1.4 working days per person / per year;
– 10-15% of all sickness absence is related to back pain.
• Back problems are also responsible for 25% of all
disabling occupational injuries
– $10 billion plus USD treatment costs
 Key Points
• No specific diagnosis in 85% of cases.

• Initial assessment
– Do NOT miss serious pathology.

• Relief of discomfort.
Agency for Health Care Policy and Research (AHCRP)
Classification of low back pain

Clinical Category Description

Potentially serious spinal condition Spine tumors, infection, fractures,

cauda equina syndrome

Sciatica Radicular pain

Non specific back pain Symptoms mainly in back with no

features of serious underlying
problems or nerve compression
 Differential Diagnosis
• Extra- spinal origin
– Retroperitoneal structures
• Requires thorough history and examination.
• Spine Tumours
– Malignant – primary or secondary
– Benign
• Infections
• Inflammatory
• Fractures
• Degenerative Lumbar Disease ( 95%)
 Markers of serious pathology
Condition Red Flags

1. Age > 50 or < 20 years

Cancer or Infection 2. History of cancer
3. Weight loss
4. Immunosuppression
5. UTI, fever, chills, IVI drug abuse
6. Pain not improved with rest
1. History of trauma
Spine fracture 2. Prolonged use of steroids
3. History of osteoeperosis

1. Urinary retention or incontinence

Cauda equina syndrome or 2. Fecal incontinence or loss of anal sphincter
neurological deficit tone
3. Saddle anaesthesia
4. Weakness in lower extremity
 Assessment
• 90 % of patients will improve in 4 weeks
and require no further assessment.

• In the absence of “ red flags” no further

investigation needed.
If we just follow people who don’t have
RED FLAGS what happens?
 Natural History- Return to work
• 95% return to work within 3 months from
symptom onset
• Failure to return within 3 months is a poor
prognostic sign
– Total disability > 1 yr results in only 20% returning to
work
– Total disability > 2 yr have <2% chance of returning to
work

Note- mixed population of LBP +/- radiculopathy

Natural History of radiculopathy
• Weber and colleagues
– 208 conservatively managed patients
– 60% returned to work within 4 weeks
• Saal et al
– 64 patients with herniated lumbar discs
received non surgical treatment during a 1yr
period
– satisfactory recovery in 90%.
 Investigations
• Plain Lumbo-sacral X-rays (AP, lat, oblique
and flexion/extension).
• Magnetic Resonance Imaging.
• Lumbo-sacral CT scan ( +/- myelography).
• Bone Scan
• Electromyography and nerve conduction
testing.
• Discography.
 Discography
• Highly controversial

• Very high rate of false-positive

responses

• Probably adds nothing to the

diagnosis of DDD when a good
quality MRI is provided.
 MRI natural history
• Asymptomatic patients have MRI findings:
– 64% with one or more bulging disks
– 56% loss of disc height (degeneration)
– 32% at least one disk extrusion
• Persistent herniated disc present in 37% of conservatively treated
patients who were previously symptomatic
• Lumbar disc herniation can subside with time on MRI
• Matsubara et al.
– 32 pts serial MRI
– 62% had disc regression
– More degeneration and larger herniations resulted in more
dramatic regression
 Treatment
• Urgent Surgery Indications ( Red Flag
Group)
– To stabilize an Unstable spine.
– Decompression of neurological element.
– To obtain a pathological diagnosis.
– Severe pain uncontrolled with analgesia
(relative indication)
 Treatment
• Conservative – Non surgical management.
– Lifestyle Modification ( CLASS 3 Evidence)
• Bed rest
– Reduces disc pressure and movement (theory).
– Bed rest > 4 days worsens condition.
– Recommend no more than 48 hours for severe pain ONLY.
– Maybe no better than watchful waiting and may be harmful.
• Activity Modification
– Achieve tolerable level of discomfort while continuing physical activity.
– High risk jobs – heavy or repetitive lifting, total body vibration, asymmetric or prolonged positions ( including sitting).
– Recommend – limit heavy lifting, prolonged sitting, bending and twisting.
• Exercise
– 1st two weeks – walking, bicycling , swimming
– 2 – 4 weeks – low impact aerobic exercise
– After 4 weeks – condition trunk muscles
– No evidence to support specific type exercise or back stretching
 Treatment

• Conservative – Non surgical management.

– Analgesia
• Acetaminophen, NSAID or COX 2 inhibitor
• Opiods
– Required for severe pain
– should not be used for longer than 2-3 weeks
– No earlier return to work than with NSAIDs
• Muscle Relaxants
– Similar efficacy to NSAID
– Use less than 2-3 weeks
 Treatment

• Conservative – Non surgical management.

– Education
• Explanation of the condition and its natural
history.
• Proper posture.
• Formal back school ( minimally effective)
 Treatment

• Conservative – Non surgical management.

– Spinal Manipulation
• Loads applied to the spine using lever methods
– May be helpful in acute back pain ( not to exceed 1
month)
– Not to be used until severe conditions ruled out.
 Treatment

• Conservative – Non surgical management.

– Epidural Injection (steroids)
• Some improvement at 3-4 weeks.
• No functional, long term benefit or need for
surgery.
 Treatment

• Not Recommended
– Medications
• Oral steroids
• Antidepressants
• Colchine
– Physical treatments
• TENS
• Traction
• Messages, ultrasound, cold and heat.
• Lumbar corsets and support belts.
• Biofeedback
 Treatment

• Not Recommended
– Injections
• Trigger points
• Facet joint injection
• Epidural injection
• Acupuncture.
Specific Conditions
 L-Spine Degenerative Disease
• Mechanical back pain / facet dysfunction
• Lumbar disc herniation
• Degenerative disc disease
• Lumbar spondylosis / spinal stenosis
• Spondylolisthesis (degenerative)
 Mechanical Back Pain
• Facet joint blocks are diagnostic and
therapeutic
• Physiotherapy/exercise, education on
“healthy back practices” and NSAIDs form
the core of treatment
46 y.o. healthy man with 3 weeks of severe
left leg pain.

What should we do with him?

Lumbar disc herniation Historical
Perspective
• 400 B.C. Hippocrates - first description of sciatica
• 1908 Oppenheim and Krause described removal of
a lumbar “enchondroma”
• Until the 1930s, disc herniations were thought to
be cartilaginous neoplasms
• 1934 Mixter and Barr landmark paper -
intervertebral disc prolapse, surgery via an
intradural approach ( N Engl J Med , 1934)
 Lumbar disc herniation :
Historical Perspective
• 1963 Smith - chymopapain
chemonucleolysis
• 1977- lumbar microdiscectomy- Williams
Yasargil, Caspar
• Current era - minimally invasive spinal
surgery
 Risk factors for lumbar disc
disease
• Genetic -Vitamin D receptor, matrix
metalloproteinase -3, collagen IX alleles
• Cigarette smoking
• Sedentary lifestyle
• Increased body mass
• Tall stature
 Pathophysiology of lumbar disc
herniation
• Decrease in proteoglycan - decreased water content which
reduces ability of disc to dissipate an axial load, wich in
turn causes annular fissuring, allowing herniation of
nucleus pulposus
• weakest area of annulus is posterolateral, therefore most
herniations occur in this location
• Degrees of disc displacement –
– bulging, but contained within annulus,
– extruded beyond the annulus,
– sequestered, i.e. outside annulus but within the posterior
longitudinal ligament,
– free i.e. fragment completely separated from intervertebral space
 Pathophysiology of lumbar disc
herniation
• Radicular pain due to mechanical compression of
nerve root, which causes oedema, and enhanced
sensitivity of the nerve root

• Herniated nucleus pulposus generates an

inflammatory response, mediated by cytokines e.g.
interleukins, tumour necrosis factor, and
prostaglandin E2
 Clinical features of lumbar disc
herniation
• History-initially low back pain, followed by
leg pain as the predominant symptom, in a
dermatomal distribution corresponding to
the involved nerve root
• Pain made worse by coughing, sneezing,
straining at stool, relieved by rest
 Imaging studies

• CT scan - sensitivity of 80-95%, specificity

- 68-88%.
• MRI - gold standard, however it reveals
asymptomatic disc herniation
• Myelography - CT/MRI not available
 Management of lumbar disc
herniation
• Natural history - spontaneous resolution
with time
• Treatment modalities :
– Non-operative - bed rest, analgesia, physical
therapy, epidural steroids
– Operative –
• options - laminectomy and discectomy,
microdiscectomy, microendoscopic discectomy
» Percutaneous - chemonucleolysis, laser discectomy
 Lumbar Disc Herniation
• With a solid understanding of Natural
History we should be able to determine:
– Appropriate timing for investigations
• Right away, delayed, never
– Efficacy of conservative treatment vs. surgery
• Surgery for all / none?
• Timing of surgery
Lumbar Disc Herniation: A controlled,
prospective study with tens years of
observation

Weber, 1983 Spine (8): 2; 131-140

1982 Volvo Award in Clinical Science
 LEVEL 1 evidence: Weber 1983
• 208 patients with herniated lumbar discs
– 126 incapacitated
– Randomized to Surgery vs. conservative Tx
– Followed for 10 year period
• Statistically significant improvement @ 1 year in favour of
surgery (good outcome)
– Surgery 90% vs Conservative 60%
– Identical at 10yrs
– Motor deficits nearly completely resolved
– 1/3 had residual sensory problems
– Worse prognosis if symptoms present > 3 months preoperatively
 Atlas et al. 2005
• Prospective cohort study in Maine
• 400 patients treated with Surgery or non-
Surgery and followed for 10 years
– slightly favours Surgery at 10yrs (NS) (69%
improvement vs 61%)
– Complete resolution of pain at 10yrs (56% vs.
40%)
 Timing of Sx
• Nachemson 1985- successful rehab drops to 40%
if symptoms present > 6 months prior to operation

• Weber 1983- worse prognosis for symptoms > 3

months

• Rothoerl 2001- worse if symptoms > 2 months

Surgical Treatment
 Lumbar microdiscectomy
• Advantages compared to standard discectomy- better pain
relief, shorter hospital stay, faster return to work
(retrospective studies)
• Tullberg et al Spine 1993,
– prospective randomized study
– no difference in clinical outcome between microdiscectomy and
standard discectomy .
• Pappas et al, Neurosurgery, 1992 -Outcome of
microdiscectomy –
– 654 patients,
– 80% good outcome, 11% complications, 1 death due to vascular
injury
 Complications of lumbar
microdiscectomy
• Wrong level exploration
• Dural tear
• Nerve root injury
• Superficial wound infection
• Disc space infection
• Vascular injury
• Visceral injury
 Degenerative Disc Disease
• The role of disc disease as a
cause of nonradicular back
pain is controversial.
• Opponents state that there are
no pain receptors within the
disc
• Proponents state that
sinovertebral nerve ends at
PLL and outer surface of disc
annulus.
What is the role of surgery in DDD (in
the absence of neurology)?


ALIF, PLIF, Posterolateral Fusion:
When should they be used for DDD?
• Positive “prognostic” signs:
– High ratio of organic:function signs/symptoms
– MRI reveals 1- or 2-level moderate to severe
DDD
– Otherwise healthy pt. with motivation to get
well
– No pending litigation/insurance/WSIB, etc.
 Spondylolisthesis
• Five categories • Five grades
– Isthmic – I = < 25%
– Degenerative – II = 25 – 50%
– Dysplastic (congenital) – III = 50 – 75%
– Traumatic – IV = 75 – 100%
– Pathologic – V = > 100%
 Isthmic Spondylolisthesis

• A failure of the neural arch,

• Defect in the pars interarticularis
– Manifests as back pain
– No neurological deficit
• Occurs in young (10-14 years), usually at L5/S1.
• Three subtypes :
– Distinct pars fracture
– Elongated pars due to repeated microfractures
– Acute pars fracture
Isthmic Spondylolisthesis
 Degenerative Spondylolisthesis
• Occurs in patients with chronic intersegmental
instability and degenerative joint disease
• Most common at L4/5
• More common in women (10% over age 60) and
in diabetics
• Sacralization of L5 associated with degenerative
spondy
 Clinical features of
spondylolisthesis
• Majority of patients are asymptomatic
• Back pain
• Neurogenic claudication
• Radiculopathy
• Imaging - oblique X-rays important to show
pars
 Lumbar spinal fusion
• Indications :
– Intractable pain
– Following decompressive laminectomy
– Grade III, IV spondylolisthesis
• Fritzell et al, Spine,2001 (Swedish Lumbar
Spine study Group)
– PRCT better outcome with fusion compared to
non-surgical treatment.
82 y.o man with long history of back pain
and 1 year of tired, heavy, numb legs after
walking (R worse than left). Pain is not
relieved with standing (has to sit for a few
minutes).

Examination reveals mild kyphosis, pain

at 60o with SLR, reduced ankle reflexes,
but otherwise a normal exam.

What should we do with this man?

 Lumbar spinal stenosis
• Narrowing of the spinal canal resulting in
compression of the neural elements
• Congenital e.g. achondroplasia, idiopathic
• Acquired - degenerative (central, lateral recess,
foraminal)
• Acromegaly
• Paget disease
• Ankylosing spondylitis
Pathophysiology of lumbar spinal
stenosis
• Disc degeneration, facet joint hypertrophy, ligamentum
flavum hypertrophy, spondylolisthesis.

• Mechanical compression, vascular compromise -

neurogenic claudication.

• Most common levels - L4/5, L3/4, L2/3, L5/S1

Clinical features of lumbar spinal
stenosis
• Neurogenic claudication - pain, numbness tingling in lower
limbs, exacerbated by extension of the spine and relieved in
flexion.

• Examination - SLR usually negative.

• Neurological examination may be normal or weakness of

muscle groups may be present.

• Differential diagnosis- vascular claudication, trochanteric

bursitis, osteoarthrosis of the hip joint, peripheral neuropathy
Imaging studies in lumbar spinal
stenosis
• Plain X-rays- AP diameter < 11mm indicates
stenosis, spondylolisthesis, flexion/extension
views.

• CT/myelogram - shows bony pathology well.

• MRI - hourglass shape on sagittal, trefoil shape on

axial images
 Treatment of lumbar spinal
stenosis
• Non-operative- NSAIDS, physical therapy,
epidural steroids.

• Decision of surgery based on quality of life

issues.

• Most common indication for spinal surgery

in people over the age of 65 years.
 Surgical options for lumbar
spinal stenosis
• Wide decompressive laminectomy with foraminotomies
(disadvantages - extensive muscle dissection, delayed
spinal instability)
• Interlaminar decompression
• Microendoscopic decompressive laminotomy(shorter
hospital stay,decreased analgesic use, decreased blood
loss)
• Outcome of surgery - 80% success rate
• Maine Lumbar Spine study - 4 year follow-up 77% of
surgical group improved compared to 52% of medical
group (Atlas et al, Spine, 2000)
 Failed back syndrome
• Clinical condition in which patients who undergo one
or more surgical procedures for lumboscaral disease
obtain unsatisfactory long term relief of symptoms,
with persistent or recurrent low back pain
• Aetiologies
– inappropriate patient selection
– poor operative technique
– iatrogenic instability
– surgical complications
• nerve root injury, adhesive arachnoiditis, epidural fibrosis,
pseudomeningocoele
 Evaluation of failed back
syndrome.
• History - number of previous operations,
distribution of pain.

• Examination - neurological, general, psychiatric.

• Imaging studies - CT/myelogram especially

useful, gadolinium MRI
 Treatment of failed back
syndrome
• Non-operative - rehabilitation, psychotherapy, pain
management

• Surgery- for neural decompression, spinal stabilization

• Dorsal rhizotomy

• Spinal cord stimulation

 Psychological factors in back
pain
• Psychological factors including depression,
secondary gain play a significant role in
amplifying pain.
• May start originally as pain
• 3 of the following suggest psychological distress-
– Pain on axial loading ( pressing on the head)
– Inconsistent performance ( difficulty with SLR when supine but not
sitting)
– Overreaction during physical exam
– Inappropriate tenderness that is superficial or widespread
– Motor or sensory abnormalities not confined to anatomy
 Chances of patient Returning to
work
• The amount of time a
50%
50%

45%

patient is out of work 40%

is related to the 35%

chances of them 30%

returning .
25%

20%
20%

15%

10%

5%
5%

0%
< 6 mths 1 yr 2 yrs
Time out of work