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Updated: Feb 22 2024

Low Back Pain - Introduction

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https://upload.orthobullets.com/topic/2034/images/normal lumbar film.jpg
  • Epidemiology
    • Low back pain affects 50-80% of population in lifetime
      • $100 billion in annual cost
      • second only to respiratory infection as cause to visit doctors office
  • Etiology
    • Mechanism
      • muscle strain
        • most common cause of low back pain
      • most common degenerative disorders
        • lumbar spinal stenosis
        • lumbar disc herniation
        • discogenic back pain
    • Risk factors
      • obesity, smoking, gender
      • lifting, vibration, prolonged sitting
      • job dissatisfaction
    • Red flags
      • infection (IV drug user, h/o of fever and chills)
      • tumor (h/o or cancer)
      • trauma (h/o car accident or fall)
      • cauda equina syndrome (bowel/bladder changes)
    • Outcomes
      • 90% of low back pain resolves within one year
  • Presentation
    • Symptoms
      • axial pain
        • musculogenic
          • most common cause of back pain
          • associated with activity
          • characterized by stiffness and difficulty bending
        • discogenic pain
          • controversial
          • confirmed by discogram
        • mechanical pain
          • caused by
            • facet degeneration
            • micro and macro instability
          • worse with activity such as lifting objects and prolonged standing
        • sacroiliac symptoms
          • pain originating from sacroiliac joint
      • peripheral / neurogenic
        • radicular pain
          • unilateral leg pain
          • usually dermatomal
        • referred pain
          • buttocks
          • posterior thighs
          • inguinal region (think L5-S1)
        • neurogenic claudication
          • pain in buttock and legs that is worse with prolonged standing
          • fairly specific for spinal stenosis
        • myelopathy
          • clumsiness in hands
          • gait instability
          • due to injury of spinal cord (~ L1 or above)
        • conus medullaris syndrome
        • cauda equina syndrome
          • bilateral leg pain
          • LE weakness
          • saddle anesthesia
          • bowel/bladder symptoms
        • spinal cord injury
          • incomplete
          • complete
    • Wadell Signs
      • system to evaluate non-organic back pain symptoms,
      • clinically significant if three positive signs are present
        • superficial and non-anatomic tenderness
        • pain with axial compression or simulated rotation of the spine
        • negative straight-leg raise with patient distraction
        • regional disturbances which do not follow dermatomal pattern
        • overreaction to physical examination
  • Imaging
    • Radiographs
      • indications for radiographs
        • pain lasting > one month and not responding to not nonoperative management
        • red flags are present
    • MRI
      • highly sensitive and specific
      • high rate of abnormal findings on MRI in normal people
      • Positive MRI Findings in Asymptomatic Patients
      • Age
      • % HNP
      • % Disc Bulge
      • % Degeneration
      • 20-39
      • 21
      • 56
      • 34
      • 40-59
      • 22
      • 50
      • 59
      • 60-79
      • 36
      • 79
      • 93
  • Differential
    • Neck and arm pain
      • trauma
      • cervical spondylosis
      • metastatic disease / infection
      • cervical radiculopathy
      • cervical myelopathy
      • ankylosing spondylitis
    • Thoracic back and rib pain
      • trauma
      • metastatic disease / infection
      • thoracic disc herniation
      • osteoporotic comression fracture
      • trauma
    • Low back pain
      • muscles strain
      • disc herniation / discogenic pain
      • degenerative spondylolithesis
      • spinal stenosis
      • lumbar radiculopathy
      • abdominal aortic aneurism
    • Sacroiliac pain
      • SI infection
      • ankylosing spondylitis
    • Sacral pain
      • coccydynia
      • sacral insufficiency fracture
  • Treatment
    • Treatment dictated by cause of pain.
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