2. LOW BACKACHE

About The Author Dr Manoj R. kandoi is the founder president of “Institute of Arthritis Care & Prevention”

an NGO involved in the field of patient education regarding arthritis. Besides providing

literature to patient & conducting symposiums, the institute is also engaged in creating

patients “Self Help Group” at every district level. The institute also conducts a certificate

course for healthcare professionals & provide fellowship to experts in the field of arthritis.

The author has many publications to his credit in various journals. He has also written a

book “ The Basics Of Arthritis” for healthcare professionals.

The author can be contacted at:

Dr manoj R. kandoi

C-202/203 Navare Arcade

Shiv Mandir Road, Opposite Dena Bank

Shiv mandir Road, Opposite Dena bank

Shivaji Chawk, Ambarnath(E) Dist: Thane Pin:421501

State: Maharashtra Ph: (0251)2602404 Country: India

Membership Application forms of the IACR for patients & healthcare professionals

can be obtained from.

Institute of Arthritis Care & Prevention

C/o Ashirwad Hospital

Almas mension, SVP Road, New Colony,

Ambarnath(W) Pin:421501 Dist: Thane

State: Maharashtra Country: India

Ph: (0251) 2681457 Fax: (0251)2680020

Mobile ;9822031683

Email: drkandoi@yahoo.co.in

CONTENT

2.1 ANATOMY

2.2 EPIDEMIOLOGY

2.3 CLASSIFICATION OF LOW BACKACHE

2.4 CLINICAL EXAMINATION

2.5 DIAGNOSTIC STUDIES

2.6 EVALUATION OF SYMPTOMS IN PATIENTS WITH LOW BACKACHE

2.7 CONSERVATIVE MODALITY OF TREATMENT OF LOW BACKPAIN

2.8 CLINICAL APPROACH IN MANAGEMENT OF LOW BACKACHE

2.9 COCCYGODYNIA

2.10 RADIOGRAPHIC APPROACH TO LOW BACKACHE

2.1 ANATOMY : In the adult the inter-vertebral disc is composed of the annulus fibrosus and the nucleus pulposus.

The annulus fibrosus is composed of numerous concentric rings of fibro-cartilaginous tissue. The

rings are thicker anteriorly than posteriorly. The nucleus pulposus, a gelatinous material forms the

center of the disc. The disc proper is separated from the vertebral body by hyaline cartilage plate.

The intervertebral discs in adults receive nutrition through two routes (a) the bidirectional flow from

vertebral body to disc & from disc to vertebral body, and (a) the diffusion through the annulus from

blood vessels on its surface.

Weight is transmitted to the nucleus through the hyaline cartilage plate, Because of this axial loading

the nucleus pulposus is under considerable pressure & disc tangential load is absorbed by annulus

fibrosus.

2.2 EPIDEMIOLOGY : Back pain has now appeared as a modern international epidemic. Up to 80% of the population is

affected by this symptom at some point of time.

Risk Factors:

1. Cigarette smokers & with greater tobacco consumption

2. Type I personality

3. Patients taller than 181 cm

4. Patients with slightly higher body weight

5. Multiple pregnancies.

6. Jobs requiring heavy and repetitive lifting

2.3 CLASSIFICATION OF LOW BACKACHE :

1. Psychogenic back pain (Nonorganic Spinal pain)

2. Viscerogenic back pain

3. Neurogenic back pain

4. Vascular back pain

5. Spondylogenic back pain.

6. Endocrine / metabolic

1. Non-organic spinal pain: These groups of disorders include

I. Psychosomatic spine pain

a. Tension syndrome (fibrositis)

II. Psychogenic Spinal pain

III. Situational spinal pain

a. Litigation reaction

b. Exaggeration reaction.

Index 2.1

Organic Spinal Pain Non-Organic Spinal Pain

Well localized & usually mechanical pain - Multifocal & nonmechanical pain

No superficial tenderness - Superficial tenderness

SLR reduced in cases of PID - SLR may be normal

Lasegue test +ve in PID - Lasegue test +ve

Flip test: painful - Flip test: not painful

Flip Test: Normally in a case of prolapsed intervertebral disc, SLR is reduced which can also be

cheeked with patient in sitting position with knee extended. If true root Lesion were patient, one

patient would “flip” back on sitting SLR testing. A patient with non-organic spinal pain may show

reduced SLR in supine position, it that will be normal on Flip test.

2. Spondylogenic Back Pain:

A. Osseous Lesions:

I. Trauma: These can be

1. Compression in an osteoporotic spine

2. Fracture of vertebral appendices

3. Fracture of vertebral body following high-energy trauma.

Causes of pain: I. Nonunion of fracture

II. Misalignment of spine

III. Spinal instability

IV. Compression of nerve or spinal cord

II. Infection: Infections involving the vertebral column include

a. Vertebral osteomyelitis:

Pyogenic

Tuberculous

Miscellaneous.

b. Intervertebral disc Infection.

c. Intervertebral disc inflammation.

The infection is characterized by restriction of range of motion, paraspinal muscle spasm, localized

tenderness, sometimes associated paraspinal mass or abscess. The offending organism can be

identified by blood culture or a vertebral biopsy and culture.

III. Neoplasm: - Benign Tumours - Anterior column (Haemangioma & eosinophilic

granuloma)

- Posterior column (Giant cell tumor, osteod osteoma)

- Malignant Tumours - Primary usually involve vertebral body

- Secondary metastasis. Lymphoma & Leukemia

The diagnosis of these tumors is largely dependent on x-rays.

IV) Metabolic Bone Diseases: These include osteofibrosis, osteopetrosis, alkcaptonuria , familial

hypophosphataemia etc but the metabolic bone problem most commonly presenting with low back

pain is osteoporosis.

V) Spondylolisthesis: Spondylolisthesis is due to forward displacement of one vertebra over other. It

may be because of traumatic, congenital, dysplastic, degenerative etiology. Cause of pain includes

mechanical derangement including spinal instability, neuropathy (compression of nerve root)

myelopathy (compression of spinal card) & pain arising from defect site at pars interarticularis.

VI) Sacroiliac Joint Strain: More common after repeated pregnancies.

Clinically characterized by tenderness over lower third of the sacroiliac joint below the posterior

inferior iliac spine and positive pelvic compression test.

VII) Ankylosing Spondylitis

B) Soft Tissue Lesions:

I. Myofascial sprains or strains.

II. Fibrositis (Fibromyalgia) and myofascial pain syndrome.

III. Disc Degeneration: These pain in general is aggravated by general and specific activities & is

relieved, to some extend be recumbency.

3. Viscerogenic Back Pain: It is derived from disorders of the kidneys or the pelvic viscera, from

the lesser sac, & from retroperitoneal tumors. These are usually associated with other symptoms of

visceral involvement. The pain is not aggravated by activity, nor is it relieved by rest. It includes:

A. Pelvic Disorders:

a) Pelvic inflammatory disease

b) Endometriosis

c) Torsion of a mass, cyst or fibroid

d) Prostatitis

e) Cystitis.

B Abdominal Disorders:

a) Peptic ulcer

b) Pancreatitis.

4. Vascular Back Pain: These include

A. Abdominal aortic aneurysm (Atherosclerotic or inflammatory)

I. Rupture

II. Erosion of surrounding structures

III. Dissection

B. Epidural Hematoma

C. Sickle cell disease

D. Insufficiency of superior gluteal artery

E. Intermittent claudication.

Abdominal aneurysm presents as a boring type of deep seated lumbar pain unrelated to activity.

Insufficiency of the superior gluteal artery may give rise to buttock pain of a claudicant character,

aggravated by walking, relieved by standing still. Intermittent claudication caused by peripheral

vascular disease can mimic sciatic pain, but usually can be easily distinguished by the fact, pain

aggravated by walking is relieved immediately by standing still.

Difference between neurological and vascular claudication :

Neurological claudication Vascular claudication

Vague heaviness, cramping pain. Sharp, cramping pain.

It is aggravated by walking and sometimes by

standing.

Aggravated by walking.

May radiate usually proximal to distal after

onset.

Rare after onset.

Relieved only in flexed position of spine such as

lying down or sitting down.

Relieved with rest even with standing position.

Relief is slow takes many minutes. Relief is faster.

Pulses present. Absent pulses and other trophical changes.

Neurological symptoms and SLR positive. Absent.

5. Neurogenic back pain: Intradural & extradural tumors & cyst may mimic symptoms produced

the day & history of night pain may be there. Diagnosis is mainly on M. R .I.

6. Endocrine / Metabolic:

a. Osteoporosis

b. Paget’s disease

c. Diabetes.

d. Hypothyroidism

e. Hyperthyroidism

f. Hyperparthyroidism

2.4 CLINICAL EXAMINATION :

History

Age: Adolescents: - Postural

- Traumatic

- Infective.

Adults: - Ankylosing spondylitis

- P I D

Elderly persons: - Degenerative arthritis

- Osteoporosis

- Secondary matastasis

Sex: Back pain is slightly more common in women due to lack of exercise, nutritional osteomalacia,

multiple pregnancies.

Sex incidence of painful back conditions :

Commonly in males Commonly in females

Spondytoarthropathies Osteoporosis

Work related mechanic backache Fibromyalgic

Tuberculosis Polymyalgic rheumatica

Neoplasms Hyperparathyroidism

Paget’s disease

Peptic ulcer

Retroperiteneal fibrosis

Occupation: Back pain is common in surgeons, dentists, truck drivers etc.

Past History: Past history of trauma, tuberculosis etc

Pain: Site: Lumbar spine; - P I D

- Degenerative spondylosis

D L spine - Infection

- trauma

Onset : - acute, subacute, chronic

Progress of pain : - pain of infection & tumor tends to be progressive, pain of

arthritis & spondylitis is constant, pain of disc prolapse & trauma may

decrease over time.

Relieving & Aggravating Factors: Most back pains are worsened by activity relieved by rest

especially in arthritis. Pain due to inflammatory spondyloarthropathy is more at rest & may initially

improve with activity.

Osteod osteoma is associated with severe pain at night that responds to aspirin. Patient with spinal

canal stenosis will complain of pain on walking & standing relieved by sitting, stooping forwards.

Associated Symptoms:

1. Stiffness: It is seen in inflammatory arthropathies.

2. Fever or chills: It suggests possibility of infection

3. Weight loss, chronic cough, change in bowel habits, night pain, other constitutional

symptoms may be seen in malignancy.

4. Pain in other joints: e.g. in seronegative spondyloarthropathies or endocrine disorders.

5. Fatigue or sleep disturbances: fibromyalgia should be ruled out

Differential diagnosis of ankylosing spondylitis with other causes of backache :

Ankylosing spondylisis Backache due to other causes

Morning stiffness >30minutes <15 minutes

Rest Aggravates pain and stiffness Relieves pain

Physical activity Relieves pain Increases pain

Restriction of joint motion Restricted pain in all directions Only in some direction

Neurological Symptoms: Weakness, paraesthesia or numbness in dermatomal distribution points to

possible nerve root impingement & the level of impingement. Commonest cause is P I D (in age

group of 20-50 years) & tuberculosis.

L 3-4 disc affects the L 4 nerve root, L 4-5 disc affects L 5 nerve root & L 5-S1 affects the S1 nerve

root.

The other cause of neurological symptoms is neoplasm.

Presence of bladder / bowel involvement suggest cauda equina syndrome requiring immediate

investigations & further management.

Physical Examination: The patient should be stripped to undergarments

A. Patient Standing:

1. Alignment of spine: normally a person stands erect with the center of occiput in the line with the

natal cleft.

Pelvic tilt may suggest paravertebral spasm

Loss of lumbar lordosis suggest spasm or ankylosis

Structural scoliosis.

2. Evaluate:

Gait

Station

Posture

3. Range of motion: It is restricted in organic diseases .of the spine.

4. Swelling: Cold abscess may suggest TB

5. Localized tenderness may suggest trauma

Twist Tenderness: On rotating the 2 spinous processes over each other suggest P I D or local

infection.

Tenderness at SI joint

B. Patient Supine

1. Straight leg raising (SLR): it is indication of nerve root impingement.

2. Neurological examination

3. Peripheral pulse.

4. Adjacent Joints: Hips & SI joint

5. Chest expansion

6. Abdominal, rectal or per vaginal examination if required.

C. Patient Prone

- Femoral stretch test (extending the hip) may be positive in L4 radiculopathy : This test detects

L234 disc prolapse. The femoral nerve is stretched by extending the hip by 150 with patient in prone

position. Now the knee is slowly flexed to further stretch the femoral nerve. Pain radiating to the

anterior thigh is suggestive of radiculopathy. Depending upon the dermatome of pain radiation,

exact nerve can be identified.

- Palpate bony tenderness & trigger points, nodules.

POSITIVE FEMORAL STRETCH TEST

NEUROLOGICAL EXAMINATION :

Neurological examination :

Nerve tension tests : These tests are for checking nerve root compression of femoral or sciatic nerve. Femoral nerve

(formed of L2,3 and L4 nerve roots) runs along the anetomedial aspect of the thigh and sciatic nerve

(formed of L4,5 S1,2 and 3 nerve roots) runs along the posterior aspect of thigh.

Straight leg rising test : (SLRT)

Principle : Normally while doing SLRT during the first 0 to 300 the slack nerve roots become taut

but there is no tension. Between 30 to 700 the sciatic nerve root stretches over the intervertebral disc.

Above 700, there is no further deformation of the root and pain may be because of SI joint strain or

nerve root compression beyond the spine. The sciatica due to PID is therefore positive between 30 to

700. Upto 30

0 pain maybe due to hamstring tightness, which can be differentiated by Laseque’s test.

Method :

Position : Patient lies in supine position with the head and the pelvis flat.

Procedure : It is a passive test and each leg is tested one by one. With knee in full extension, one

limb is progressively elevated until maximal hip flexion is reached or patient develops radiating pain.

The angle formed by the lower limb and the examination cot is noted. The test is considered positive

if there is back pain radiating along the course of sciatic nerve below the knee.

Alternative method : Patient sits at the end of the table with spine erect and the legs hanging at the

edge from the knees. The affected side leg is extended suddenly with patient supporting himself

with both hands on the table. In case of sciatic root impingement, patient will develop radiating pain

and low backache.

Laseque test : This test is performed after SLR by lowering the affected leg by few degrees from

the point of pain and then dorsiflexing ankle. This maneuver again deforms the sciatic nerve.

Positive test strengthens the diagnosis of sciatica.

Reverse SLR test : It is performed by plantar flexing rather than dorsiflexing the foot, positive test

is suggestive of malingering.

Crossed SLR test : This is performed on the side opposite that of the sciatica. If this maneuver

reproduces or exacerbates the patient’s other side sciatica, the result is considered to be extremely

sensitive and specific for herniated L4,5 or L5 S1 disk. This test is usually seen in large disc

herniation and is also known as well leg raising test of Faserstanzn’s.

Lateral flexion test of spine : With the patient in standing or supine position, ask the patient to

acutely flex the spine laterally on the affected side. Due to approximation and stretching of root to

the protruded disc from lateral sides, the patient will feel a catching pain. If symptoms are produced

on flexing the spine on the opposite side, it is suggestive of pressure on the root from the medial side.

Bowstring sign : In this method, SLRT test is performed to reproduce pain. The knee is then

flexed to 900 and digital pressure is applied over the posterior aspect of sciatic nerve. If it reproduces

the pain it is suggestive of sciatica.

Cox sign : In this method the patient is asked to raise pelvis from the table rather than hip flexing.

This test is suggestive of intervertebral foraminal prolapse of intervertebral disc.

Lewing punch test : Here the patient is in standing position, the patient’s buttock on the affected

side is precussed to reproduce pain of sciatica. Positive test is suggestive of a protruded disc.

Valsalva’s maneuver : In this maneuver, patient is asked to bear down as if attempting to have a

bowel movement, which increases the intrathecal pressure thereby exacerbating pain of nerve root

stretching.

Hoover’s test : It is done along with active straight leg rising to determine whether patient is

malingering. When a patient genuinely attempts an active SLR he puts downward pressure on

calcaneus of his opposite leg to gain leverage. It can be confirmed by putting examiners hand

between calcaneum and the examination table.

False positive SLRT : False positive SLRT may be found in myogenic pain, ishial bursitis, annular

tear and hamstring tightness. These can be differentiated by Lasegue’s test and Bowstring sign,

which are positive in prolapsed intervertebral discs.

Limitations of SLRT : The straight leg raising stretches the L5 and S1 nerve roots by 2mm to 6mm,

but it puts little tension on the more proximal nerve roots. An abnormal straight leg raising test,

therefore, suggests a lesion of either L5 or S1 nerve root.

3. Motor testing :

Lumbar Root Lesions:

Root Muscle group weakness Tendon reflex decreased

L2 Hip Flexion / Adduction

L3 Hip adduction / Knee extension Knee Jerk

L4 Knee extension

Foot inversion / dorsiflexion Knee Jerk

L5 Hip extension / abduction

Knee Flexion

Foot / toe dorsiflexion

S1 Knee Flexion Ankle Jerk

Foot / Toe planter Flexion

Foot eversion.

4. Sensory testing :

Special tests : Phalen’s test : This test attempts to reproduce features of leg pain, weakness or numbness by

accentuating spinal stenosis thereby causing neural ischaemia. With the patient upright, bend the

patient into extension for one minute; positive test is associated with the symptoms, which gets

relieved on flexing forward.

Squat test : This test is done to rule out joints of lower limb involvement. Patient is asked to squat

down bouncing 2 to 3 times and then returning to the standing position. If patient is able to do so

then hips, knee and ankles are normal.

Schober test : It detects limitation of forward flexion of the lumbar spine. Two marks at a distance

of 10 cms are placed, one at the level of posterior superior iliac spine and another above in the

midline. With maximal forward spinal flexion with locked knees, the measured distance should

increase from 10 cm to at least 15 cms.

Chest expansion : Measured at the fourth intercostal space, normal chest expansion is

approximately 5cm.

Bulbocavernous reflex : It refers to contraction of anal sphincter in response to tugging of foley

catheter or squeezing of glans penis. This is a spinal cord mediated reflex arch involving S1,2 & S3

nerve roots. In injuries above L1 vertebral levels the reflex is lost during the stage of spinal shock

(which usually resolves with 48 hours); at the level of L1 vertebra it may be because of conus

medullaris injury and below L1 vertebra it may be because of cauda equina injury. If the

bulbocavernous reflex (stage of spinal shock) returns and there is no sensory or motor recovery then

it is suggestive of complete lesion.

Sacral sparing : Sacral sparing is associated with perianal sensation, rectal motor function and

great toe sluxor activity. Presence of sacral sparing may be the only sign of an incomplete spinal

lesion. If bulbodavernous reflex returns and there is not even sacral sparing then it is suggestive of

complete lesion.

Lesions in a nutshell :

L4 root compression :

Motor weakness Quadriceps muscles

Sensory involvement Hypoasthesia at L4 dermatome

Reflexes Decreased knee jerk

SLRT test Negative

Femoral stretch test Positive

L5 root compression :

Motor weakness Extensor hallucis longus

Sensory involvement Hypoesthesia / Hyperaesthesia at L5

dermatome.

Reflexes Negative

SLRT test Positive

Patient is unable to walk on the heel.

S1 root compression :

Motor weakness Gastrocnemius and peronei weakness

Sensory involvement Hypoesthesia / Hypperaesthesia at S1 dermatome

Reflexes Ankle jerk diminished

SLR test Positive

Patient is unable to walk on the toes.

Signs suggestive of functional backache :

Waddell has described five tests to identify functional backache, presence of 3 or more positive tests

is suggestive of functional backache.

Waddell tests :

1. Tenderness to superficial touch.

2. Simulation tests : a. Axial loading.

b. Spinal rotation in one plane.

3. Distraction tests.

4. Abnormalities not following neuro-anatomic structures

5. Disproportionate symptomatology (overreaction)

2.5 DIAGNOSTIC STUDIES :

1. X-Rays:

Routinely AP Lateral view should be ordered for low backache

Oblique views may be required if spondylolysis is suspected.

Flexion & Extension view may be ordered if instability suspected.

Radiographic Evaluation of Inflammatory Versus Noninflammatory spinal Arthritis

Features Non Inflammatory Infection Spondyloarhropathy

S. I. Joint Normal Normal / Single joint Erosions +

Vertebral bodies Sclerosis - osteoporosis - squaring +

- Irregular eroded end - erosions

Plates - Osteoporosis

Discspace - Decreased -Decreased -may be calcified or convex

- Vacuum phenomenon -Usually one space -multiple.

Osteophyte Prominent Absent Absent

Soft tissues mass - + -

Syndesmophyte Absent Absent Present

Degenerative Lumbar Spondylosis Degenerative Spondylolisthesis

2. Bone scan: If malignancy or infection is suspected

3. CT SCAN / MRI: Especially useful in acute emergencies, unresponsive cases or in those case

where surgery is contemplated.

4. EMG -NCV: may be useful in chronic radiculopathy (radiating pain with or without

neurological deficit)

5. Blood investigation:

These include:

CBC ESR: If infection suspected

Mantoux test: To rule out Tuberculosis

Urine( RM) : urinary infection ruled out

Serum Calcium; Phosphorus & alkaline phosphatase: Secondary metastasis is associated with

raised alkaline phosphate.

Urine for Bence zones proteins: To rule out multiple myeloma

Serum electrophoresis

HLA B27: If serongative spondylo arthropathy suspected.

2.6 EVALUATION OF SYMPTOMS IN PATIENTS WITH LOW BACKACHE :

2.7 CONSERVATIVE MODALITY OF TREATMENT OF LOW BACKPAIN :

1) Rest:

Absolute bed rest on a hard bed (a mattress if allowed)

Usually up to 2-3 weeks

After 3 week, rest does not have added advantage & gradual mobilization with or without

brace is advisable

2) NSAIDS:

To break pain, spasm & pain cycle

Symptomatic relief

To allow mobilization of patient.

3) Muscle Relaxants: In cases with stiff spine, tizanidine or chlorzoxazone may be used.

4) Physical modalities: Such as SWD, hot packs & USG therapy

5) Exercise programme

Symptoms Possible Etiology Clinical Evaluation

Fever or weight loss Infection tumor - CBC ESR

- X-rays

- Bone Scan

- CT / MRI

- SOS Biopsy

Night Pain - Tumor of bone - X-rays

- Spinal cord tumor - Bone Scan

- CT / MRI

- Hb CBC ESR

- Serum Calcium

Phosphorus &

alkaline

phosphatase

- Other chemical profile

Morning Stiffness - RA - ESR

- AS - RA

- Psoriatic arthritis - ANA Factor

- X-rays including

S I Joints

Colicky Pain - Kidney - Urine (R&M)

- Gall Bladder - sos Urine culture

- Acrtic - Amylase

- Gastrointestinal - USG abdo

- Barium studies

- sos CT SCAN

- Aortogram

6) Traction:

It immobilises the patient

Distracts neural formina there by decompressing nerve root

Relieves muscle spasm

7. Brace : Especially useful in trauma, infection & osteoporotic fracture.

Education : This includes avoidance of stressful activities, improvement of posture, dietary advice

as related to weight reduction & calcium intake.

2.8 CLINICAL APPROACH IN MANAGEMENT OF LOW BACKACHE :

A. Acute Backache:

Commonest Causes are:

I. Prolapsed Intervertebral Disc.

II. Trauma:

Soft tissue injury

Bony injury

III Infection

IV Neoplasm

V Referred pain due to viscerogenic or vasculogenic causes.

VI Sickle cell crisis, diabetic neuritis.

STEP I: Rule out condition, which require urgent intervention.

1. Cauda Equina Syndrome:

Saddle Anaesthesia around anus

Bladder / Bowel involvement

Bilateral sensory motor deficit

2. Aortic Aneurysm:

Pulsatile Abdominal mass

Absent Dorsalis pedis pulse

Older patient

History of claudication or other circulatory problems

Circulatory instability

Acute Low Backache

Neurological deficit with NO NO Ruptured aortic aneurysm

Bladder / bowel Further

Evaluation

Yes Yes

Urgent MRI Immediate angiogram

Yes Yes

Surgical Intervention Resuscitative surgery

B. Chronic Back Pain (Subacute Backache) :

Subgroups

I. Localized Chronic Back pain

II. Low back pain with sciatica

III. Anterior thigh pain

IV. Chronic Back pain with posterior thigh pain

1. Localized Low Backache:

Etiology:

Disc Degeneration.

Vertebral instability

Osteoarthritis

Osteoporosis

Spondyloarthropathy

Osteomyelitis

Vertebral neoplasms

Old trauma

2. Low Backache With Sciatica

Sciatica : By definition it is radiation of pain along the distribution of sciatic nerve that is posterior

aspect of buttocks, thigh, leg, and foot.

Differential diagnosis of sciatica :

Intraspinal causes Extraspinal causes

Above the level of disc

At the level of pelvis

Conus lesions and cauda Equina lesions (e.g.

neurofibroma etc.)

Orthopaedic diseases of hip and SI joint.

Neoplasms

Gynaecological conditions

Cardiovascular conditions (e.g. peripheral

vascular diseases)

At the level of the disc Below pelvis :

PID Nerve lesions

Canal or recess stenosis Traumatic

Neoplastic Neoplastic

Infection : TB, pyogenic, discitis Herpes zoster

Arachidonitis Neuropathy due to diabetes or alcohol etc.

Causes of Sciatica

Diagnostic criteria for sciatica due to disc prolapse :

The leg pain is more than back pain.

Dermadome-wise distribution of tingling and numbness.

Positive SLRT test/Bowsting sign/crossed SLR test

Presence of at least two of the following neurological signs :

Atrophy.

Motor weakness.

Decreased sensation.

Altered reflexes.

Therapeutic Approach

Low Backache with pain on flexion Low backache with pain on

extension

Herniated Disc X-rays / CT / MRI

Lumbar canal stenosis No significant

Neurological Neurological findings

deficit –ve deficit + ve

Conservative treatment Conservative

treatment

Conservative CT/ MRI +ve

Treatment Epidural steroids

- Rest

- Heat therapy Surgical decompression

- Brace

- NSAIDS

- Enzyme preparation Orthopaedic management

- Low dose steroid

3. Low Backache With Posterior Thigh Pain

Causes:

Back strain

Localized spinal stenosis

High herniated discs.

Treatment modalities:

Local injection of hydrocortisone at tender spots

NSAIDS

If no relief radiographic evaluation & further management according to the diagnosis

4. Low backache With Anterior Thigh Pain

Causes:

Back Strain

Inguinal Hernia

Hip Etiology

Diabetic Femoral Neuropathy

Abdominal Aneurysm

Renal stone

Retroperitoneal tumor.

Therapeutic Approach : Low Backache With Anterior Thigh Pain

Clinical Examination

Inguinal hernia Anterior hip tenderness/ hip stiffness Negative

X-rays PBH Blood Sugar

+ ve

Hip disorders - ve +ve

Abdo + pelvic Diabetic

neuropathy

ultrasound

- ve + ve

CT Scan with contrast Renal stone or

aneunym

+ ve - ve

- Retroperitoneal tumor Conservative therapy

- Retroperitoneal infection

2.9 COCCYGODYNIA :

This term is used for pain in and around the coccygeal region. ( The term coccyx implies Greek

word kokkoux meaning cuckoo since it resembles the shape of a cuckoo’s beak. )

Incidence :

M : F 1:5 (as coccyx is more prominent and exposed in females)

Less than 1% of low back pain incidence.

Etiology :

Trauma to sarococcygeal joint e.g. due to kick, fall with resultant fracture subluxation or dislocation.

Childbirth with concomitant hormonal changes can lead to stretching and inflammation of coccyx.

Indiopathic.

Pilonodal cyst formation.

Piriformis pain.

Repetitive strain such as in cycling or rowing.

Obesity, which causes excessive pressure on coccyx in sitting.

Frictional bursitis at tip of coccyx.

Clinical examination :

Tenderness on direct palpation of the coccyx.

PR and PV examination must be done to rule out masses.

Investigations :

X-rays lateral view of coccyx : If possible both standing and sitting lateral view should be taken to

look for and abnormal coccygeal mobility. Presence of more than 250 flexion or dynamic x-rays

suggest hypermobility, presence of more than 250 displacement suggests subluxation.

MRI may be useful in suspected neoplastic or infective lesions

Treatment :

1. Conservative therapy : It includes :

a. NSAID.

b. Air ring cushion.

c. Hot-sitz-type baths.

d. Phonophoresis or iontophoresis of local corticosteriod or analgesic combination.

2. Local steroid injection.

3. Manipulation under GA.

4. Surgical Therapy : It includes coccygectomy. The complication of this procedure include

infection, rectal injury, local wound dehiscence, scarring etc. Surgery is indicated if conservative

therapy fails after an adequate trial of atleast 2 months. Recovery after surgery may take 6

months to 1 year.

2.10 RADIOGRAPHIC APPROACH TO LOW BACKACHE :

X-rays of spine

Changes suggesting of Miscellaneous condition seen Non inflammatory

inflammatory arthritis e.g. - Pagets

- Metastasis

- Myeloma

- Fluorosis

Age > 50 Age < 50

-Degeneration Ochronosis

Arthritis ( Disc space

-CPPD calcification)

Sacroiliac joint lesion single disc space infection

Symmetrical Asymmetric Unilateral

Syndesmophytes Bilateral

- AS syndesmophyte septic

- Ulcerative bowel - Reiter’s disease reiter’s

disease - psoriasis psoriasis

Radiographic Evaluation of Inflammatory Versus Noninflammatory spinal Arthritis

Differential diagnosis of lytic lesion of spine :

Malignant :

osteosarcoma

chondrosarcoma

fibrosarcoma

Ewing’s sarcoma

myeloma

plasmacytoma

lymphoma

leukemia

Benign :

GCT

Haemangioma

Eosinophilic granuloma

ABC

fibrodysplasia

brown tumor

pagets disease

Differential diagnosis of ivory vertebra :

Pagets disease(bone is expanded)

Multiple myeloma

Lymphoma

Haemangioma(coarse marking)

metastastasis

Neoplastic lesions of vertebral column: Vertebral body :

Primary Tumours:

Multiple myeloma

Features Non Inflammatory Infection Spondyloarhropathy

S. I. Joint Normal Normal / Single joint Erosions +

Vertebral bodies Sclerosis - osteoporosis - squaring +

- Irregular eroded end - erosions

Plates - Osteoporosis

Discspace - Decreased -Decreased -may be calcified or convex

- Vacuum phenomenon -Usually one space -multiple.

Osteophyte Prominent Absent Absent

Soft tissues mass - + -

Syndesmophyte Absent Absent Present

Chordoma

Osteosarcoma Haemangioma

GCT

Eosinophilic Granuloma

About 75%of vertebral body tumors are malignant

Secondary Tumours

Posterior elements :

More commonly benign(65%).These includeABC, Osteoblastoma, Osteod osteoma.

Type Etiology

Traction osteophytes Instability.

Marginal syndesmophyte As, inflammatory B.D.

Nonmarginal syndesmophytes Dish, reiters and pscriasis

Steffie plating for spinal pathologies

Lumbar Spondylolysis Severe kyphosis

Koch’s Spine

Thoraco - Lumbar Fracture Spine Giant Cell Tumor of Spine

Scoliosis

Osteochandroma Dish Syndrome