Most Common Causes Of Low Back Pain

Common conditions causing low back
pain 90% of patients with low back pain get better within one month a
combination of time and a short period of rest with non-steroidal
anti-inflammatory medications usually improves the patient's condition

What are the risk factors for low
back pain?

• Job dissatisfaction.

• Twisting.

• Excessive continuous vibration at the job.

• Heavy lifting.

• Stress on the back or anxiety and depression.

The typical profile is an adult male
with low income that smokes a cigarette

smoke is terrible for the vascularity
and the nutrition of the disc.

Intradiscal Pressure Chart

Here is a chart that shows the intradiscal
pressure and how that pressure changes with the position of the spine

If you are supine the
intradiscal pressure is low but if you are sitting on a chair and leaning
forward and lifting weight then the intradiscal pressure is the highest in
this position.

Wadell signs

Wadell signs are controversial and
the presence of multiple Wadell signs on examination of the patient indicates
a non-organic symptom etiology.

some of these signs are an overreaction, exaggeration, or tenderness to light touch.

if you distracted a patient the
patient will give you a different response or the patient will give a pain response
in the non-anatomic distribution area.

we do not want to be judgmental or
accusatory During the patient examination.

History of examination of the
patient

• If the patient is worse with flexions like in sitting then it
  is a disc problem.

• If the pain goes to the leg then it is a disc herniation.

• If the back pain is more then this is discogenic back pain.

• If the patient is worse with extinction and there is more
  back pain then it is spondylosis or spondylolisthesis.

but if the patient is worse with
extinction and there's more leg pain than back pain it's probably spinal
stenosis.

Other movements of the spine

Straight leg raising test 

the patient will be supine
and they're gonna keep the knee extended and they're gonna flex the
hip

this maneuver stretches the sciatic
nerve and if the patient had pain between 35 to 70 degrees, then there is an irritation
of the nerve roots and usually, it's the l5, S1 nerve roots that are irritated.

The contralateral Straight leg
raising test

A positive contralateral straight
leg raise is very specific for lumbar disc herniation a positive straight leg raising
could mean nerve root irritation by the herniated disc.

Most common causes of low back
pain

• Intervertebral disc disorders
• Herniated disc
• Internal disc disruption
• Cauda Aquinas syndrome
• Degenerative disc disease
• lumbar stenosis
• Spondylolisthesis
• Degenerative sclerosis
• Failed back syndrome
• Sacroiliac joint dysfunction

Intervertebral Disc Disorders

Herniated discs

L4-L5 and L5-S1 are the most common
levels which are affected by disc herniation

The usual location of disc
herniation is posterolateral it's a common location for the disc to herniate

This posterolateral disc herniation
(L4-L5 Level)will affect the traversing nerve root, so it will get the L5 nerve
root (traversing means the descending or lower nerve root).

but if it is a far lateral disc
herniation or a foraminal disc herniation it will affect the exiting nerve root
(the upper nerve root) so it will affect the l-4 nerve root (in 5% to 10% of the
cases)

when you do straight leg raising it
will be positive and that's called the tension side.

Internal disc disruption 

Internal disc disruption is called discogenic
back pain.

Early disc degeneration can occur
due to annular tears in the disc.

the patient usually has back pain
and no leg pain and the pain will be worsened with flexion and sitting.

Cauda equina syndrome

Cauda equina syndrome central disc
herniation affects multiple nerve roots that control the bladder and the bowel

The patient will complain of back
pain more than radicular pain, and will also complain of bladder and bowel
symptoms, frequency, incontinence, and the sensation over the perianal area is
affected.

Early
diagnosis with an MRI and early surgery is important!

Degenerative disc disease 

With degenerative disc disease, there
will be a loss of disc height and the l4-l5 disc level is significant.

Lumbar Stenosis

Lumbar stenosis is the narrowing and degeneration
of the spinal canal

There are two types a Central type and a Lateral
type

Centeral type lumbar stenosis

In the central type, the pain worsened
with extension, the patient may have neurogenic claudication and rule out
vascular problems.

sitting and flexion of the spine
will relieve the pain because it increases the spinal canal size.

There will be cramps and heaviness
in the calves.

The pain starts proximally and goes distally 

Lateral type lumbar stenosis

In lateral stenosis, you'll get
ridiculous symptoms

Spondylolisthesis 

If there is a bony defect in the
pars intraarticular, this is called spondylolisthesis

If the stress fracture weakens the
bone so much that it is unable to maintain its proper position, the vertebra
can start to shift out of place

The slippage of the vertebrae could compress
the nerves and narrow the spinal canal

It can occur in younger age groups
from repetitive activities such as gymnastics.

There will be pain with the extension of
the spine and it may progress with time

There are multiple types but one of
them is the Isthmic Type or Degenerative Type

Isthmic Type

Occurs more in males (L5-S1 usually
involved) and it will involve the L5 nerve root with hamstring spasticity

Degenerative Type

The degenerative type occurs more in
females and it usually affects the L4-L5 level

This leverage is not severe the
parts remain intact and this condition is (common in middle age females).

Degenerative scoliosis

There are degenerative changes in the
spinal disc and the facet joints causing the spine to curve which may cause low
back pain.

Failed back syndrome

Chronic back and possible leg pain
that is experienced by the patient after spine surgery.

it could be due to non-mechanical
causes such as psychological factors, post-operative infection, or adhesions
and epidural fibrosis.

it may also be due to mechanical
causes, such as inadequate surgery, recurrent disc herniation, failure of
fusion and or fixation, and maybe due to instability of the spine.

For example, if the surgeon removed one facet on one side, or 50%
partial facet removal but it is done on both sides, that may cause a
heterogenic spondylolisthesis.

Sacroiliac joint dysfunction

sacroiliac joint dysfunction is an occult
cause of low back pain.

The pain is in the lower back region,
usually to the side.

The Faber test is helpful in
determining the presence of SI joint problems.

The best method for diagnosing the presence
of si joint problems is by administering an injection into the SI joint to localize
the source of the pain. And this step is extremely important if you're going to
decide to do surgery for the fusion of the SI joint.

In addition to all these factors
look for osteoporotic compression spine fractures in the elderly and rule out
multiple myeloma or metastatic tumors

Try to rule out other conditions, such
as hip conditions we need to deal with a spine condition. 

Be aware that hip conditions and spying conditions may affect each other, not only in the management but also
can confuse the diagnosis.

Also, try to differentiate sciatica that's
caused by a disc herniation from sciatica that's caused by the peripheral syndrome.