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Low back pain and sciatica

Lumbar back pain is one of the commonest causes of chronic disability


Usually due to abnormality of intervertebral discs at L4/5 or L5/S1 level

Pathology

With age nucleus pulposus of disc dries out


Annulus fibrosis also develops fissures
Nuclear material may herniate through annulus
May perforate vertebral end-plate to produce a Schmorl node
Flattening of the disc with marginal osteophyte formation is known as
spondylosis
Osteoarthritis may develop in the facet joints
Osteophyte formation may narrow lateral recesses of spinal canal
These can encroach on spinal canal and result in spinal stenosis
Acute herniation of disc contents can occur
Usually occurs to one side of the posterior longitudinal ligament
Posterolateral rupture can compress nerve roots
Central posterior rupture can compress the cauda equina

Acute disc rupture

Can occur at any age


Usually occurs in fit adults between 20-45 years

Clinical features

Presents with acute low back pain on stooping or lifting


Pain often radiates to buttock or leg
May be associated with paraesthesia or numbness in the leg
Cauda equina compression can cause urinary retention
Examination may show a 'sciatic' scoliosis
All back movement is restricted
May be lumbar tenderness and paravertebral spasm
Straight leg raising is often restricted
Neurological examination is essential
L5 root signs include:
o Weakness of hallux extension
o Loss of knee reflex
o Sensory loss over the lateral aspect of the leg and dorsum of the
foot
S1 root signs include:
o Weakness of foot plantar flexion

Loss of ankle reflex


Sensory loss over the lateral aspect of the foot
Cauda equina compression causes
o Urinary retention
o Loss or perianal sensation
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Imaging

Lumbar spine x-ray will exclude other bone lesions


Myelography is a historical investigation
MRI is now the investigation of choice

Management

Bed rest is of unproven benefit


Recovery is not hasten by traction
NSAID provide symptomatic relief
The role of epidural steroid injection is unclear
Chemonucleolysis is less effective than surgical discectomy
Surgery is required if:
o Cauda equina compression - neurosurgical emergency
o Neurological deterioration with conservative management
o Persistent symptoms and neurological signs
Surgical options are:
o Partial laminectomy

Microdiscectomy
Postoperative rehabilitation and physiotherapy are essential
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Facet joint dysfunction

Usually present with recurrent low back pain


Pain often related to physical activity
May be referred to the buttock
Often relieved by lying down
Lumbar spine movement is often good
Neurological signs may be few
Lumbar spine x-rays show narrowing of the disc space
Oblique views may show facet joint malalignment
Treatment includes:
o Physiotherapy
o Analgesia
o Facet joint injections
o Spinal fusion

Spinal stenosis

Narrowing of the spinal canal due to hypertrophy of the posterior disc


margin
May be compounded by facet joint osteophyte formation
Spinal stenosis may also be associated with:
o Achondroplasia
o Spondylolisthesis
o Paget's disease
Usually presents with either unilateral or bilateral leg pain
Initiated by standing or walking
Relieved by sitting or leaning forward - 'spinal claudication'
Patient prefers to walk uphill rather than downhill
X-rays often show degenerative spondylolisthesis
Diagnosis can be confirmed by MRI
Often treated conservatively
Surgery involves wide laminectomy and decompression

Spondylolisthesis

Spondylolisthesis means forward shift of the spine


Occurs at L4/L5 or L5/S1 level
Can only occur if facet joint locking mechanism has failed
Classified as:
o Dysplastic - 20%

Lytic - 50%
Degenerative - 25%
Post-traumatic
Pathological
Postoperative
In lytic spondylolisthesis the pars interarticularis is in two pieces
(spondylolysis)
Vertebral body and superior facet joints subluxate and dislocate forward
Degree of overlap is usually expressed as percentage
Cauda equina or nerve roots may be compressed
Presents with back pain and neurological symptoms
Patients have a characteristic stance
A 'step' in the lumbar spine may be palpable
Diagnosis can be confirmed on a plain x-ray
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o
o
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Most patients improve with conservative management


Surgery may be required if:
o Disabling symptoms
o Progressive displacement more than 50%
o Significant neurological compromise
Anterior or posterior fusion may be required

Bibliography
Deyo R A, Weinstein J N. Low Back Pain. N Engl J Med 2001; 344: 363-370.
Hagen H D, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute low back
pain. Cochrane Database Syst Rev 2000; 2: CD001254.
Koes B W, van Tulder M W, Thomas S. Diagnosis and treatment of low back
pain. BMJ 2006; 332: 1430-1434.
Nelemas P J, de Bie R A, de Vet H C, Sturmans F. Injection therapy for
subacute and chronic low back pain. Cochrane Database Syst Rev 2000; 2:
CD001824.
van Tulder M W, Scholten R J, Koes D C V, Deyo R A. Non-steroidal antiinflammatory drugs for low back pain. Cochrane Database Syst Rev 2000; 2:
CD000396.

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