General Practice, Chapter 33

Chapter 33 - Low back pain

Last Wednesday night while carrying a bucket of water from the well, Hannah Williams slipped upon the icy path and fell
heavily upon her back. We fear her spine was injured for though she suffers acute pain in her legs she cannot move them. The
poor wild beautiful girl is stopped in her wildness at last.
Francis Kilvert 1874

Low back pain accounts for at least 5% of general practice presentations. The most common cause is minor soft tissue injury,
but patients with this do not usually seek medical help because the problem settles within a few days.
Most back pain in patients presenting to general practitioners is due to dysfunction of elements of the mobile segment, namely
the facet joint, the intervertebral joint (with its disc) and the ligamentous and muscular attachments. This problem, often referred
to as mechanical pain or traumatic joint derangement, will be described as vertebral dysfunctiona general term that, while
covering radicular and non-radicular pain, includes dysfunction of the joints of the spine.

Key facts and checkpoints

Back pain accounts for at least 5% of all presenting problems in general practice in Australia and 6.5% in Britain. 1
In the United States it is the commonest cause of limitation of activity under the age of 45. 2
Approximately 85% of the population will experience back pain at some stage of their lives, while 70% of the world's
population will have at least one disabling episode of low back pain in their lives. 2
At least 50% of these people will recover within 2 weeks and 75% within 1 month, but recurrences are frequent and
have been reported in 40-70% of patients.
The most common age groups are the 30s, 40s and 50s, the average age being 45 years.
The most common cause of back pain is a minor strain to muscles and/or ligaments, but people suffering from this type
of back pain usually do not seek medical treatment as most of these soft tissue problems resolve rapidly.
The main cause of back pain presenting to the doctor is dysfunction of the intervertebral joints of the spine due to injury,
also referred to as mechanical back pain (at least 70%).
The causes of this dysfunction are disorders of the facet joints and internal disruption of the intervertebral disc, the exact
balance being uncertain.
The second most common cause of back pain is spondylosis (synonymous with osteoarthritis and degenerative back
disease). It accounts for about 10% of cases of low back pain.
L5 and S1 nerve root lesions represent most of the cases of sciatica presenting in general practice. They tend to present
separately but can occur together with a massive disc protrusion.
An intervertebral disc prolapse has been proven in only 6-8% of cases of back pain. 2

Causes of low back pain

To develop a comprehensive diagnostic approach, the practitioner should have a clear understanding of the possible causes of
low back and leg pain and of the relative frequency of their clinical presentations. The major causes of low back pain in several
hundred patients presenting to the author's general practice are summarised in Table 33.1 .
Table 33.1 Major causes of low back leg pain presenting in the author's general practice
Patients

Vertebral dysfunction

71.8

Lumbar spondylosis

10.1

Depression

3.0

Urinary tract infection

2.2

Spondylolisthesis

2.0

Spondyloarthropathies

1.9

Musculoligamentous strains/tears 1.2

file:///D|/Study/NZREX/murtagh/GP_Murtagh/html/GP-C33.htm[3/27/2012 1:13:06 PM]

Malignant disease

0.8

Arterial occlusive disease

0.6

Other

6.4
100.0

Relevant causes are illustrated in Figure 33.1

Fig. 33.1 Relevant causes of back pain with associated buttock and leg pain

Anatomical and pathophysiological concepts

Recent studies have focused on the importance of disruption of the intervertebral disc in the cause of back pain. A very
plausible theory has been advanced by Maigne 3 who proposes the existence, in the involved mobile segment, of a minor
intervertebral derangement (MID). He defines it as 'isolated pain in one intervertebral segment, of a mild character, and due to
minor mechanical cause'.
It is independent of radiological and anatomical disturbances of the segment. The most common clinical situation occurs where
a vertebral level is found to be painful and yet to have a normal static and radiological appearance.
The MID always involves one of the two apophyseal joints in the mobile segment, thus initiating nociceptive activity in the
posterior primary dermatome and myotome. The overlying skin is tender to pinching and rolling, while the muscles are painful
to palpation and feel cord-like.
Maigne points out that the functional ability of the mobile segment depends intimately upon the condition of the intervertebral
disc. Thus, if the disc is injured, other elements of the segment will be affected. Even a minimal disc lesion can produce
apophyseal joint dysfunction which is a reflex cause of protective muscle spasm and pain in the corresponding segment, with
loss of function (Fig 33.2 ).

Fig. 33.2 Reflex activity from a MID in the intervertebral motion segment. Apart from the local effect caused by the disruption
of the disc (A), interference can occur in the facet joint (B) and interspinous ligament (C) leading possibly to muscle spasm (D)
and skin changes (E) via the posterior rami
REPRODUCED FROM C. KENNA AND J. MURTAGH, BACK PAIN AND SPINAL MANIPULATION, BUTTERWORTHS,
SYDNEY, 1989, WITH PERMISSION
In theory any structure with a nociceptive nerve supply may be a source of pain. Such structures include the ligaments, fascia
and muscles of the lumbosacral spine, intervertebral joints, facet joints, dura-mater and sacroiliac joints. 4

A diagnostic approach

A summary of the safety diagnostic model is presented in Table 33.2 .

Table 33.2 Low back pain: diagnostic strategy model

Q. Probability diagnosis
A. Vertebral dysfunction esp. facet joint and disc
Spondylosis (degenerative OA)
Q. Serious disorders not to be missed
A. Cardiovascular
ruptured aortic aneurysm
retroperitoneal haemorrhage (anticoagulants)
Neoplasia
myeloma
metastases
Severe infections
osteomyelitis
discitis
tuberculosis
pelvic abscess/PID Cauda
equina compression
Q. Pitfalls (often missed)
A. Spondyloarthropathies
ankylosing spondylitis
Reiter's disease
psoriasis
bowel inflammation
Sacroiliac dysfunction
Spondylolisthesis
Claudication
vascular
neurogenic
Prostatitis
Endometriosis
Q. Seven masquerades checklist

A. Depression

Diabetes
Drugs
Anaemia
Thyroid disease
Spinal dysfunction
UTI

x
x

Q. Is this patient trying to tell me something?

A. Quite likely. Consider lifestyle, stress, work problems, malingering, conversion reaction

Note: Associated buttock and leg pain included.

Probability diagnosis

The commonest cause of low back pain is vertebral dysfunction, which then has to be further analysed.
Muscle or ligamentous tears or similar soft tissue injuries are uncommon causes of back pain alone: they are generally
associated with severe spinal disruption and severe trauma such as that following a motor vehicle accident.
In the lumbar spine most problems originate from either the apophyseal joints or the intervertebral discogenic joint, or from both
simultaneously. The disc can cause pain, either intrinsically from internal disruption or extrinsically by pressure on adjacent
pain-sensitive structures, leading to radicular pain (if the nerve root is involved) or non-radicular pain.
Degenerative changes in the lumbar spine (lumbar spondylosis) are commonly found in the older age group. This problem, and
one of its complications, spinal canal stenosis, is steadily increasing along with the ageing population.

Serious disorders not to be missed

It is important to consider malignant disease, especially in an older person. It is also essential to consider infection such as
acute osteomyelitis and tuberculosis, which is often encountered in recent immigrants, especially those from Asia. These
conditions are considered in more detail under thoracic back pain. For pain or anaesthesia of sudden onset, especially when
accompanied by neurological changes in the legs, consider cauda equina compression due to a massive disc prolapse and
also retroperitoneal haemorrhage. It is important to ask patients if they are taking anticoagulants.

Pitfalls

The inflammatory disorders must be kept in mind, especially the spondyloarthropathies, which include psoriatic arthropathy,
ankylosing spondylitis, Reiter's disease, inflammatory bowel disorders such as ulcerative colitis and Crohn's disease, and
reactive arthritis. The spondyloarthropathies are more common than appreciated and must be considered in the younger person
presenting with features of inflammatory back pain, i.e. pain at rest, relieved by activity. The old trap of confusing claudication
in the buttocks and legs, due to a high arterial obstruction, with sciatica must be avoided.
Table 33.3 'Red flag' pointers to serious low back pain conditions 5

Age > 50 years

History of cancer
Temperature > 37.8C
Constant painday and night
Weight loss
Significant trauma
Features of spondyloarthropathy
Neurological deficit
Drug or alcohol abuse
Use of anticoagulants
Use of corticosteroids
No improvement over 1 month
Possible cauda-equina syndrome
saddle anaesthesia
recent onset bladder dysfunction
severe or progressive neurological deficit

General pitfalls
Being unaware of the characteristic symptoms of inflammation and thus misdiagnosing one of the spondyloarthropathies
Overlooking the early development of malignant disease or osteomyelitis; if suspected, and an X-ray is normal, a
radionuclide scan should detect the problem
Failing to realise that mechanical dysfunction and osteoarthritis can develop simultaneously, producing a combined
pattern
Overlooking anticoagulants as a cause of a severe bleed around the nerve roots and corticosteroids leading to
osteoporosis
Not recognising back pain as a presenting feature of the drug addict.

'Red flag' pointers

There are several so called 'red flag' or precautionary pointers to a serious underlying cause of back pain. Such symptoms and
signs should alert the practitioner to a serious health problem and thus guide selection of investigations, particularly plain films
of the lumbar spine.

Seven masquerades checklist

Of these conditions, depression and urinary tract infection have to be seriously considered. For the young woman with upper
lumbar pain, especially if she is pregnant, the possibility of a urinary tract infection must be considered. These patients may not
have urinary symptoms such as dysuria and frequency.
Depressive illness has to be considered in any patient with a chronic pain complaint. This common psychiatric disorder can
continue to aggravate or maintain the pain even though the provoking problem has disappeared. This is more likely to occur in
people who have become anxious about their problem or who are under excessive stress. Many doctors treat such patients
with a therapeutic trial of antidepressant medication, for example, amitriptyline or doxepin.

Psychogenic considerations

The patient may be unduly stressed, not coping with life or malingering. It may be necessary to probe beneath the surface of
the presenting problem.
A patient with low back pain following lifting at work poses a problem that causes considerable anguish to doctors, especially
when the pain becomes chronic and complex. Chronic pain may be the last straw for patients who have been struggling to
cope with personal problems; their fragile equilibrium is upset by the back pain. Many patients who have been dismissed as
malingerers turn out to have a genuine problem. The importance of a caring, competent practitioner with an insight into all
facets of his or her patient's suffering, organic and functional, becomes obvious. The tests for non-organic back pain are very
useful in this context.

Nature of the pain

The nature of the pain may reveal its likely origin. Establish where the pain is worst whether it is central (proximal) or
peripheral. The following are general characteristics and guides to diagnosis:
aching throbbing pain = inflammation, e.g. sacroiliitis
deep aching diffuse pain = referred pain, e.g. dysmenorrhoea
superficial steady diffuse pain = local pain, e.g. muscular strain
boring deep pain = bone disease, e.g. neoplasia, Paget's disease
intense sharp or stabbing (superimposed on a dull ache) = radicular pain, e.g. sciatica
A comparison of the significant features of the two most common types of painmechanical and inflammatoryis presented in
Table 33.4 .
Table 33.4 Comparison of the patterns of pain for inflammatory and mechanical causes of low back
pain
6
Feature

Inflammation

Mechanical

History

Insidious onset

Preciptating injury/previous episodes

Nature

Aching, throbbing

Stiffness

Severe, prolonged
Morning stiffness

Deep dull ache, sharp if root compression

Moderate, transient

Effect of rest

Exacerbates

Relieves

Effect of activity Relieves

Exacerbates

Radiation

More localised, bilateral or alternating Tends to be diffuse, unilateral

Intensity

Night, early morning

End of day, following activity

The clinical approach

History

Analysing the history invariably guides the clinician to the diagnosis. The pain patterns have to be carefully evaluated and it is
helpful to map the diurnal variations of pain to facilitate the diagnosis (Fig 33.3 ).
It is especially important to note the intensity of the pain and its relation to rest and activity. In particular, ask whether the pain
is present during the night, whether it wakes the patient, is present on rising or whether it is associated with stiffness.
Continuous pain present day and night is suggestive of neoplasia or infection. Pain on waking also suggests inflammation or
depressive illness. Pain provoked by activity and relieved by rest suggests mechanical dysfunction while pain worse at rest and
relieved by moderate activity is typical of inflammation. In some patients the coexistence of mechanical and inflammatory
causes complicates the pattern.
Pain aggravated by standing or walking that is relieved by sitting is suggestive of spondylolisthesis. Pain aggravated by sitting
(usually) and improved with standing indicates a discogenic problem.
Pain of the calf that travels proximally with walking indicates vascular claudication; pain in the buttock that descends with
walking indicates neurogenic claudication. This latter problem is encountered more frequently in older people who have a
tendency to spinal canal stenosis associated with spondylosis.

Fig. 33.3 Typical daily patterns of pain for conditions causing back pain. Note conditions that can wake patients from sleep
and also the combined mechanical and inflammatory patterns

Key questions
What is your general health like?
Can you describe the nature of your back pain?
Was your pain brought on by an injury?
Is it worse when you wake in the morning or later in the day?
How do you sleep during the night?
What effect does rest have on the pain?
What effect does activity have on the pain?
Is the pain worse when sitting or standing?
What effect does coughing or sneezing or straining at the toilet have?
What happens to the pain in your back or leg if you go for a long walk?
Do you have a history of psoriasis, diarrhoea, penile discharge, eye trouble or severe pain in your joints?
Do you have any urinary symptoms?
What medication are you taking? Are you on anticoagulants?

Are you under any extra stress at work or home?

Do you feel tense or depressed or irritable?

Physical examination

The basic objectives of the physical examination are to reproduce the patient's symptoms, detect the level of the lesion and
determine the cause (if possible) by provocation of the affected joints or tissues. This is done using the time-honoured method
of joint examinationlook, feel, move and test function. The patient should be stripped to a minimum of clothing so that careful
examination of the back can be made. A neurological examination of the lower limb should be performed if symptoms extend
below the buttocks.
A useful screening test for a disc lesion and dural tethering is the slump test. 6
The main components of the physical examination are:
1. Inspection
2. Active movements
forward flexion (to reproduce the patient's symptoms)
extension (to reproduce the patient's symptoms)
lateral flexion (R & L) (to reproduce the patient's symptoms)
3. Provocative tests (to reproduce the patient's symptoms)
4. Palpation (to detect level of pain)
5. Neurological testing of lower limbs (if appropriate)
6. Testing of related joints (hip, sacroiliac)
7. Assessment of pelvis and lower limbs for any deformity, e.g. leg shortening
8. General medical examination including rectal examination

Important landmarks

The surface anatomy of the lumbar region is the basis for determining the vertebral level. Key anatomical landmarks include
the iliac crest, spinous processes, the sacrum and the posterior superior iliac spines (PSISs).
The tops of the iliac crest lie at the level of the L4-L5 interspace (or the L4 spinous process).
The PSISs lie opposite S2 (Fig 33.4 ).

Fig. 33.4 Surface anatomy and important landmarks of the lumbosacral spine

Inspection

Inspection begins from the moment the patient is sighted in the waiting room. A patient who is noted to be standing is likely to
have a significant disc lesion. Considerable information can be obtained from the manner in which the patient arises from a
chair, moves to the consulting room, removes the shoes and clothes, gets onto the examination couch and moves when
unaware of being watched.
The spine must be adequately exposed and inspected in good light. Patients should undress to their underpants; women may
retain their brassiere and it is proper to provide them with a gown that opens down the back. Note the general contour and
symmetry of the back and legs, including the buttock folds, and look for muscle wasting. Note the lumbar lordosis and any
abnormalities such as lateral deviation. If lateral deviation (scoliosis) is present it is usually away from the painful side.
Note the presence of midline moles, tufts of hair or haemangioma that might indicate an underlying congenital anomaly such as
spina bifida occulta.

Movements of the lumbar spine

There are three main movements of the lumbar spine. As there is minimal rotation, which mainly occurs at the thoracic spine,
rotation is not so important. The movements that should be tested, and their normal ranges are as follows:

extension (20-30) (Fig 33.5 a )

lateral flexion, left and right (30) (Fig 33.5 b )
flexion (75-90: average 80) (Fig 33.5 a )
Measurement of the angle of movement can be made by using a line drawn between the sacrum and large prominence of the
C7 spinous process.

Fig. 33.5 (a) Degrees of movement of the lumbar spine: flexion and extension (b) degree of lateral flexion of the lumbar
spine REPRODUCED FROM C. KENNA AND J. MURTAGH, BACK PAIN AND SPINAL MANIPULATION, BUTTERWORTHS,
SYDNEY, 1989, WITH PERMISSION

Palpation

Have the patient relaxed, lying prone, with the head to one side and the arms by the sides. The levels of the spinous
processes are identified by standing behind the patient and using your hands to identify L4 and L5 in relation to the top of the
iliac crests. Mark the important reference points.
Palpation, which is performed with the tips of the thumbs opposed, can commence at the spinous process of L1 and then
systematically proceed distally to L5 and then over the sacrum and coccyx. Include the interspinous spaces as well as the
spinous processes. When the thumbs (or other part of the hand such as the pisiforms) are applied to the spinous processes, a
firm pressure is transmitted to the vertebrae by a rocking movement for three or four 'springs'. Significant reproduction of pain is
noted.
Palpation occurs at three main sites:
centrally (spinous processes to coccyx) unilateral
right and left sides (1.5 cm from midline)
transverse pressure to the sides of the spinous processes (R and L)

Provocation tests

Quadrant test
This test compresses the spinal joints, especially facet joints, on the painful side and can be used if active movements fail to
reproduce the patient's pain. Stand behind the patient, place a hand on each shoulder and extend the lumbar spine to its limit.
Ensuring the patient does not bend the knees, extend the spine to its limit, then laterally flex to the painful side, and then
rotate to that side and apply some downwards pressure.
Slump test

The slump test is an excellent provocation test for lumbosacral pain and is more sensitive than the straight leg raising test. It is
a screening test for a disc lesion and dural tethering. It should be performed on patients who have low back pain with pain
extending into the leg, and especially for posterior thigh pain.
A positive result is reproduction of the patient's pain, and may appear at an early stage of the test (when it is ceased).

Method
1.
2.
3.
4.
5.
6.

The patient sits on the couch in a relaxed manner.

The patient then slumps forward (without excessive trunk flexion), and then places the chin on the chest.
The unaffected leg is straightened.
The affected leg only is then straightened (Fig 33.6 ).
Both legs are straightened together.
The foot of the affected straightened leg is dorsiflexed.

Note: Take care to distinguish from hamstring pain. Deflexing the neck relieves the pain of spinal origin, not hamstring pain.

Significance of the slump test

It
If
If
If

is positive if the back or leg pain is reproduced.

positive, it suggests disc disruption.
negative, it may indicate lack of serious disc pathology.
positive, one should approach manual therapy with caution.

Fig. 33.6 The slump test: one of the stages

Neurological examination
A neurological examination is performed only when the patient's symptoms, such as pain, paraesthesia, anaesthesia and
weakness, extend into the leg.
The importance of the neurological examination is to ensure that there is no compression of the spinal nerves from a prolapsed
disc or from a tumour. This is normally tested by examining those functions that the respective spinal nerves serve, namely
skin sensation, muscle power and reflex activity.
The examination is not daunting but can be performed quickly and efficiently in two to three minutes by a methodical technique
that improves with continued use. The neurological examination consists of:
1. Quick tests
walking on heels (L5)
walking on toes (S1)
2. Dural stretch tests
slump test
straight leg raising (SLR)
3. Specific nerve root tests (L4,
L5, S1) sensation
power
reflexes

Main nerve
roots Refer to Figure
33.7 . L3:

femoral stretch test (prone, flex knee, extend hip) motor

extension of knee
sensationanterior thigh
reflexknee jerk (L3, L4)
L4:
motorresisted inversion foot sensation
inner border of foot to great toe reflex
knee jerk
L5:
motor

walking on heels
resisted extension great toe
sensationmiddle three toes (dorsum)
reflexnil
S1:
motor

walking on toes
resisted eversion foot
sensationlittle toe, most of sole
reflexankle jerk (S1, S2)

Fig. 33.7 The main motor, sensory and reflex features of the nerve roots L5 and S1
REPRODUCED FROM S. HOPPENFELD, PHYSICAL EXAMINATION OF THE SPINE AND EXTREMITIES, APPLETON AND
LANGE NORWALK, CT, USA, 1976, WITH PERMISSION

Other examination

The method of examining the sacroiliac and hip joints is outlined in Chapter 59 .

Investigations

Investigations for back pain can be classified into three broad groups: front-line screening tests; specific disease investigations;
and procedural and preprocedural tests.

Screening tests

These are most important for the patient presenting with chronic back pain when serious disease such as malignancy,
osteoporosis, infection or spondyloarthropathy must be excluded. The screening tests for chronic pain are:
plain X-ray

urine examination (office dipstick)

erythrocyte sedimentation rate (ESR)
serum alkaline phosphatase
prostatic specific antigen (in males > 50)

Specific disease investigation

Such tests include:

peripheral arterial studies

HLA-B27 antigen test for ankylosing spondylitis and Reiter's disease
serum electrophoresis for multiple myeloma
brucella agglutination test
blood culture for pyogenic infection and bacterial endocarditis
bone scanning to demonstrate inflammatory or neoplastic disease and infections (e.g. osteomyelitis) before changes are
apparent on plain X-ray
tuberculosis studies
X-rays of shoulder and hip joint
electromyographic (EMG) studies to screen leg pain and differentiate neurological diseases from nerve compression
syndromes
radioisotope scanning
technetium pyrophosphate scan of SIJ for ankylosing spondylitis
selective anaesthetic block of facet joint under image intensification
selective anaesthetic block of medial branches of posterior primary rami and other nerve roots

Procedural and preprocedural diagnostic tests

These tests should be kept in reserve for chronic disorders, especially mechanical disorders, that remain undiagnosed and
unabated, and where surgical intervention is planned for a disc prolapse requiring removal.
Depending on availability and merit, such tests include:
computerised tomography (CT scan)
myelography or radiculography
discography
magnetic resonance imaging (MRI)

Summary of diagnostic guidelines for spinal pain

Continuous pain (day and night) = neoplasia, especially malignancy or infection.
The big primary malignancy is multiple myeloma.
The big three metastases are from lung, breast and prostate.
The other three metastases are from thyroid, kidney/adrenal and melanoma.
Pain with standing/walking (relief with sitting) = spondylolisthesis.
Pain (and stiffness) at rest, relief with activity = inflammation.
In a young person with inflammation think of ankylosing spondylitis or Reiter's disease.
Stiffness at rest, pain with or after activity, relief with rest = osteoarthritis.
Pain provoked by activity, relief with rest = mechanical dysfunction.
Pain in bed at early morning = inflammation, depression or malignancy/infection.
Pain in periphery of limb = discogenic radicular or vascular claudication or spinal canal stenosis claudication.
Pain in calf (ascending) with walking = vascular claudication.
Pain in buttock (descending) with walking = neurogenic claudication.
One disc lesion = one nerve root (exception is L5-S1 disc).
One nerve root = one disc (usually).
Two or more nerve rootsconsider neoplasm.
The rule of thumb for the lumbar nerve root lesions is L3 from L2-L3 disc, L4 from L3-L4, L5 from L4-L5 and S1 from L5S1.
A large disc protrusion can cause bladder symptoms, either incontinence or retention.
A retroperitoneal bleed from anticoagulation therapy can give intense nerve root symptoms and signs.

Back pain in children

The common mechanical disorders of the intervertebral joints can cause back pain in children, which must always be taken

seriously. Like abdominal pain and leg pain, it can be related to psychogenic factors, so this possibility should be considered by

diplomatically evaluating problems at home, at school or with sport.

Especially in children under the age of 10, it is very important to exclude organic disease. Infections such as osteomyelitis and
tuberculosis are rare possibilities, and 'discitis' has to be considered. This painful condition can be idiopathic, but can also be
caused by the spread of infection from a vertebral body. It has characteristic radiological changes.
Tumours causing back pain include the benign osteoid osteoma and the malignant osteogenic sarcoma. Osteoid osteoma is a
very small tumour with a radiolucent nucleus that is sharply demarcated from the surrounding area of sclerotic bone. Although
more common in the long bones of the leg, it can occur in the spine.
In older children and adolescents the organic causes of back pain are more likely to be inflammatory, congenital or from
developmental anomalies and trauma.
A prolapsed intervertebral disc, which can occur (uncommonly) in adolescents, can be very unusual in its presentation. There is
often marked spasm, with a stiff spine and lateral deviation, which may be out of proportion to the relatively lower degree of
pain.
Spondylolisthesis can occur in older children, usually due to a slip of L5 or S1, because the articular facets are congenitally
absent or because of a stress fracture in the pars interarticularis. It is necessary to request standing lateral and oblique X-rays.

Back pain in the elderly

Traumatic spinal dysfunction is still the most common cause of back pain in the elderly and may represent a recurrence of
earlier dysfunction. It is amazing how commonly disc prolapse and facet joint injury can present in the aged. However,
degenerative joint disease is very common and, if advanced, can present as spinal stenosis with claudication and nerve root
irritation due to narrowed intervertebral foraminae.
Special problems to consider are malignant disease, degenerative spondylolisthesis, vertebral pathological fractures and
occlusive vascular disease.

Acute back and leg pain due to vertebral

dysfunction

Mechanical disruption of the vertebral segment or segments is the outstanding cause to consider, while the main serious
clinical syndromes are secondary to disruption with or without prolapse of the intervertebral disc, usually L4-L5 or L5S1. Table
33.5 presents the general clinical features and diagnosis in acute back pain (fractures excluded) following vertebral dysfunction:
the symptoms and signs can occur singly or in combination.
Table 33.5 Clinical features and diagnosis of vertebral dysfunction leading to low back and leg
pain 6
Clinical features

Syndrome A
(surgical emergency)

Syndrome B
(probable surgical
emergency)

Frequency

Very rare

Diagnosis

Spinal cord (UMN) or cauda equina

(LMN) compression

Saddle anaesthesia (around anus, scrotum or

vagina)
Distal anaesthesia
Evidence of UMN or LMN lesion
Loss of sphincter control or urinary retention
Weakness of legs peripherally
Uncommon

Large disc protrusion, paralysing nerve

root

Anaesthesia or paraesthesia of the leg

Foot drop
Motor weakness
Absence of reflexes
Syndrome C

Common

Posterolateral disc protrusion on nerve

root or disc disruption

Distal pain with or without paraesthesia

Radicular pain (sciatica)
Positive dural stretch tests
Syndrome D

Very common
Lumbar pain (unilateral, central or bilateral)

Disc disruption or facet dysfunction

buttock and posterior thigh pain

Fortunately, syndromes A and B are extremely rare but, if encountered, urgent referral to a surgeon is mandatory. Clinical
features of the cauda equina syndrome are presented in Figure 33.8 . Syndrome B can follow a bleed in patients taking
anticoagulant therapy or be caused by a disc sequestration after inappropriate spinal manipulation.

Fig. 33.8 Cauda equina syndrome due to massive prolapsed intervertebral disc

Vertebral dysfunction with non-radicular pain

This outstanding common cause of low back pain is considered to be due mainly to dysfunction of the pain-sensitive facet joint.
The precise pathophysiology is difficult to pinpoint but invariably is dysfunction of one of the spinal joints, most likely a facet
joint of the MID as proposed by Maigne.

Typical profile
Age:

Any agelate teens to old age, usually 22-55

History of injury:
Yes, lifting or twisting
Site and radiation:
Unilateral lumbar (may be central)
Refers over sacrum, SIJ areas, buttocks
Type of pain:
Deep aching pain, episodic
Aggravation:
Activity, lifting, gardening, housework (vacuuming, making beds, etc.)
Relief:
Rest, warmth
Associations:
May be stiffness, usually good health
Physical examination (significant):

Localised tendernessunilateral or central L4, L5 or S1 levels, may be restricted flexion, extension, lateral flexion
Diagnosis confirmation:
Investigation usually normal
Note: diagnosis made clinically

Management
complete rest for 2 days (for acute pain only); otherwise, activity directed by degree of pain but normal activity
encouraged from outset
back education program
analgesics
exercise program and swimming (as tolerated)
physical therapymobilisation, manipulation (for persistent problems). Click here for further reference.

Radiculopathy
Radicular pain, caused by nerve root compression from a disc protrusion (most common cause) or tumour or a narrowed
intervertebral foramina, typically produces pain in the leg related to the dermatome and myotome innervated by that nerve root.
Leg pain may occur alone without back pain and vary considerably in intensity.

Typical profile of radicular pain (discogenic)

Age:

Any age, usually middle-aged

History of injury:
Yes, lifting or twisting
Can be spontaneous
Site and radiation:
Unilateral low back, distal radiation along dermatome, tends to have a 'distal' emphasis
Type of pain:
Deep aching or stabbing pain (episodic) develops soon after rising in morning
Has a 'travelling' nature
Aggravation:
Activity, lifting, intercourse, sitting, bending, car travel, coughing, sneezing, straining
Relief:
Rest, lying, standing
Associations:
Distal paraesthesia numbness, stiffness
Physical examination (significant):
Guarded and restricted movement
Loss of lumbar lordosis
Lateral deviation (scoliosis)
Restricted flexion, extension, lateral flexion
SLR and slump test positive
specific muscle/myotomal weakness (typically unilateral)
reduced distal sensation (typically unilateral)
reduced ankle jerk (S1) (typically unilateral)

Diagnostic confirmation (for special reasons):

CT scan, discogram, radiculogram, MRI or myelogram
The two nerve roots that account for most of these problems are L5 and S1. Most settle with time (6 to 12 weeks). The
management is outlined at the end of this chapter and under 'Sciatica' (Chapter 60 ).

Spondylolisthesis

About 5% of the population have spondylolisthesis but not all are symptomatic. The pain is caused by extreme stretching of the
interspinous ligaments or of the nerve roots. The onset of back pain in many of these patients is due to concurrent disc
degeneration rather than a mechanical problem.

Typical profile
Age:

Any age; young adult if congenital, older person (over 50) if degenerative
History of injury:
May precipitate problem
Site and radiation:
Low lumbar
Radiates bilaterally or unilaterally into buttocks, hip, thighs and feet
Type of pain:
Dull ache, episodic depending on activity
Onset:
Onset usually midmorning after standing
Aggravation:
Prolonged standing, walking, exercise
Relief:
Sitting down, lying down
Associations:
Paraesthesia in legs
Stiffness after exercise
May be associated discogenic lesion
Physical examination (significant):
Stiff waddling gait
Increased lumbar lordosis
Flexed knee stance
Tender prominent spinous process of 'slipped' vertebrae
Limited flexion
Hamstring tightness or spasm
Diagnosis confirmation:
Lateral X-ray (standing) (Fig 33.9 ).

Fig. 33.9 Spondylolisthesis: illustrating a forward shift of one vertebra on another

Management

It is amazing how this instability problem can be alleviated with excellent relief of symptoms by getting patients to follow a strict
flexion exercise program for at least 3 months. The objective is for patients to 'splint' their own spine by strengthening
abdominal and spinal muscles.
Extension of the spine should be avoided, especially hyperextension. Gravity traction might help. Recourse to lumbar corsets or
surgery (for spinal fusion) should be resisted although it is appropriate in a few severe intractable cases.

Lumbar spondylosis

Lumbar spondylosis, also known as degenerative osteoarthritis or osteoarthrosis, is a common problem of wear and tear that
may follow vertebral dysfunction, especially after severe disc disruption and degeneration.

Typical profile
Age:

Over 50 years
More common with increasing age
History of injury:
Heavy manual work, trauma to spine, e.g. motor vehicle accident
Site and radiation:
Low back pain
May radiate to buttocks
Type of pain:
Dull nagging ache (often constant)
Acute episodes on chronic background
Aggravation:
Heavy activity, bending
Limited tolerance of standing and sitting
Relief:
Resting by lying straight, gentle exercise, hydrotherapy
Associations:
Stiffness, especially in mornings
Stiffness with immobility
Generally good health
Physical examination
All movements restricted
Diagnosis confirmation:

X-ray
Stiffness of the low back is the main feature of lumbar spondylosis. Although most people live with and cope with the problem,
progressive deterioration can occur leading to subluxation of the facet joints. Subsequent narrowing of the spinal and
intervertebral foramen leads to spinal canal stenosis (Fig 33.10 ).

Fig. 33.10 Lumbar spondylosis with degeneration of the disc and facet joint, leading to narrowing of the spinal canal
and intervertebral foramen

Management
basic analgesics (depending on patient response and tolerance)
NSAIDs (judicious use)
appropriate balance between light activity and rest
exercise program and hydrotherapy (if available)
regular mobilisation therapy may help
consider trials of electrotherapy such as TENS and acupuncture

The
spondyloarthropathies

The seronegative spondyloarthropathies are a group of disorders characterised by involvement of the sacroiliac joints with an
ascending spondylitis and extraspinal manifestations such as oligoarthritis and enthesopathies (Fig 33.11 a, b, c ) (refer Chapter
31 ). The pain and stiffness that are the characteristic findings of spinal involvement are typical of inflammatory disease; namely,
worse in the morning, may occur at night and improves rather than worsens with exercise.

Fig. 33.11 (a) Ankylosing spondylitis and psoriasis: main target areas on vertebral column and girdle joints (b) Crohn's

disease and ulcerative colitis: main target areas of enteropathies (c) Reiter's disease: main target areas
The main disorders in this group are ankylosing spondylitis, psoriatic arthritis, Reiter's disease, reactive spondyloarthropathies
and the inflammatory bowel disorders. Hence the importance of searching for a history of psoriasis, diarrhoea, urethral
discharge, eye disorders and episodes of arthritis in other joints. The following profile for ankylosing spondylitis serves as a
typical clinical presentation of back pain for this group.

Typical profile of ankylosing spondylitis

Age and sex:

Young men 15-30 (rare onset after 40)

History of injury:
None, unless coincidental
Has a slow insidious onset
Site and radiation:
Low back, may radiate to both buttocks or posterior thigh (rare below knees)
Can alternate sides
Type of pain:
Aching, throbbing pain of inflammation
Commonly episodic
Aggravation:
Often worse at night (can wake patient), turning over in bed and rising in the morning
Relief:
Activity including exercise
Patient may walk around during night for relief
Associations:
Back stiffness, especially in morning
Pain and stiffness in thoracic or cervical spine
Pain and stiffness in thoracic cage
Peripheral joint pain (up to 50% of cases)
Iritis (up to 25% of cases)
Physical examination (significant):
Absent lumbar lordosis
Lateral flexion limited first, then flexion and extension
Positive sacroiliac joint stress tests
Positive Schober's test
Diagnosis confirmation:
X-ray of pelvis (sacroiliitis)
Bone scans and CT scans
ESR usually elevated
HLA-B27 antigen positive in over 90% of cases (10% of population are positive)

Schober's test

This test is a useful objective means of measuring the mobility of the lumbar spine and is useful to detect the
spondyloarthropathies in younger patients.
Modified method
Stand the patient erect and mark the spine in line with the dimples of Venus (the posterior superior iliac spines).
Place another mark 10 cm above the first and a third mark 5 cm below the first mark.

Ask the patient to bend forward, as if to touch the toes, to the point of maximal flexion.
Finally, measure the distance between the upper and lower marks.
Interpretation
Normal is > 5 cm increase in length.
Less than 5 cm represents hypomobility, common in the inflammatory spinal disorders, severe spondylosis and
intervertebral disc disorders.

Treatment

The earlier the treatment the better the outlook for the patient; the prognosis is usually good. The basic objectives of treatment
are:
prevention of spinal fusion in a poor position
relief of pain and stiffness
maintenance of optimum spinal mobility
The basic methods of management are:
advice on good back care and posture
general education and counselling
exercise programs to improve the range of movement and maintain mobility
referral to physiotherapist
drug therapy, especially tolerated NSAIDs, preferably indomethacin in optimal dosage sulphasalazine
a useful second-line agent if the disease progresses despite NSAIDs

Malignant disease

It is important to identify malignant disease and other space-occupying lesions as early as possible because of the prognosis
and the effect of a delayed diagnosis on treatment.

Typical profile
Age:

Usually over 50, but the older the patient the greater the risk
History of injury:
Usually insidious onset
Site and radiation:
Localised pain anywhere in lumbar spine
Radiates into buttocks or legs (if nerve root involved)
Type of pain:
Boring deep ache, can be referred or radicular, unrelenting continuous pain, getting worse
Aggravation:
Movement
Specific activities such as lifting, gardening
Relief:
Usually none
No response to treatment
Associations:
Malaise, fatigue, weight loss
Muscular weakness
Night pain

Physical examination (significant):

Flattened lumbar lordosis
Localised tenderness over vertebrae
All movements restricted and protective (if advanced)
Neurologically normal unless roots involved
More than one root may be involved
Major neurological signs incompatible with pain level
Diagnosis confirmation:
X-ray
Serum alkaline phosphatase
ESR
Bone scan
With respect to the neurological features, more than one nerve root may be involved and major neurological signs may be
present without severe root pain. The neurological signs will be progressive.
If malignant disease is proved and myeloma is excluded a search should be made for the six primary malignancies that
metastasise to the spine (Fig 33.12 ). If the bone is sclerotic consider prostatic secondaries, some breast secondaries or
Paget's disease.

Non-organic
pain

back

Like headache, back pain is a symptom of an underlying functional, organic or psychological disorder. 5 Preoccupation with
organic causation of symptoms may lead to serious errors in the assessment of patients with back pain. Any vulnerable aching
area of the body is subject to aggravation by emotional factors.
Depressed patients are generally less demonstrative than patients with extreme anxiety and conversion disorders and
malingerers, and it is easier to overlook the non-organic basis for their problem.

Fig. 33.12 Important primary malignancies to the spine. Note the difference between sclerotic and osteolytic
metastases; multiple myeloma also causes osteoporotic lesions

Typical profile
Age:

Any age, typical 30-50

General Practice, Chapter 33

History of injury:
Yesusually remote in the past; often motor vehicle accident
Site and radiation:
Low back, central, often bilateral
May radiate to leg (may be bizarre pattern)
Type of pain:
Variable, usually deep ache or burning
Continuousacute or chronic
Aggravation:
Work, especially housework, or manual work
Worse in mornings on waking
Stress and worry
Relief:
Better in the evenings and on retiring
Associations:
Headache
Fatigue, exhaustion, tiredness
Insomnia, inability to cope
Other aches and pains
Physical examination:
Diffuse tenderness to palpation
Possible hyperactive reflexes
This profile is typical of the depressed patient with back pain. A trial of antidepressants for a minimum of 3 weeks is
recommended and quite often a positive response with relief of backache eventuates.
Failure to consider psychological factors in the assessment of low back pain may lead to serious errors in diagnosis and
management. Each instance of back pain poses a stimulating exercise in differential diagnosis. A comparison of organic and
non-organic features is presented in Table 33.6 .
Table 33.6 Comparison of general clinical features of organic and non -organic based low back
pain 6 7
Organic disorders

Non -organic disorders

Symptoms
Presentation

Appropriate

Often dramatic

Pain

Localised

Pain radiation

Appropriate
Buttock, specific sites

Bilateral/diffuse
Sacrococcygeal
Inappropriate
Front of leg/whole leg

Time pattern

Pain-free times

Paraesthesia/anaesthesia

Dermatomal
Points with finger

Response to treatment

Variable

Constant, acute or chronic

Delayed benefit

General Practice, Chapter 33

M
a
y
b
e

whole leg Shows

with hands
Patient often refuses treatment
Initial improvement (often dramatic) then deterioration (usually within

24 hours)
Signs
Observation

Appropriate
Guarded

Overreactive under scrutiny

Inconsistent

Tenderness

Localised to appropriate
level
Consistent

Often inappropriate level

Withdraws from probing finger
Inconsistent

Spatial tenderness
(Magnuson)

Often all movements affected

Active movements

Specific movements
affected

Axial loading test

No back pain (usually)

Back pain

SLR 'distraction' test

Consistent

Inconsistent

Sensation

Dermatomal

Non-anatomical 'sock' or 'stocking'

Motor

Appropriate myotome

Reflexes

Appropriate
May be depressed

Muscle groups, e.g. leg 'collapses'

Brisk hyperactive

Assessment of the pain demands a full understanding of the patient. One must be aware of his or her type of work, recreation,
successes and failures; and one must relate this information to the degree of incapacity attributed to the back pain.
Patients with psychogenic back pain, especially the very anxious, tend to overemphasise their problem. They are usually
demonstrative, the hands being used to point out various painful areas almost without prompting. There is diffuse tenderness
even to the slightest touch and the physical disability is out of proportion to the alleged symptoms. The pain distribution is often
atypical of any dermatome and the reflexes are almost always hyperactive. It must be remembered that patients with
psychogenic back painfor example, depression and conversion disordersdo certainly experience back pain and do not fall
for the traps set for the malingerer.

Tests for non -organic back pain

Several tests are useful in differentiating between organic and non-organic back pain (e.g. that caused by depression or
complained of by a known malingerer).
Magnuson's method (the 'migratory pointing' test)
1. Request the patient to point to the painful sites.
2. Palpate these areas of tenderness on two occasions separated by an interval of several minutes, and compare the sites.
Between the two tests divert the patient's attention from his or her back by another examination.
Paradoxical straight leg raising test
Perform the usual straight leg raising test. The patient might manage a limited elevation, for example 30. Keep the degree in
mind. Ask the patient to sit up and swing the leg over the end of the couch. Distract attention with another test or some
question, and then attempt to lift the straight leg to the same level achieved on the first occasion. If it is possible, then the
patient's response is inconsistent.
Burn's 'kneeling on a stool' test
1. Ask the patient to kneel on a low stool, lean over and try to touch the floor.
2. The person with non-organic back pain will usually refuse on the grounds that it would cause great pain or that he or
she might overbalance in the attempt.
Patients with even a severely herniated disc usually manage the task to some degree.
The axial loading test
1. Place your hands over the patient's head and press firmly downward (Fig 33.13 ).
2. This will cause no discomfort to (most) patients with organic back pain.

Fig. 33.13 The axial loading test

Treatment options for back pain

General aspects of management

Relative rest
For acutely painful back problems 2 days strict rest lying on a firm surface is optimal treatment. 8 Resting for longer than 3
days does not produce any significant healing.
Patient education
Appropriate educational material leads to a clear insight into the causes and aggravation of the back disorder plus coping
strategies.
Exercises
An early graduated exercise program as soon as the attack phase settles has been shown to promote healing and prevent
relapses. 9 All forms of exercise (extension, flexion and isometric) appear to be equally effective with extension exercises being
favoured for a discogenic problem and flexion exercises for most dysfunctional problems (see Figs 33.14a , b ). Swimming is an
excellent exercise for back disorders.

Fig. 33.14 Examples of exercises for low back pain: (a) rotation exercise; (b) flexion exercise

Pharmacological agents

Basic analgesics
Analgesics such as aspirin, paracetamol and codeine plus paracetomol (acetaminophen) should be used for pain relief.
NSAIDs
These are useful where there is clinical evidence of inflammation, especially with the spondyloarthropathies, severe
spondylosis and in acute radicular pain, to counter the irritation on the nerve root. NSAIDs should not be used for mechanical
dysfunction.
Antiepileptic drugs
These have been helpful in controlling acute radicular pain subject to repetitive bursts of lightning-like pains. Examples include
carbamazepine and clonazepam.
Antidepressants

These have been used with success in the treatment of chronic back pain (especially without demonstrable pathology) and in
patients with depression and associated back pain.

Injection techniques

Trigger point injection. This may be effective for relatively isolated points using 5-8 mL of local anaesthetic.
Chymopapain. This enzyme has been advocated for the treatment of acute nuclear herniation that is still intact. The indications
are similar for surgical discectomy. However, its use is controversial.
Facet joint injection. Corticosteroid injection under radio image intensification is widely used in some clinics. The procedure is
delicate and expertise is required. Some good results are obtained.
Epidural injections. Injections of local anaesthetic with or without corticosteroids are used, especially for nerve root pain. The
author favours the caudal (trans-sacral) epidural injection for persistent sciatica using 15 mL of half-strength local anaesthetic
only, e.g. 0.25% bupivacaine (Fig 33.15 ).

Fig. 33.15 Caudal epidural injection: the needle should lie free in the space and be well clear of the dural sac

Physical therapy

Active exercises are the best form of physical therapy (Fig 33.14 a, b ).
Spinal mobilisation is a gentle, repetitive, rhythmic movement within the range of movement of the joint. It is safe and quite
effective (Fig 33.16 ).

Fig. 33.16 Lumbar spinal mobilisation: illustration of the effective forces

involved
REPRODUCED FROM C. KENNA AND J. MURTAGH, BACK PAIN AND SPINAL MANIPULATION, BUTTERWORTHS,
SYDNEY, 1989, WITH PERMISSION
Spinal manipulation is a high velocity thrust at the end range of the joint. It is generally more effective and produces a faster
response but requires accurate diagnosis and greater skill. It is extremely effective for uncomplicated persistent dysfunctional
low back pain (without radicular pain) and, together with exercises, is the treatment of choice (Fig 33.17 ). 10 11 12

Fig. 33.17 Lumbar spinal mobilisation (for left-sided pain): illustration of the specific technique for the L4-L5 level with arrows
indicating the direction of applied force
REPRODUCED FROM C. KENNA AND J. MURTAGH, BACK PAIN AND SPINAL MANIPULATION, BUTTERWORTHS,
SYDNEY, 1989, WITH PERMISSION

Other treatments

The following treatments have a significant role in the management of back pain, although clearcut evidence for the efficacy of
these modalities is still lacking.
hydrotherapy
traction
transcutaneous electrical nerve stimulation (TENS)
facet joint injection
posterior nerve root (medial branch) blocks with or without denervation (by cryotherapy or radiofrequency)
deep friction massage (in conjunction with mobilisation and manipulation)
acupuncture
pain clinic (if unresponsive to initial treatments)
biofeedback
gravitational methods (home therapy)

Management guidelines for lumbosacral

disorders (summary)
The management of 'mechanical' back pain depends on the cause. Since most of the problems are mechanical and there is a
tendency to natural resolution, conservative management is quite appropriate. The rule is: 'if patients with uncomplicated back
pain receive no treatment, one-third will get better within 1 week and by 3 weeks almost all the rest of the other two-thirds are
better'. 13 Practitioners should have a clear-cut management plan with a firm, precise, reassuring and conservative clinical
approach.
The problems can be categorised into general conditions for which the summarised treatment protocols are outlined.
Acute pain = pain less than 2 weeks.
Subacute pain = 2-12 weeks.
Chronic pain = greater than 3 months.

Acute low back painno spasm

The common problem of low back pain caused by facet joint dysfunction and/or limited disc disruption usually responds well to
the following treatment. The typical patient is aged 20-55 years, is well and has no radiation of pain below the knee. 14
back education program
encouragement of normal daily activities according to degree of comfort
regular non-opioid analgesics, e.g. paracetamol
exercise program (when exercises do not aggravate), swimming (if feasible)
physical therapy: stretching of affected segment, muscle energy therapy, spinal mobilisation or manipulation (if no
contraindication on first visit) 10 12 14
review in about 5 days (probably best time for physical therapy)
no investigation needed initially
Most of these patients can expect to be relatively pain free in 14 days and can return to work early (some may not miss work
and this should be encouraged). The evidence concerning spinal manipulation is that it reduces the period of disability.
Note: NSAIDs are not usually recommended. They can be used for 10-14 days if evidence of inflammation.

Acute low back pain (only) with spasm

back education program

strict rest lying on a firm surface for 2 days 8 (keep the spine as straight as possible)
regular simple analgesics with review as the patient mobilises
cold or hot compresses to the painful area
simple mobilisation exercises as tolerated
muscle energy therapy
consider trigger point injection of local anaesthetic
relaxant, e.g. diazepam (if appropriate) for 4-5 days
review in 3-5 days
When the acute phase settles, treat as for uncomplicated low back pain.

Sciatica with or without low back pain

Sciatica is a more complex and protracted problem to treat, but most cases will gradually settle within 12 weeks.
Acute
strict bed rest for 2-3 days (keep the spine straightavoid sitting in soft chairs and for long periods)
regular non-opioid analgesics with review as the patient mobilises
NSAIDs for 10-14 days, then cease and review
back education program
resume normal activities as soon as possible exercises
straight leg raising exercises to pain tolerance swimming
traction (a trial of intermittent traction is worthwhile)
weekly or 2 weekly follow up
Chronic
continue physiotherapy with possible traction
reassurance that problem will subside (assuming no severe neurological defects)
consider epidural anaesthesia (if slow response)
General guidelines for surgical intervention
bladder/bowel disturbance
progressive motor disturbance, e.g. significant foot drop, weakness in quadriceps
severe prolonged pain
failure of conservative treatment with persistent pain (problem of permanent nerve damage)
Note: An important controlled prospective study comparing surgical and conservative treatment in patients with sciatica over 10
years showed that there was significant relief of sciatica in the surgical group for 1 to 2 years but not beyond that time. At 10
years both groups had the same outcome including neurological deficits. 15

Chronic back pain

The basic management of the patient with uncomplicated chronic back pain should follow the following guidelines:
back education program and ongoing support
encouragement of normal activity
exercise program
swimming
analgesics, e.g. paracetamol
NSAIDs for 10-14 days (only if inflammation, i.e. pain at restrelieved by activity)
trial of mobilisation or manipulation (at least 3 treatments)if no contraindications 11 12
consider trigger point injection
a multidisciplinary team approach is recommended

Prevention of further back pain

Patients should be informed that an ongoing back care program should give them an excellent outlook. Prevention includes:
education about back care, including a good layperson's reference
golden rules to live by: how to lift, sit, bend, play sport and so on
an exercise program: a tailor-made program for the patient
posture and movement training, e.g.

the Alexander technique 16

the Feldenkrais technique 17

When to refer
Urgent referral

Myelopathy, especially acute cauda equina compression syndrome

Severe radiculopathy with neurologic deficit
Spinal fractures

Other referrals
Neoplasia or infection
Undiagnosed back pain
Paget's disease
Continuing pain of 3 months duration without a clearly definable cause

Practice tips
Back pain that is related to posture, aggravated by movement and sitting, and relieved by lying down is due to vertebral
dysfunction, especially a disc disruption.
The pain from most disc lesions is generally relieved by rest.
Plain X-rays are of limited use, especially in younger patients, and may appear normal in disc prolapse.
Remember the possibility of depression as a cause of back pain; if suspected, consider a trial of antidepressants.
If back pain persists, possibly worse during bed rest at night, consider malignant disease, depressive illness or other
systemic diseases.
Pain that is worse on standing and walking, but relieved by sitting, is probably caused by spondylolisthesis.
If pain and stiffness is present on waking and lasts longer than 30 minutes upon activity, consider inflammation.
Avoid using strong analgesics (especially opioids) in any chronic non-malignant pain state.
Bilateral back pain is more typical of systemic diseases, while unilateral pain typifies mechanical causes.
Back pain at rest and morning stiffness in a young person demand careful investigation: consider inflammation such as
ankylosing spondylitis and Reiter's disease.
A disc lesion of L5-S1 can involve both L5 and S1 roots. However, combined L5 and S1 root lesions should still be
regarded with suspicion, e.g. consider malignancy.
A large central disc protrusion can cause bladder symptoms, either incontinence or retention.
Low back pain of very sudden onset with localised spasm and protective lateral deviation may indicate a facet joint
syndrome.
The T12-L1 and L1-L2 discs are the groin pain discs.
The L4-L5 disc is the back pain disc.
The L5-S1 disc is the leg pain disc.
Severe limitation of SLR (especially to less than 30) indicates lumbar disc prolapse.
A preventive program for dysfunctional back pain based on back care awareness and exercises is mandatory advice.
Remember that most back problems resolve within a few weeks, so avoid overtreatment.

References
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9. Kendall PH, Jenkins SM. Exercises for backache: A double blind controlled study. Physiotherapy, 1968; 54:154-157.
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Feldenkrais M. Awareness through movement. New York: Harper and Row, 1972.