ABC of Rheumatology

LOW BACK PAIN

J

R Jenner, M Barry

Low back pain is a major and increasing cause of disability in the

United Kingdom. In 1993, 1 1% of the population reported that their
activities had been restricted by back pain within the past four weeks.
Satisfactory treatment of low back pain depends on an accurate
diagnosis, but finding the cause for low back pain is often not possible
because of difficulties in localising the source of the pain.

Radiation of pain after injection of 0.1-0.3 ml 6%

hypertronic saline into sacrospinal muscle (yellow)
and multifidus muscle (red). Note similarity to
distribution of sciatic pain.

In 1938 it was shown that many structures in the lumbar spine,

when irritated, give rise to pain with very similar distributions. Despite
technological advances the identification of an exact source of pain or
an exact pathological diagnosis often remains elusive. It is important
for doctors and patients to understand that the diagnosis of low back
pain therefore depends on identifying some clinical syndromes on the
basis of a patient's history and examination, with appropriate
investigations to exclude serious pathology and support the clinical
diagnosis. If this principle is misunderstood the result can be a
misleading diagnosis and inappropriate treatment.

Back pain syndromes

Clinical feature of back pain due to mechanical
cause
History ofpain
Sudden onset
Previous recurrent episodes
Unilateral symptoms
Eased by rest

Examination
Asymmetrical lumbar movements
Asymmetrical straight leg raise or
Femoral stretch test
Uniradicular neurological signs

Functional distribution of lumbar nerve roots

Nerve root
L2

Muscle weakness
Hip flexion

L3
L4

Hip adduction
Knee extension
Knee extension

L5

Foot dorsiflexion
Foot inversion
Great toe dorsiflexion

Si

Knee flexion
Foot plantar flexion
Knee flexion

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Reflex changes

Sensation
Front of thigh

Knee
Knee

Inner knee
Inner shin

Outer shin
Dorsum of foot
Ankle

Lateral border of
foot and sole

Mechanical back pain or prolapsed lumbar disc

It is vital to distinguish mechanical causes
of back pain from other causes as patients
with mechanical causes are likely to respond
to physical forms of treatment. The symptoms
and signs of mechanical back pain differ
considerably from those associated with back
pain caused by underlying systemic disease.
Most acute episodes of low back pain arise
in the triad of joints that allow one vertebra to
articulate with another (that is, the
intervertebral disc anteriorly and the two facet
joints posteriorly). The commonest primary
pathology is degeneration of the nucleus
pulposus in the lumbar disc. The disc itself is
often not the source of pain; this may arise in
other structures, such as the facet joints or the
many surrounding ligaments, that come under
stress as a result of the disc pathology. It is
important that doctors explain this to patients
so that they understand why just removing
their disc will not always cure the pain.
True sciatica, with pain and numbness in
the distribution of a single lumbar nerve root,
may be accompanied by sensory, motor, or
reflex changes and is most commonly caused
by a posterolateral protrusion of a disc
impinging on the nerve root.
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Clinical feature of back pain due to systemic cause

History of pain
Gradual onset and progressive
Symmetrical or alternating distribution
Worse with rest
Disturbs sleep
Morning stiffness for over 30 minutes

Examination
Stiff or rigid spine
Symmetrical restriction of lumbar
movements

Symmetrical restriction of straight

leg raising
Multiradicular neurological signs

Clinical feature of back pain due to spinal stenosis

History of pain
Leg pain on walking
Neurogenic claudication
Eased by leaning forward or sitting
but not standing still
At ages over 60

Examination
Stiff spine
Normal straight leg raising
Normal peripheral pulses
Nerve root signs appear late

Common predisposing factors for postural back pain

Postural fault
Flat lordosis

Exaggerated lordosis
Scoliosis

Systemic back pain

As well as back pain, there may be
associated systemic features such as weight
loss, pyrexia, and general malaise.
Examination should include the testicles and
prostate in male patients and the breasts in
female patients as tumours in the sex organs
metastasise preferentially to the skeleton.

Cause
Seating-car seats, low sofas and armchairs
Beds-old, soft beds
Household tasks-ironing, vacuuming, low work
surfaces
Bending-gardening, poor lifting technique
Footwear-high heeled shoes
Unequal leg length-congenital, old leg fracture,
running on cambered roads

Ankylosing spondylitis
This can be difficult to distinguish from
mechanical pain, especially in the early stages.
However, morning stiffness for more than 30
minutes, pain that alternates from side to side
of the lumbar spine (a symptom rarely
reported in any other cause of back pain),
sternocostal pain, and chest expansion of less
than 5 cm suggest ankylosing spondylitis.
Education, anti-inflammatory drugs, and
exercise are the mainstays of treatment.
Special and lateral recess stenosis
Spinal stenosis is common in people aged
over 60 and is often not considered in the
diagnosis of back and leg pain. It is caused by
a narrowing of the spinal canal or
intervertebral foramen resulting from
degenerative disease. The symptoms should
be compared with those of peripheral vascular
disease (in this condition the pain eases when
a patient stands still and upright). Computed
tomography is the investigation of choice. In
severe cases surgery may be required to
decompress the stenotic area.
Postural pain
Bad posture is probably the commonest
cause of persistent back pain. The spine
depends for its strength on maintaining a
series of arches. Sitting and leaning forward
tend to flatten the arch or lordosis, while
wearing high heels tends to exaggerate the
arch (hydcerlordosis or sway back).

Unequal leg length is easily overlooked; 2% of the normal adult

population have differences in leg length of at least 2 cm, and such
people are more prone to back pain. This can be diagnosed in the
surgery by placing wooden blocks of different thicknesses under the
short leg and checking the pelvic level visually. Up to a third of patients
with back pain and differences in leg length of more than 2 cm will
gain relief with a heel raise.
Advice on correcting bad postural habits may be difficult for a
patient to accept and may need to be reinforced through programmes
such as a back school.

Ideal posture for working at a computer terminal.

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Referred pain
Pathology in organs in the posterior part of the abdominal cavity
may refer pain to the back-for example, aortic aneurysm or enlarged
lymph nodes. Examination of the abdomen is vital for exclusion of
these diagnoses.

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Psychological aspects
Symptoms and signs of chronic low back pain in
patients with physical disease and abnormal illness
behaviour
Physical disease
Localised
Tenderness
No lumbar pain
Axial loading
Simulated rotation No lumbar pain
Straight leg raising Limited despite
distraction
Dermatomal
Loss of sensation
Myotomal
Loss of power
General response Appropriate pain

Abnormal illness behaviour

Superficial, widespread, non-anatomical
Lumbar pain
Lumbar pain
Improves with distraction
Regional
Regional, jerky, giving way
Overt pain response

Some patients' symptoms seem to be

exaggerated and disproportionate to the
physical signs. A history of involvement in
medicolegal proceedings may be obtained.
While the possibility of missed pathology
must always be borne in mind, examination
may reveal inappropriate physical signs.

If a patient has been off work for many months the prognosis is
poor; the longer people are off work with low back pain the less likely
they are to work again. The reasons for this are unclear but have as
much to do with psychological processes as organic pathology. The
concept of learned illness behaviour is popular and may explain the

persistence of symptoms of chronic unremitting back pain in patients

in whom an organic cause cannot be found. This syndrome probably
has links with other syndromes such as fibromyalgia and chronic
fatigue syndrome.
because of back pain.

Investigations

Radiographic evidence of disc infection

or vertebral collapse occurs late in the
course of a disease, and blood tests are

probably a better initial screen for

systemic disease

Computed tomogram showing malignant

infiltration of lower thoracic vertebra.

Blood tests
A blood count, erythrocyte, sedimentation rate, and biochemical
screen (calcium, phosphate, and alkaline phosphate) should be
performed when a systemic cause for back pain is suspected. Testing
for prostate specific antigen is useful if prostatic malignancy is
suspected.

Radiological investigation
Plain radiographs of the lumbar spine are rarely helpful, particularly
when taken early in the course of an episode of back pain, and should
be performed only if systemic disease is suspected.
Bone scans are helpful in cases of suspected malignancy and may be
abnormal in metabolic bone disease and ankylosing spondylitis.
Other imaging techniques
These should be performed only when initial conservative treatment
has failed and surgery is being considered.
Computed tomography is the method of choice for showing bony
abnormalities such as bone destruction due to malignancy, infection,
or spinal canal stenosis. It can also help in revealing lesions of discs
and other soft tissue.
Magnetic resonance imaging is still not widely available but is the
investigation of choice for showing lesions of soft tissues, including
lumbar disc lesions and tumours.
Radiculography was until recently the standard method for
investigating lumbar disc lesions. It is now used only when the level of
the lesion is uncertain and magnetic resonance imaging is not available.
Discography is a specialist investigation and may help to identify
patients who would benefit from surgical fusion of the spine.

Electromyography
A segmental electromyograph may help to confirm the presence of
nerve root degeneration if radiological evidence of abnormal anatomy
is

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not conclusive.

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Treatment
Treatment should be given early, with the aim of stopping the
problem from becoming chronic.
Bed rest should be kept to a minimum,
and early mobilisation should be
encouraged

Bed rest
Bed rest has been the main treatment for all forms of acute back
pain for many years, with recommendations varying from a few days to
over six weeks. The few satisfactory trials that have been published
suggest that bed rest for two or three days has the same or greater
benefit than longer periods of rest and that shorter bed rest leads to an
earlier return to work. Slightly longer periods of rest may be justified
for sciatica.

Elements of a back school

Session 1-Principles of anatomy of the spine
Session 2-Applied body mechanics and
posture
Session 3-Ergonomics
Session 4-Relaxation techniques and
exercises

Treatment of low back pain

Patient education and exercise-Reassuring patients, giving them
appropriate information, and advising them on posture and exercise
programmes are important. These measures are most effective when
given as part of a structured programme such as a back school.
Back schools are effective for treating acute back pain. The concept
of back schools was developed in Sweden and is based on a series of
four sessions, each lasting an hour. Treatment is in groups so that
several patients may be treated in one session by a single therapist with
no need for specialist facilities. Patients can also benefit from talking
with fellow sufferers.
Manipulation has been the subject of many studies, with conflicting
results. Manipulation seems to be effective in the first three weeks after
the start of acute back pain and gives quicker relief of pain, but after
three weeks it may have little advantage over natural recovery. The
most effective method is unknown, but physiotherapists, chiropractors,
and osteopaths, who use a variety of techniques, all seem effective.
Manipulation should not be used with patients with sciatica and
evidence of nerve root entrapment as it may make the root lesion
worse.

Treatment of sciatica
pain.

Traction-Continuous or intermittent traction remains a popular

though recent studies

treatment for patients suffering from sciatica,

have not consistently confirmed its benefit.

Interventional techniques for

treating sciatica
Chemonucleolysis-intradiscal injection of
proteolytic enzyme
Percutaneous discectomy-by automated
nucleotome or laser

Microdiscectomy
Conventional discectomy

The sources of the data presented in illustrations are as

follows: J H Kellgren, Clin Sci 1939;4:35-46 for the diagram
of radiation of pain; G Wadell et al, Spine 1983;9:209-13 for
the box of symptoms and signs of physical illness and
abnormal illness behaviour; G Wadell Spine 1987;12:632-44
for the graph of return to work after time off because of back
pain; and J A Mathews et al, BrJ Rheumatol 1987;26:416-23
for the graph of effect of manipulation on acute back pain.
J R Jenner is consultant in rheumatology and
rehabilitation at Department of Rheumatology,
Addenbrooke's NHS Trust, Cambridge, and M Barry is
consultant rheumatologist at Department of
Rheumatology, James Connolly Memorial Hospital,
Dublin, Republic of Ireland.
The ABC of Rheumatology is edited by Michael L
Snaith, senior lecturer in rheumatology at Nether Edge
Hospital, Sheffield.

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Epidural injections of local anaesthetic and depot preparations of

corticosteroid may speed recovery from sciatica. Both the caudal and
lumbar routes ae used. Depot corticosteroid preparations are not
licensed for use in the epidural space, but serious adverse reactions are
rare.

Interventional treatments-For patients with symptoms of sciatica

lasting more than six weeks despite conservative treatment and in
whom the prescence of a disc protrusion is confirmed, surgical or
chemical removal of the nucleus of the disc should be considered. The
success rates for these techniques are 70-80% at one year after
treatment, but the rates tend to fall with time, particularly for some
surgical techniques.
Chronic low back pain
Once back pain has been established for more than a year the
prognosis is poor. Lesions that might be amenable to surgery, such as
disc protrusion or spondylolysis, must be excluded. Patients may be
referred to a pain clinic for local injections of corticosteroid or
cryotherapy to facet joints or sclerosant injections into ligaments, but
the success of these procedures for chronic pain is low.
The main aim of treatment should be to help patients to come to
terms with their pain and to accept that they can do much themselves
to relieve their symptoms. This can be achieved with help from
intensive rehabilitation programmes or "schools for bravery," which
are available in specialist centres. Treatment, carried out either on a
day case basis or as an intensive three to four week inpatient
programme, combined physical and psychological approaches to
managing back pain.
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