Fast Facts: Low Back Pain

146 Pages·4.671 MB·English

by  Borenstein D., Calin A.

© 2012 Health Press Ltd. www.fastfacts.com
Fast Facts
Fast Facts:
Low Back Pain
Second edition
David G Borenstein MD
Clinical Professor of Medicine
The George Washington University Medical Center
Arthritis and Rheumatism Associates
Washington, DC, USA
Andrei Calin MD FRCP
Consultant Rheumatologist
The Bath Clinic, Combe Down
Bath, UK
Declaration of Independence
This book is as balanced and as practical as we can make it.
Ideas for improvement are always welcome: [email protected]
© 2012 Health Press Ltd. www.fastfacts.com
Fast Facts: Low Back Pain
First published 2003; reprinted with revisions 2006
Second edition February 2012
Text © 2012 David G Borenstein, Andrei Calin
© 2012 in this edition Health Press Limited
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ISBN 978-1-908541-10-9
Borenstein, DG (David)
Fast Facts: Low Back Pain/
David G Borenstein, Andrei Calin
Medical illustrations by Dee McLean, London, UK.
Typesetting and page layout by Zed, Oxford, UK.
Printed in China with Xpedient Print Services.
© 2012 Health Press Ltd. www.fastfacts.com
Glossary 4
Introduction 9
List of therapeutic exercises and protective maneuvers 10
Clinical assessment 11
Investigations 35
Causes of low back pain 46
Conservative management 73
Injections and surgery 117
Future prospects 127
Back maintenance exercises 129
Useful addresses 137
Index 140
© 2012 Health Press Ltd. www.fastfacts.com
Glossary
Acupuncture: The Chinese practice of in regions subject to friction, such as
stimulating particular locations along a bony prominence where a tendon
the body’s meridians to free the flow passes over the bone
of energy (qi). Acupressure is another
Ischial gluteal bursa lies beneath
form of this therapy using hand
the gluteus maximus muscle and the
pressure instead of needle punctures
inferior aspect of the ischium
Allopathy: The use of conventional
Subgluteus maximus trochanteric bursa
medical and surgical treatments
lies just beneath the gluteus maximus
Ankylosing spondylitis (AS): An muscle over the inferior slope of the
inflammatory arthritis of the spine greater trochanter
associated with pain and stiffness that
Bursitis: Inflammation of a bursa
can result in the fusion (ankylosis) of
the spinal joints and ligaments Cauda equina: A bundle of nerves,
resembling the tail of a horse, that
Annulus fibrosus: The strong, fibrous
descends vertically from the lumbar,
outer portion of the intervertebral disc;
sacral and coccygeal spinal nerves
also spelled anulus fibrosus
Claudication: A cramping, burning,
Anterolisthesis: Forward slippage
aching sensation in limbs brought on
of one vertebra (or other skeletal
by activity that decreases blood flow to
structure) over another
the nerves (neurogenic) or the muscles
α-receptors: Large nerve fibers in the (vascular) supplying the extremity
peripheral nervous system that serve
Coccygodynia (or coccydynia):
as mechanoreceptors to transmit
Persistent pain in the region of the
proprioception and pain
coccyx
αβ-receptors: Somewhat smaller fibers
Conus medullaris: The cone-shaped
than α-receptors that, like them,
tapering of the lower terminal portion
are mechanoreceptors and transmit
of the spinal cord
proprioception and vibration
Diathermy: Shortwave or microwave
Arthritis: Inflammation of a joint
diathermy is the therapeutic
Bone morphogenetic protein application of high-frequency currents
(BMP): A substance that is injected for musculoskeletal pain control
percutaneously into a bony structure
Dimples of Venus: Small, natural
and in particular into the vertebral
indentations or pits overlying the
body to stimulate bone formation and
posterior superior iliac spine, which is
fracture repair
a region that is commonly associated
Bursa: A closed envelope-like sac lined with referred pain in the lumbosacral
with synovial membrane containing region
4 a thin layer of fluid. These are found
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Glossary
Disc: The cylinder-like structure, Foot drop gait: The foot drop
composed of a gel center (nucleus (steppage) gait is caused by weakness
pulposus) and a fibrous outer covering of dorsiflexion of the foot causing the
(annulus fibrosus), that acts as a shock foot to drop when the leg is raised and
absorber and a universal joint in the to slap down when walking. In the
spine case of sciatica, this is a consequence of
primarily L5 nerve root compression
DISH: Diffuse idiopathic skeletal
hyperostosis. Typically manifested by Fusion: A surgical procedure that
thickening of the anterior longitudinal unites two or more vertebrae with bone
ligament bridging its intervertebral graft, with or without metal supports,
portion to immobilize a portion of the spine.
(Anterior, posterior or posterior lateral
Dysesthesia: Abnormal sensation such
interbody spinal fusion are procedures
as burning or itching, produced by a
to replace a disc space with bone graft
normal stimulus
from the front, back, or back and side
Dystrophy: Any disorder causing of the spinal column, respectively.)
weakness or atrophy, most commonly
Gadolinium: The contrast material
of the muscles
utilized with magnetic resonance
FABERE: Flexion, Abduction, External imaging (MRI) to identify tissues with
Rotation, Extension. Range of motion increased blood flow. Gadolinium-
to test for hip joint pathology enhanced MRI is used to identify
tumors, postsurgical scar tissue and
Facet/zygapophyseal joint: Four small
infections
joints, the ligaments of which connect
the backs of the vertebrae, serving as Interarticular lamina: Interarticular
hinges that permit spinal movement; means between two joints or
they are susceptible to age- and injury- articulating surfaces. A lamina is a thin,
related deterioration and osteoarthritis flat layer or membrane, specifically the
flattened region of either side of the
Facetectomy: A surgical procedure to
arch of a vertebra
remove a portion of the facet joint to
relieve neural compression in the root Lasègue sign or test: With the patient
canal supine with knees flexed and feet on the
table, the affected leg is straightened
Fibromyalgia: A generalized idiopathic
and raised to see if this produces sciatic
non-inflammatory muscle disorder
nerve irritation. A crossed Lasègue test
associated with symmetrical areas of
is performed on the opposite leg to
focal tenderness in the cervical, dorsal,
see if raising of the straight leg on the
lumbar and lower extremities. The
asymptomatic side produces symptoms
condition is often associated with
on the symptomatic side, and is a
depression, irritable bowel syndrome,
more precise measure of sciatic nerve
migraine and tension headache and may
irritability
be associated with other connective
tissue disorders
5
© 2012 Health Press Ltd. www.fastfacts.com
Fast Facts: Low Back Pain
Litigation neurosis: Pain and related Osteochondromatosis: Benign osseous
symptomatology that is intensified and/or cartilaginous bodies typically
by the legal process. This includes occur near the end of bony (vertebral)
the potential perpetuation and and articular structures. Hereditary
intensification of pain syndromes osteochondromatosis is associated with
and disability, either consciously or multiple osteochondromata which more
otherwise, as a consequence of the commonly than not are asymptomatic
psychosomatic stress of a legal process,
Osteoporosis: A disorder associated
and the potential for secondary gain
with decreased calcium in bone. Bone
from prolonged or intensified disability
calcium deficiency is associated with
Lordosis: The forward curve located in increased risk of fracture in the spine
the low back and neck (vertebrae), hip and wrist
Manual muscle test: The muscle Oswestry scale: A simple questionnaire
strength of various muscle groups on low back pain used to measure the
is determined by manual resistance extent of disability as a consequence
applied at specific anatomic regions. of pain
Typically, muscle testing is performed
Piriformis syndrome: Sciatic pain
on the affected side and then the results
caused by compression of the sciatic
are compared with those on the normal
nerve or a branch of the sciatic nerve
side
by the piriformis muscle, owing to
Meniscoid: Pertaining to a crescent post-traumatic scarring, congenital
(meniscus)-shaped fold of intra-articular malformation or focal referred
facet joint synovium piriformis muscle spasm
Neurogenic claudication: Lameness or PMMA: Polymethyl methacrylate, a
limping as a consequence of impairment bone-cementing substance administered
of nerve impulses, particularly as a percutaneously into the vertebral
consequence of spinal or nerve root body in the treatment of compression
canal stenosis fractures
Nociceptor: A peripheral neural Radiculopathy: Disease of the roots
structure that is capable of generating or origins of a spinal nerve after it has
nerve impulses in response to painful or emerged from the spinal canal
injurious stimuli
Reactive arthritis: Inflammatory
Nucleus pulposus: The soft, central arthritis characterized by joint
portion of the intervertebral disc inflammation associated with
spondylitis, urethritis, diarrhea,
Osteoarthritis: The most common
conjunctivitis and dermatitis
form of arthritis. The lumbar spine is
a frequent location for this pathology. Rheumatism: Any ache or pain in the
Osteophytes are bony projections that musculoskeletal system. Arthritis is a
form on spinal joints in response to the special form of rheumatism
changes of osteoarthritis
RICE: Rest, ice, corset (brace) and
6 exercise
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Glossary
Rolfing: A technique also called Spina bifida: Developmental anomaly
‘structural integration’ by its inventor of the posterior spinal column through
Dr Ida Rolf. The concept is deep fascial which spinal membranes and, rarely, the
massage and often painful manipulation spinal cord may protrude
with the purpose of correcting
Spondylolisthesis: Weakening of a stress
contractures and malalignment
fracture in a vertebral body such that
Romberg test: Standard neurological it is displaced forwards or backwards
test for balance dysfunction, (retrolisthesis) relative to the vertebra
particularly in patients with impaired below
sensation in the feet due to nerve
Spondylolysis: A unilateral or bilateral
compression or disease. The patient
congenital defect or stress fracture in
stands with their feet close together and
the vertebral body, with no slippage of
closes their eyes. If the test is positive,
the vertebrae
the patient has no gross imbalance
with the eyes open but sways or loses Spondylosis: A degenerative disease of
balance when the eyes are closed the discs and facet joints of the spine
Scheuermann’s disease: Adolescent Substance P: Member of a group
dorsal epiphyseal aseptic necrosis of peptide neurotransmitters highly
of the endplates of vertebral bodies concentrated in the dorsal horn
(osteochondritis deformans) where the dorsal horn nociceptors
are stimulated by pain. P stands for
Schmorl’s node: Indentation of the
pain, and in addition to transmission
superior or inferior bony endplate
of painful stimuli it may, along with
or flat surface of a vertebra due to a
other chemical mediators, contribute
protrusion or herniation of disc tissue
to associated soft-tissue inflammatory
Sciatic scoliosis: A deviation of the responses
trunk and hence the vertebrae to
Tender point: A focal area of tenderness
minimize pressure from the protrusion
on pressure over a bursal area,
of a disc on a nerve root. Scoliosis
tendinous insertion or joint
may be either to the right or the left
depending on the position of the disc TENS: Transcutaneous electrical nerve
protrusion and adjacent traumatized stimulation
nerve root Trigger point: A focal area of
Sclerotomes: The cluster of cells that are accentuated muscle tenderness
the primordial embryonic structures of VAS: Visual analog scale. A simple
the vertebral-related tissues instrument for pain and function
SEP: Sensory evoked potentials. Used in monitoring
electrodiagnosis Vertebral pars articularis: Posterior
SIP: Sickness Impact Profile. A measure plate of bone that connects the vertebral
of the effects of an illness on discomfort body in front with the vertebral joints
and quality of life behind
7
© 2012 Health Press Ltd. www.fastfacts.com
© 2012 Health Press Ltd. www.fastfacts.com
Introduction
The symptom of low back pain is second only to the common cold, the
most common affliction of mankind. In 70% of cases, low back pain has
no obvious etiology or pathogenesis. So what makes the back hurt?
Most back pain is actually muscular or ligamentous in origin rather
than skeletal. These soft tissue structures are located deep inside the
body, so although radiography including MRI and CT scans can
pinpoint anatomic anomalies in skeletal structures, such investigations
cannot identify the specific causes of pain. The same degree of injury
in a gastrocnemius muscle or distal interphalangeal joint would not
generate the same degree of mystery.
Listening to the patient gives the physician the best opportunity to
find the cause of low back pain. A thoughtful history and physical
examination is essential in developing a diagnostic plan to identify the
cause of symptoms and put in place a therapeutic regimen to relieve
the pain.
Serendipitously, most of the structures of the musculoskeletal
system, whether in the lumbar spine or in the appendicular skeleton,
respond to a set of non-surgical therapies that encourage the patient
toward a gradual return to normal activity. Patients need to be
encouraged to get out of bed and move despite the presence of pain, as
prolonged bed rest deconditions the spinal musculature and can
prolong recovery. A regimen of increasingly intense range of motion
and strengthening exercises offers improved stability of the lumbar
spine, while drug therapy facilitates increased movement and
resumption of normal activities. Drug regimens may include simple
analgesics, non-steroidal anti-inflammatory drugs (NSAIDs) and
muscle relaxants, and can hasten a return to function. Also reassuring
is the knowledge that the vast majority of episodes of low back pain
will resolve without radiographic or laboratory evaluation.
Fast Facts: Low Back Pain describes the clinical assessment and
causes of low back pain, and aims to provide guidance on making
appropriate therapeutic choices to gain optimal relief for each
individual back pain patient with the least invasive therapy. This fully 9
© 2012 Health Press Ltd. www.fastfacts.com