Rheumatology

Back Pain

Does this patient have back pain?

Low back pain is among the most common ailments people will encounter in their lifetime, leading to the second most likely cause for doctors visits after the common cold.

It has been calculated that up to 80% of the population will complain of low back pain at some point during their lifetime, with spontaneous resolution within 6 weeks in another 80-90% of the cases. However, chronic low back pain can be a disabling and complicated condition to deal with. Given the complexity of the lumbar spine, deciphering the pathology that is generating a patient’s symptoms can be difficult to identify, and more difficult to treat.

Lumbosacral radiculopathy

Patients affected by lumbosacral radiculopathies generally complain of low back pain with radiating symptoms into the lower limb, usually following a dermatomal distribution pattern associated with the nerve root being affected. Symptoms tend to be unilateral as opposed to the bilateral symptoms found in spinal stenosis.

The frequently affected L5 and S1 nerve roots produce symptoms radiating into the buttock region, down the posterolateral thigh and lower leg, and frequently into the foot. An L5 lesion will frequently cross into the anterior aspect of the lower leg and into the dorsum of the foot, whereas an S1 lesion will remain posterior and lateral into the foot.

Upper lumbar lesions (L2-L4) will generally radiate into the anterior thigh region, with L4 radiculopathies radiating into the anteromedial aspect of the lower leg. Patients may often complain of numbness and tingling in similar distribution patterns associated with affected nerve roots. Additionally, myodermal weakness may be noted, although this may be subtler, and less likely to be reported.

Pain exacerbation may also be noted upon coughing, sneezing, and straining maneuvers.

On physical examination, a thorough and comprehensive neurologic evaluation is essential in identifying a lumbosacral radiculopathy, as well as the likely affected nerve root. A thorough neurologic examination will also help differentiate from other potential diagnoses causing similar pain referral patterns, such as with facet or disc related low back pain. However, each of these neurologic signs has been shown to have a low sensitivity with a relatively high specificity when studied in isolation.

Weakness of lower limb muscles affiliated with certain nerve roots, in conjunction with sensory deficits along dermatomal distribution can help identify a radiculopathy originating from a specific nerve root. Additionally, asymmetrical hyporeflexia on deep tendon reflex testing can aide in pinpointing a lesion (L2-4: patellar tendon reflex, L5: medial hamstring reflex, S1: Achilles tendon reflex). Dural tension testing is also a crucial aspect of the physical examination for lumbosacral radiculopathy.

In upper lumbar injuries (L2-L4), a femoral nerve stretch test (reverse straight leg raise) can be used to evaluate for reproduction of anterior thigh symptoms. Conversely, in lower lumbosacral injuries (L5-S1), Straight Leg Raising Test and Slump Test can be used to stress the affected nerve roots, recreating their radicular complaints.

Although the straight leg raise has generally been used more frequently in practice, the slump test has been shown to be more sensitive with similar specificities in the identification of L5and S1 radiculopathies.

Facet (zygapophyseal) arthropathy

The identification of facet joint pain using conventional history, physical examination, and imaging studies has been proven to be inconsistent and difficult to diagnose. Lumbar facet mediated pain has generally been described as axial low back pain, with referral patterns identified into the groin, posterolateral thigh, and buttock regions.

Patients will frequently complain of exacerbation of pain with standing, as well as transitional movements from sitting to standing positions. However, studies using two-level intra-articular facet blocks to correlate with historic complaints and pain distribution have shown that no consistent subjective data reliably predicts an objective diagnosis of facet joint pain.

Much like subjective complaints, physical exam findings can be inconsistent in identifying facet joint pain. As structures located in the posterior elements of the lumbar spine, many have described a painful response to loading of the facet joints to be associated with facet-mediated pain. Again, studies have shown no consistent data to corroborate any specific physical exam findings to be associated with objectively diagnosed facet mediated low back pain.

Spondylolysis

Although the vast majority of individuals with spondylolysis remain asymptomatic and undetected, this is a frequent culprit in adolescent low back pain, responsible for up to 47% of low back pain in this population. Patients may present complaining of insidious onset of cramping, aching low back pain with referral into the buttock and posterior thigh region being described.

Symptoms may generally be exacerbated with prolonged standing and lumbar extension. Neurologic deficits are generally absent without any associated weakness, numbness, or tingling.

On physical examination, these patients are frequently found to have tenderness in the lumbar paraspinal region, with exacerbation of pain on lumbar hyperextension and a positive “stork test” (one-legged lumbar hyperextension) on the affected side.

Hamstring tightness has been noted to be one of the most common physical exam findings, with popliteal angles greater than 30-45 degrees considered a positive finding in this population. Neurologic evaluation is generally unremarkable with normal motor, sensory, reflexes, and dural tension signs.

Spondylolisthesis

Patients with spondylolisthesis often complain of chronic, axial low back pain, with referral into the posterolateral thighs frequently reported. The presence of neurologic complaints can be variable, but the risk of a superimposed spinal stenosis is high due to narrowing of the spinal canal from translation of the vertebral segments.

These patients may complain of radicular pain with associated numbness and tingling into bilateral lower limbs, with reports of neurogenic claudication upon ambulation. Radicular symptoms may follow the L4 and L5 nerve root distributions into the lower limbs, as these are the roots most likely to be affected.

Symptoms may be relieved with rest as well as maintaining a forward flexed position (shopping cart sign). In more advanced cases, patients may report associated bowel and bladder incontinence.

On physical examination, physicians may notice a step-off while palpating the lumbar spinal processes, indicating a slippage of the vertebral segments. Patients may complain of paraspinal tenderness upon palpation.

Neurologic examination may be variable depending on presence and extent of spinal stenosis, with diminished motor strength, sensation, and deep tendon reflexes present.

Spinal stenosis

Spinal stenosis results from compression of the nerve roots lying within the spinal canal due to central canal narrowing. Subsequently, patients often complain of symptoms associated with nerve root compression or irritation, leading to radiating pain, numbness, tingling, or weakness in the lower limbs.

Symptoms are frequently present in the L4 and L5 distribution, as these are the nerve roots most commonly affected. Unlike lumbar radiculopathy, which is generally a unilateral process associated with an isolated nerve root impingement, patients with spinal stenosis complain of bilateral lower limb complaints.

Patients frequently report exacerbation of pain with lumbar extension, as this further compromises the area within the spinal canal. This is particularly evident during ambulation and walking down stairs or down a hill, which places patients in increased lumbar extension. This is frequently called neurogenic claudication.

Conversely, alleviation of radiating symptoms can be elicited with opening the canal through lumbar flexion. Patients may report increased walking tolerance while leaning on a walker or shopping cart, leading to a positive “shopping cart sign”. They may also complain of axial low back pain, which may be due to concomitant degenerative spondylolisthesis, degenerative disc disease, or facet arthropathy leading to spinal stenosis. In the presence of cauda equina syndrome, patients may also report associated bowel or bladder incontinence.

On physical examination, patients may be noted to stand and walk in a forward flexed position, as this is their desired alignment for symptomatic relief. A thorough neurologic examination is essential in the diagnosis of lumbar spinal stenosis. Neurologic deficits such as decreased motor strength, sensory loss, and diminished deep tendon may be noted along the nerve root distributions affected by the stenosis.

Discogenic low back pain

Low back pain secondary to internal disc disruption can be difficult to diagnose based on history and physical examination alone. No specific factors in a patient’s history or physical exam have proven to be consistently present in the identification of discogenic low back pain.

Patients may report complaints of axial low back pain, with referral patterns described into the anterior thigh (L3-L4, L4-L5 disc lesions) as well as posterior thigh and leg regions (L4-5, L5-S1 discs), which can emulate radicular pain patterns without nerve root involvement. Pain exacerbation with prolonged sitting, particularly without support and in a forward flexed position has also been reported.

These complaints would seem to be consistent with reports of increased intradiscal pressures in these positions when compared with lying supine, standing, and a reclined position.

What tests to perform?

Lumbosacral radiculopathy

Imaging studies of the lumbar spine can be useful in the identification of lumbosacral disc herniations and nerve root compression, which may correlate with subjective complaints and objective findings on physical examination. Initial imaging studies should consist of AP and lateral plain films to evaluate for bony pathology, coronal and sagittal malalignment, and degeneration of intervertebral discs.

Subsequently, MRI can be used to identify structural lesions that may be compressing or irritating an affected nerve root, helping to make a clinical diagnosis of a lumbosacral radiculopathy. It can also be useful in identifying any potential masses or inflammation contributing to the reported symptoms.

For patients in whom MRI imaging is contraindicated (i.e. pacemaker placement) or bony impingement is suspected, CT can be used as an alternative to identify structural lesions. However, imaging studies should not be used in isolation, as asymptomatic volunteers have been found to have a high proportion of lumbar disc herniations on imaging studies. Therefore, imaging should be used with caution to supplement clinical findings, with correlation to patient symptoms being used to verify its significance.

Whereas imaging studies are useful in identifying the anatomy and structural pathology of the lumbosacral spine, it does not provide any diagnostic information regarding the function of an affected nerve root.

In patients with an unclear diagnosis or persistent weakness, Electromyography can subsequently be considered in patients to aide in localizing a lesion, while also assessing the function of the nerve.

Facet (zygapophyseal) arthropathy

Radiographic imaging studies provide inconclusive correlation with facet joint pain. CT and MRI studies have shown facet degeneration in 8-14% of asymptomatic volunteers. Nonetheless, severe osteoarthritis was not noted in any of the asymptomatic individuals, suggesting a possible association between radiographic findings of severe facet osteoarthritis with the likely pain generator.

However, studies using imaging studies to predict a positive response to intra-articular anesthetic blocks have provided conflicting data, limiting their reliability. At this time, the diagnostic imaging of choice would consist of MRI with the inclusion of STIR sequences to identify bony edema, while avoiding the misinterpretation of increased signal seen in fat.

Spondylolysis

Radiographic imaging studies have been noted to be quite useful in identifying pars defects, although false negative rates have proven to be unreasonably high. Plain radiographic images of the lumbar spine are useful in detecting a lucency within the region of the pars interarticularis, with collimated lateral views providing the most sensitive images.

Lateral view will demonstrate anterolisthesis of the vertebral body in patients with bilateral spondylolysis. Oblique views have frequently been considered the x-rays of choice. However, the position of the iliac crest frequently obscures the view of the lower lumbar segments, where the condition is most prevalent.

Historically, the use of SPECT in combination with CT was the gold standard in the identification of pars lesions. SPECT scans allow for the detection of physiologic activity within the pars interarticularis, identifying prespondylolytic lesions. In addition, their ability to provide tomographic images in multiple planes allows for a more precise anatomic localization of lesions.

Similarly, CT scans provide superior detail of morphologic abnormalities compared to plain radiographs. However, the progression of MRI with 3-4 mm thin slices has proven to be useful in providing adequate morphologic and physiologic information to identify prespondylolysis as well as chronic spondylolysis, making closed MRI with fat suppressed sequencing the diagnostic imaging of choice. The use of MRI also helps in identifying other potential pathologies that may be contributing to the reported symptoms.

Spondylolisthesis

Plain radiographs can be used to identify spondylolisthesis, as well as grading the severity of the translation. Using lateral spine x-rays, the extent of spondylolisthesis can be divided into grade one (0-25% slippage), grade two (25-50%), grade three (50-75%), and grade four (75-100%), with complete translation called spondyloptosis. Slippage greater that30% is rarely seen. Lateral flexion and extension views are frequently obtained to evaluate for segmental motion.

Spinal stenosis

Plain radiographs should be obtained initially to identify any bony pathology that may be leading to stenosis of the spinal canal. Findings of degenerative disc disease, degenerative spondylolisthesis, or facet hypertrophy may suggest a concomitant spinal stenosis. Reversal of lumbar lordosis may also be noted, given the avoidance of lumbar extension in these individuals.

MRI can subsequently be obtained to identify spinal canal narrowing. On sagittal images, disc protrusions and ligamentum flavum hypertrophy can be identified impinging on the central canal.

On axial views, central disc protrusions, facet hypertrophy, and ligamentum flavum hypertrophy can be identified, leading to narrowing of the spinal canal. A trefoil shaped canal may be noted, as opposed to the round or ovoid shape typically seen within the spinal canal.

A spinal canal diameter of less than 10 cm has been identified in patients with severe stenosis, whereas a diameter of 11-14 cm has been shown in individuals with moderate spinal stenosis.

Discogenic low back pain

The use of MRI for the identification of annular tears through the presence of high intensity zones (HIZ) has been controversial, with some studies finding a positive predictive value of up to 86% when correlated with CT discography. Conversely, more recent studies have found MRIs to have a low sensitivity in identifying annular tears. They should therefore be used as an initial diagnostic tool, with discography used to identify symptomatic discogenic pain.

CT discography is widely considered to be the most reliable tool in identifying intradiscal pathology responsible for discogenic low back pain. However, this too has been proven to be controversial in the literature, with some studies showing provocation of pain upon injection of discs with HIZ in 70% of patients, regardless of complaints of symptomatic low back pain.

A positive discogram requires reproduction of concordant pain upon intradiscal injection of contrast solution, with confirmation of an annular tear noted on CT imaging within 2 hours of procedure.

The use of discography can be used to diagnose a specific disc as a pain generator, while helping guide further treatment and interventions. However, this procedure should be used with caution, as studies have shown increased progression of disc degeneration following discography on long-term follow-up studies. It should therefore be reserved for few individuals in whom a specific treatment plan would require identification of the specific pain generator.

How should patients with back pain be managed?

Lumbosacral radiculopathy

The natural history of lumbosacral radiculopathy shows spontaneous resolution of symptoms in 23-48% of patients, with approximately 30% complaining of continued symptoms after one year of onset. The treatment of lumbosacral radiculopathy is generally initiated with conservative management consisting of NSAIDs and/or oral analgesics for pain control, with a trial of physical therapy.

Physical therapy focuses on pain reduction, maintaining pain free range of motion, and stabilization of the lumbar spine.

Interventional spinal injections have also proven to be of benefit in decreasing pain related to an acute lumbosacral radiculopathy. The use of transforaminal epidural steroid injections has been shown to provide significant subjective and objective improvement of radicular pain in the short-term, without any long-term benefits noted compared to placebo.

It has also been proven to be a surgery-sparing procedure, as Riew et al showed 29% of patients undergoing TFESIs proceeded to have surgerical intervention within 28 month follow-up compared to 67% in control group (transforaminal injection with bupivicaine). The benefits of TFESIs have been shown to be particularly useful for the symptoms of lumbosacral radiculopathy of shorter duration.

When comparing transforaminal epidural steroid injections with other forms of epidural steroid injections (interlaminar and caudal), TFESIs have been shown to provide significantly more improvement in pain at 2 weeks post injection, with fewer injections needed to achieve adequate relief. This has been attributed to the ventral dispersion provided by TFESI compared with the other techniques.

In the failure of conservative treatment to provide adequate relief of symptoms or continued progressive weakness associated with lumbosacral radiculopathy, surgical referral for laminotomy and discectomy is warranted.

Discectomy has been proven to provide significant reduction of pain in 65-90% of patients. However, given the invasive nature and potential risks, as well as the increased healthcare costs associated with surgery, this should be considered as a last resort to all non-operative treatments.

Facet (zygapophyseal) arthropathy

The treatment for facet-mediated pain includes a multifaceted approach, starting with conservative management including pain medication and physical therapy. Although there are not many studies detailing a beneficial therapy program tailored for facet arthropathy, a program centered on spinal stabilization and postural retraining has been shown to be advantageous for chronic low back pain of varied etiologies.

A flexion based exercise has generally been preferred to avoid stressing the posterior elements, although studies have not shown this to be more beneficial than other interventions in acute low back pain. Therapy, in conjunction with non-steroidal anti-inflammatory pain medications and analgesics has been proven useful in diminishing pain in these patients, with NSAIDs being particularly beneficial in its use for joint pain.

The use of interventional spine procedures for lumbar facet pain includes intra-articular corticosteroid injections and radiofrequency denervation of the nerves supplying the facet joints. The benefit of facet corticosteroid injections has been debated in the literature, with inconclusive results attributed to inconsistencies in the current studies available.

However, several of these studies have shown there to be improvement in pain scores for a 3-6 month period of time following injections. It can therefore be considered the first line treatment among interventional procedures, as a less invasive treatment option prior to proceeding with denervation to the nerves supplying the joints.

Radiofrequency denervation is a slightly more invasive procedure, in which the medial branches supplying the affected facet joints are ablated to provide pain alleviation. When used in carefully selected patients, pre-screened to ensure the correct diagnosis of facet mediated pain, this has been proven to be an effective treatment option in this very selective group of patients, improving patient’s pain, activity level, and quality of life. The nerves will regenerate in 6 months and could require subsequent injections bi-annually.

Surgical procedures, predominantly consisting of lumbar fusion, have been used as a last resort to treat facet joint pain. However, no significant evidence has been found in the literature to support the use of surgical interventions for the treatment facet-mediated low back pain.

Spondylolysis

Treatment of patients with spondylolysis should be started early, with a significantly increased rate of healing noted with early treatment compared with overall healing rates. This is particularly true in unilateral stress reactions, in which an excellent rate of healing is noted with early intervention. Conversely, bilateral stress reactions show diminished overall healing potential, with virtually no chance of healing once slippage is noted.

Treatment is centered on symptomatic relief with painless return to sporting activities. Treatment to date has focused on relative rest, with activity modification and implementation of physical therapy. Traditionally, the standard of care has called for immobilization of the lumbar spine with TLSO bracing for 3-6 months, despite a lack of concrete evidence suggestive of a distinct benefit to its use.

In addition, the use of restrictive bracing impedes the activity of lumbar paraspinal musculature, leading to atrophy, weakness, and limited range of motion upon its removal. Subsequently, the current standard of care calls for relative rest without bracing in patients who are able to perform their activities of daily living without complaints of pain. In those unable to perform ADLs without pain, bracing for up to 6-8 weeks can be trialed until pain-free ADLs can be achieved.

Physical therapy programs can be implemented once symptomatic pain relief has been achieved through either rest or bracing. At that point, bracing can be discontinued and a physical therapy program focusing on core strengthening, hamstring stretching, and pelvic tilts can be implemented, showing beneficial outcomes in this patient population.

Spondylolisthesis

The overall positive prognosis in patients lacking neurologic complaints suggests a conservative treatment plan should be implemented in these patients. Treatment with NSAIDs and/or oral analgesics for pain management, in conjunction with a course of physical therapy is an appropriate plan in these individuals.

Physical therapy should ideally focus on pain reduction, restoration of pain-free lumbar range of motion, and stabilization of the lumbar spine. A flexion biased exercise program has been shown to be of particular benefit in these patients, with focus on core strengthening helpful in decreasing pain and improving function. Given the predisposition for a flexion bias, aerobic exercise with a stationary bicycle is ideal to maintain a flexed position and diminish symptoms of neurogenic claudication.

Surgical intervention for spondylolisthesis is generally reserved for individuals who complain of concomitant symptoms consistent with lumbar spinal stenosis. As noted previously, patients with neurologic deficits secondary to spinal stenosis who forewent surgical intervention were noted to have further neurologic deterioration upon follow-up.

In these patients, particularly those with complaints of neurogenic claudication and bowel or bladder incontinence, surgical referral for decompressive laminectomy would be the appropriate treatment course.

Spinal stenosis

Much like the treatment of degenerative spondylolisthesis, a conservative treatment approach should be implemented initially. Treatment with NSAIDs and/or oral analgesics for pain management, in conjunction with a course of physical therapy is an appropriate plan in these individuals. Additionally, the use of parenteral calcitonin has been proven to show transient improvement of symptoms in patients with lumbar spinal stenosis.

Physical therapy should ideally focus on pain reduction, restoration of pain-free lumbar range of motion, and stabilization of the lumbar spine. A flexion biased exercise program has been shown to be of particular benefit in spinal stenosis, with focus on core strengthening helpful in decreasing pain and improving function.

Given the predisposition for a flexion bias, aerobic exercise with a stationary bicycle is ideal to maintain a flexed position and diminish symptoms of neurogenic claudication.

The use of epidural steroid injections has been controversial in the literature, with few studies showing additional benefit in adding corticosteroids to local anesthetics in epidural injections. However, the use of epidural steroid injections has remained a part of the standard of care, with 23% of these injections performed for the treatment of lumbar spinal stenosis. Given the desired effect of bathing the spinal canal with the steroid mixture, a caudal approach would be preferred for ideal distribution of medicine.

In the failure of conservative management to provide symptomatic relief, as well as patients with progressively worsening lower limb weakness, surgical referral for lumbar laminectomy should be obtained. This is particularly the case in individuals with signs of bowel or bladder incontinence, suggestive of cauda equina syndrome.

Discogenic low back pain

The treatment of discogenic low back pain is generally initiated with conservative management consisting of NSAIDs and/or oral analgesics for pain control, with a trial of physical therapy. Physical therapy should focus on spinal stabilization and core strengthening exercises to help diminish pain and maintain pain free range of motion. However, no clinical studies are available to date evaluating the benefit of these treatment options for this condition. Subsequently, interventional procedures are frequently useful as a less invasive option to surgical procedures.

The use of intradiscal corticosteroid injections has been trialed in an attempt to decrease inflammation within the affected discs. However, recent studies have shown there to be no significant improvement of symptoms when compared to placebo controls.

The future treatment of discogenic pain may revolve around regenerative treatments such as intradiscal platelet rich plasma or bone marrow aspirate concentrates. These may be beneficial in helping to regenerate degenerative discs that are a pain generator, but these methods are currently being studied, and their efficacy has yet to be proven in clinical trials.

What happens to patients with back pain?

Lumbosacral radiculopathy

Lumbosacral radiculopathy is a common cause of disability, which can be related to a mechanical compression or an inflammatory process affecting a nerve root. Some studies have shown the prevalence of lumbosacral radiculopathy to be estimated as high as 43%, with a lifetime prevalence of surgical intervention in 10% of those diagnosed with a radiculopathy.

The most common cause of radicular nerve pain is secondary to a herniated intervertebral disc compressing on the exiting nerve roots. Less frequently, the instigating cause may be related to infection, malignancy, or associated fracture. Constitutional symptoms associated with radicular pain may be a red flag for further evaluation of a concomitant pathology contributing to the radicular symptoms.

The intervertebral discs most commonly affected by disc herniations are at the L4-5 and L5-S1 levels, with the L5 nerve root the most susceptible to compression and irritation, followed by S1. Multiple root levels can be affected simultaneously, particularly with a central disc protrusion compressing the nerve roots in the spinal canal, resulting in cauda equina syndrome.

Cauda equina syndrome presents with the typical neurologic pain and deficits associated with radiculopathy, with concomitant bowel and bladder incontinence. This should be considered a surgical emergency, with evaluation for surgical decompression requested in an urgent manner.

Facet (zygapophyseal) arthropathy

The lumbar spine consists of five lumbar vertebrae, which are interconnected by intervertebral discs and bilateral facet/zygapophyseal joints. Together, these provide support and stability to the lumbar spine, allowing for lumbar flexion/extension, lateral side-bending, and minimal rotation.

As weight bearing structures as well as stabilizers that limit motion of the lumbar spine, they are susceptible to stress and degenerative changes. These lumbar facet joints are instilled with nociceptors that are activated with stretching and/or compression within the joint capsule, subsequently eliciting low back pain.

It has been estimated between 5-90% of the population is affected by this ailment, with an 89.2% prevalence of facet osteoarthritis among people in the 60-69 year old age group. This subsequently leads to the second most frequent type of pain management procedure being performed in the United States.

Spondylolysis

Spondylolysis, a stress reaction of the pars interarticularis (area of lamina connecting superior/inferior articular processes and pedicle), historically has been the most common cause of low back pain in the adolescent population, with an estimated incidence of 3-6% in the general population.

Males have been shown to be affected 2-3 times as frequently as females, with the L5 level being the most commonly injured. It has frequently been associated with repetitive forceful extension and rotation of the lumbar spine, particularly during high impact sports such as gymnastics, diving and interior line play in football, with up to a 15% incidence in adolescent athletes.

A potential complication associated with spondylolysis, particularly with bilateral lesions, is anterior translation of the cephalad vertebral segment on its caudal counterpart, referred to as isthmic spondylolisthesis.

Spondylolisthesis

Degenerative spondylolisthesis is a vertebral translation of vertebral segments in which the neural arch remains intact. Unlike isthmic spondylolisthesis, there are no pars defects associated with degenerative spondylolisthesis. This is generally related with chronic intersegmental degeneration, frequently associated with facet joint arthropathy, ligamentous hypertrophy, and poor muscular stabilization of the spine.

TheL4-L5 level is the most frequently affected, as opposed to the L5-S1 level commonly affected in isthmic spondylolisthesis.

The natural history of spondylolisthesis is generally encouraging, particularly when there is a lack of concomitant neurologic symptoms associated with spinal stenosis. 76% of patients with degenerative spondylolisthesis without neurologic deficits upon initial presentation were noted to lack neurologic symptoms on 10-year follow-up.

Conversely, patients who did have neurologic complaints on presentation and did not undergo surgical intervention were noted to have deterioration of symptoms upon follow-up. In addition, progression of spondylolisthesis was seen in 34% of patients on follow-up, without any correlation noted with deterioration of symptoms.

Spinal stenosis

Lumbar spinal stenosis is a neurologic disorder resulting from narrowing of the spinal canal. Some cases have been attributed to a congenital etiology, whereas the majority of cases are secondary to degenerative changes (degenerative spondylolisthesis, degenerative disc disease, facet arthropathy/hypertrophy, ligamentum flavum hypertrophy, scoliosis).

Onset of symptoms generally occurs following the fifth decade of life, with a predisposition of symptom intensity seen in women with degenerative spondylolisthesis.

Discogenic low back pain

Discogenic low back pain is among the most common causes of chronic low back pain, estimated to be responsible in 29-49% of patients. It has been estimated that 10% of young adult males in the 20-49 year age group may have full annular tears, whereas this number jumps to 35% of males in the 50-59 year age group. Consequently, a high correlation has been found between the presence of annular tears and concordant low back pain.

How to utilize team care?

Lumbosacral radiculopathy

Specialty consultations

In the failure of conservative treatment to provide adequate relief of symptoms or continued progressive weakness associated with lumbosacral radiculopathy, surgical referral for laminotomy and discectomy is warranted.

Discectomy has been proven to provide significant reduction of pain in 65-90% of patients. However, given the invasive nature and potential risks, as well as the increased healthcare costs associated with surgery, this should be considered as a last resort to all non-operative treatments.

Physical therapy

Physical therapy focuses on pain reduction, maintaining pain free range of motion, and stabilization of the lumbar spine.

Facet (zygapophyseal) arthropathy

Specialty consultations

Surgical referral should be reserved for those patients who are recalcitrant to conservative treatment. Surgical procedures, predominantly consisting of lumbar fusion, have been used as a last resort to treat facet joint pain. However, no significant evidence has been found in the literature to support the use of surgical interventions for the treatment facet-mediated low back pain.

Physical therapy

Although there are not many studies detailing a beneficial therapy program tailored for facet arthropathy, a program centered on spinal stabilization and postural retraining has been shown to be advantageous for chronic low back pain of varied etiologies.

A flexion based exercise has generally been preferred to avoid stressing the posterior elements, although studies have not shown this to be more beneficial than other interventions in acute low back pain.

Therapy, in conjunction with non-steroidal anti-inflammatory pain medications and analgesics has been proven useful in diminishing pain in these patients, with NSAIDs being particularly beneficial in its use for joint pain.

Spondylolysis

Specialty consultations

Surgical intervention, consisting of arthrodesis of involved segment or pars repair, has been used as a last resort treatment for patients who have failed conservative management, including a bracing trial. Surgery should also be considered for patients with Grade 3 or 4 isthmic spondylolisthesis.

Positive outcomes have been noted with arthrodesis, however with the sacrifice of segmental mobility. Conversely, direct pars repairs have been used to correct painful non-unions while maintaining segmental mobility, with positive outcomes noted in long-term follow-up studies.

Physical therapy

A physical therapy program should focus on core strengthening, hamstring stretching, and pelvic tilts, which have shown beneficial outcomes in this patient population.

Spondylolisthesis

Specialty consultations

Surgical intervention for spondylolisthesis is generally reserved for individuals who complain of concomitant symptoms consistent with lumbar spinal stenosis. As noted previously, patients with neurologic deficits secondary to spinal stenosis who forewent surgical intervention were noted to have further neurologic deterioration upon follow-up.

In these patients, particularly those with complaints of neurogenic claudication and bowel or bladder incontinence, surgical referral for decompressive laminectomy would be the appropriate treatment course.

Physical therapy

Physical therapy should focus on pain reduction, restoration of pain-free lumbar range of motion, and stabilization of the lumbar spine. A flexion biased exercise program has been shown to be of particular benefit in these patients, with focus on core strengthening helpful in decreasing pain and improving function.

Given the predisposition for a flexion bias, aerobic exercise with a stationary bicycle is ideal to maintain a flexed position and diminish symptoms of neurogenic claudication.

Spinal stenosis

Specialty consultations

In the failure of conservative management to provide symptomatic relief, as well as patients with progressively worsening lower limb weakness, surgical referral for lumbar laminectomy should be obtained. This is particularly the case in individuals with signs of bowel or bladder incontinence, suggestive of cauda equina syndrome.

Physical therapy

Physical therapy should focus on pain reduction, restoration of pain-free lumbar range of motion, and stabilization of the lumbar spine. A flexion biased exercise program has been shown to be of particular benefit in spinal stenosis, with focus on core strengthening helpful in decreasing pain and improving function.

Given the predisposition for a flexion bias, aerobic exercise with a stationary bicycle is ideal to maintain a flexed position and diminish symptoms of neurogenic claudication.

Discogenic low back pain

Physical therapy

Physical therapy should focus on spinal stabilization and core strengthening exercises to help diminish pain and maintain pain free range of motion.

Are there clinical practice guidelines to inform decision making?

Lumbosacral radiculopathy

No.

Facet (zygapophyseal) arthropathy

No.

Spondylolysis

No.

Spondylolisthesis

No.

Spinal stenosis

No.

Discogenic low back pain

No.

What is the evidence?

Manchikanti, L, Manchikanti, KN, Manchukonda, R, . "Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: Preliminary report of a randomized, double-blind controlled trial: Clinical trial NCT00355914". Pain Physician.. vol. 10. 2007. pp. 425-440.

Lumbosacral radiculopathy

Vroomen, P, de Krom, M, Knottnerus, JA. "Consistency of History Taking and Physical Examination in Patients With Suspected Lumbar Nerve Root Involvement". Spine. vol. 25. 2000. pp. 91.

van der Windt, DAWM, Simons, E, Riphagen, II, Ammendolia, C, Verhagen, AP, Laslett, M, Devillé, W, Deyo, RA, Bouter, LM, de Vet, HCW, Aertgeerts, B. "Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain (Review)". Cochrane Database Syst Rev. 2010. pp. CD007431.

Majlesi, J, Togay, H, Unalan, H, Toprak, S. "The sensitivity and specificity of the slump and the straight leg raising tests in patients with lumbar disc herniation". Journal of Clinical Rheumatology. vol. 14. 2008. pp. 87-91.

Preston, DC, Shapiro, BE. "Electromygraphy and Neuromuscular Disorders: Clinical Electrophysiologic Correlations 2nd Edition". Elevier.

Bush, K, Cowan, N, Katz De, Gishen, P. "The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up". Spine. vol. 17. 1992. pp. 1205-1212.

Bakhtiary, AH, Safavi-Farokhi, Z, Rezasoltani, A,. "Lumbar stabilizing exercises improve activities of daily living in patients with lumbar disc herniation". J Back Musculoskeletal Rehabil. vol. 18. 2005. pp. 55-60.

Karppinen, J, Malmivaara, A, Kurunlahti, M, . "Periradicular infiltration for sciatica: a randomized controlled trial". Spine. vol. 26. 2001. pp. 1059-1067.

Ghahreman, A, Ferch, R, Bogduk, N. "The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain". Pain Med. vol. 11. 2010. pp. 1149-1168.

Riew, KD, Yin, Y, Gilula, L. "The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain". A prospective, randomized, controlled, double-blind study. J Bone Joint Surg Am. vol. 82-A. 2000. pp. 1589-1593.

Ng, L, Chaudhary, N, Sell, P. "The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double blind, controlled trial". Spine. vol. 30. 2005. pp. 857-862.

Ackermann, WE, Ahmad, M. "The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations". Anesth Analg. vol. 104. 2007. pp. 1217-1222.

Gibson, JN, Waddell, G. "Surgical intervention for lumbar disc prolapse: updated Cochrane Review". Spine. vol. 32. 2007. pp. 1735-1747.

Konstantinou, K, Dunn, KM. "Sciatica: review of epidemiological studies and prevalence estimates". Spine. vol. 33. 2008. pp. 2464-2472.

Frymoyer, JW, Pope, MH, Clements, JH. "Risk factors in low-back pain. An epidemiology survey". J Bone Joint Surg Am. vol. 65. 1983. pp. 213-218.

Della-Giustina, DA. "Emergency department evaluation and treatment of back pain". Emerg Med Clin North Am. vol. 17. 1999. pp. 877-893.

Walker, BF. "The prevalence of low back pain: a systematic review of the literature from 1966-1998". J Spinal Disord. vol. 13. 2000. pp. 205-217.

Facet (zygapophyseal) arthropathy

Jackson, RP, Jacobs, RR, Montesano, PX. "Facet joint injection in low back pain: A prospective statistical study". Spine.. vol. 13. 1988. pp. 966-971.

Helbig, T, Lee, CK. "The lumbar facet syndrome". Spine.. vol. 13. 1988. pp. 61-64.

Weishaupt, D, Zanetti, M, Hodler, J, Boos, N. "MR imaging of the lumbar spine: Prevalence of intervertebral disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers". Radiology.. vol. 209. 1998. pp. 661-666.

VanTulder, M, Malmivaara, A, Esmail, R. "Exercise therapy for low back pain: a systematic review within the framework of the Cochrane collaboration back review group". Spine. vol. 25. 2000. pp. 2784-2796.

Datta, S, Lee, M, Falco, F, Bryce, D, Hayek, S. "Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions". Pain Physician.. vol. 12. 2009. pp. 437-460.

Nath, S, Nath, CA, Pettersson, K. "Percutaneous lumbar zygapophysial (facet) joint neurotomy using radiofrequency current, in the management of chronic low back pain: A randomized double-blind trial". Spine. vol. 33. 2008. pp. 1291-1298.

Dreyfuss, P, Halbrook, B, Pauza, K. "Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain". Spine. vol. 25. 2000. pp. 1270-1277.

Cohen, SP, Raja, SN. "Pathogenesis, Diagnosis, and Treatment of Lumbar Zygapophysial (Facet) Joint Pain". Anesthesiology. vol. 106. 2007. pp. 591-614.

Cavanaugh, JM, Ozaktay, AC, Yamashita, HT, King, AI. "Lumbar facet pain: Biomechanics, neuroanatomy and neurophysiology". J Biomechanics.. vol. 29. 1996. pp. 1117-1129.

Kalichman, L, Li, L, Kim, DH. "Facet joint osteoarthritis and low back pain in the community-based population". Spine.. vol. 33. 2008. pp. 2560-2565.

Spondylolysis

Fredrickson, BE, Baker, D, McHolick, WJ. "The natural history of spondylolysis and spondylolisthesis". J Bone Joint Surg. vol. 66. 1984. pp. 699-707.

Micheli, LJ, Wood, R. "Back pain in young athletes: significant differences from adults in causes and patterns". Arch Pediatr Adolesc Med. vol. 149. 1995. pp. 15-18.

Lim, MR, Yoon, SC, Green, DW. "Symptomatic spondylolysis: diagnosis and treatment". Current Opinion in Pediatrics. vol. 16. 2004. pp. 37-46.

D’Hemecourt, PA, Zurakowski, D, Kriemler, S. "Spondylolysis: returning the athlete to sports participation with brace treatment". Orthopedics. vol. 25. 2002. pp. 653-657.

Katz, K, Rosenthal, A, Yosipovitch, Z. "Normal ranges of popliteal angles in children". J Pediatric Orthopaedics. vol. 12. 1992. pp. 229-231.

Amato, M, Totty, WG, Gilula, LA. "Spondylolysis of the lumbar spine: demonstration of defects and laminal fragmentation". Radiology. vol. 153. 1984. pp. 627-629.

Anderson, K, Sarwark, JF, Conway, JJ. "Quantitative assessment with SPECT imaging of stress injuries of the pars interarticularis and response to bracing". J Pediatr Orthop. vol. 20. 2000. pp. 28-33.

Harvey, CJ, Richenberg, JL, Saifuddin, A. "The radiological investigation of lumbar spondylolysis". Clin Radiol. vol. 53. 1998. pp. 723-728.

Congeni, J, McCulloch, J, Swanson, K. "Lumbar spondylolysis: a study of natural progression in athletes". American Journal of Sports Medicine. vol. 25. 1997. pp. 248-253.

Campbell, RS, Grainger, AJ. "Optimization of MRI pulse sequences to visualize the normal pars interarticularis". Clin Radiol. vol. 54. 1999. pp. 63-68.

Yamane, T, Yoshida, T, Mimatsu, K. "Early diagnosis of lumbar spondylolysis by MRI". J Bone Joint Surg Br. vol. 75. 1993. pp. 764-768.

Morita, T, Ikata, T, Katoh, S, Miyake, R. "Lumbar spondylolysis in children and adolescents". J Bone Joint Surg Br. vol. 92-B. 2010. pp. 751-759.

Takemitsu, M, El Rassi, G, Worantanarat, P, Shah, SA. "Low back in pediatric athletes with unilateral tracer uptake at the pars interarticularis on single photon emission computed tomography". Spine. vol. 31. 2006. pp. 909-914.

Kim, HJ, Green, DW. "Spondylolysis in the adolescent athlete". Current Opinions in Pediatrics. vol. 23. 2011. pp. 68-72.

McNeely, ML, Torrance, G, Magee, DJ. "A systematic review of physiotherapy for spondylolysis and spondylolisthesis". Man Ther. vol. 8. 2003. pp. 80-91.

Ivanic, GM, Pink, TP, Achatz, W, . "Direct stabilization of lumbar spondylolysis with a hook screw: mean 11-year follow-up period for 113 patients". Spine. vol. 28. 2003. pp. 255-259.

Askar, Z, Wardlaw, D, Koti, M. " Scott wiring for direct repair of lumbar spondylolysis". Spine. vol. 28. 2003. pp. 354-357.

Debnath, UK, Freeman, BJ, Gregory, P. "Clinical outcome and return to sport after the surgical treatment of spondylolysis in young athletes". J Bone Joint Surg Br. vol. 85. 2003. pp. 244-249.

Fredrickson, BE, Baker, D, McHolick, WJ. "The natural history of spondylolysis and spondylolisthesis". J Bone Joint Surg. vol. 66. 1984. pp. 699-707.

Roche, MA, Rowe, GG. "The incidence of separate neural arch and coincident bone variations: a survey of 4,200 skeletons". Anat Rec. vol. 6. 1951. pp. 406-411.

Sakai, T, Sairyo, K, Suzue, N, Kosaka, H, Yasui, N. "Incidence and etiology of lumbar spondylolysis: review of the literature". J Orthop Sci. vol. 15. 2010. pp. 281-288.

Rossi, F. "Spondylolysis, spondylolisthesis and sports". J Sports Med Phys Fitness. vol. 30. 1990. pp. 450-452.

Spondylolisthesis

Kotsiuk, JP, Harrington, I, Alexander, D, Rand, W, Evans, D. "Cauda equina syndrome and lumbar disc herniation". J Bone Joint Surg Am. vol. 68. 1986. pp. 386-391.

Jacobsen, S, Sonne-Holm, S, Rovsing, H, Monrad, H, Gebuhr, P. "Degenerative lumbar spondylolisthesis: an epidemiological perspective: the Copenhagen Osteoarthritis Study". Spine. vol. 32. 2007. pp. 120-125.

Gramse, RR, Sinaki, M, Ilstrup, DM. "Lumbar spondylolisthesis: a rational approach to conservative treatment". Mayo Clin Proc. vol. 55. 1980. pp. 681-686.

Sinaki, M, Lutness, MP, Ilstrup, DM, Chu, CP, Gramse, RR. "Lumbar spondylolisthesis: retrospective comparison and three-year follow-up of two conservative treatment programs". Arch Phys Med Rehabil. 1989.

O’Sullivan, PB, Phyty, GD, Twomey, LT, Allison, GT. "Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis". Spine. vol. 22. 1997. pp. 2959-2967.

Vibert, BT, Sliva, CD, Herkowitz, HN. "Treatment of instability and spondylolisthesis: surgical versus nonsurgical treatment". Clin OrthopRelat Res. vol. 443. 2006. pp. 222-227.

Weinstein, JW, Lurie, JD, Rosteson, TD. "Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis". N Engl J Med. vol. 356. 2007. pp. 2257-2270.

Kalichman, L, Hunter, DJ. "Diagnosis and conservative management of degenerative lumbar spondylolisthesis". Eur Spine J. vol. 17. 2008. pp. 327-335.

Fitzgerald, J, Newman, PH. "Degenerative spondylolisthesis". J Bone Joint Surg. vol. 58. 1976. pp. 184-192.

Matsunaga, S, Ijiri, K, Hayashi, K. "Nonsurgically managed patients with degenerative spondylolisthesis: a 10 to 18 year follow-up study". JNeurosurg. vol. 93. 2000. pp. 194-198.

Spinal stenosis

Inufusa, A, An, HS, Lim, TH. "Anatomic changes of the spinal canal and intervertebral foramen associated with flexion-extension movement". Spine. vol. 21. 1996. pp. 2412-2420.

Papp, T, Porter, RW, Aspden, RM. "Trefoil configuration and developmental stenosis of the lumbar vertebral canal". J Bone Joint Surg (Br). vol. 77-B. 1995. pp. 469-472.

Surin, V, Hedeln, E, Smith, L. "Degenerative lumbar spinal stenosis: Results of Operative Treatment". Acta Orthop Scand. vol. 53. 1982. pp. 79-85.

Tran, DQH, Duong, S, Finlayson, RJ. "Lumbar spinal stenosis: a brief review of the nonsurgical management". Can J Anesth. vol. 57. 2010. pp. 694-703.

Gramse, RR, Sinaki, M, Ilstrup, DM. "Lumbar spondylolisthesis: a rational approach to conservative treatment". Mayo Clin Proc. vol. 55. 1980. pp. 681-686.

Sinaki, M, Lutness, MP, Ilstrup, DM, Chu, CP, Gramse, RR. "Lumbar spondylolisthesis: retrospective comparison and three-year follow-up of two conservative treatment programs". Arch Phys Med Rehabil. vol. 70. 1989. pp. 594-598.

O’Sullivan, PB, Phyty, GD, Twomey, LT, Allison, GT. "Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis". Spine. vol. 22. 1997. pp. 2959-2967.

Vibert, BT, Sliva, CD, Herkowitz, HN. "Treatment of instability and spondylolisthesis: surgical versus nonsurgical treatment". Clin OrthopRelat Res. vol. 443. 2006. pp. 222-227.

Friedly, J, Chan, L, Deyo, R. "Increases in lumbosacral injections in the Medicare population: 1994 to 2001". Spine. vol. 32. 2007. pp. 1754-1760.

Koc, Z, Ozcakir, S, Sivrioglu, K, Gurbet, A, Kucukoglu. "Effectiveness of physical therapy and epidural steroid injections in lumbar spinal stenosis". Spine. vol. 34. 2009. pp. 985-989.

Discogenic low back pain

Ohnmeiss, DD, Vanharanta, H, Ekholm, J. "Relationship of pain drawings to invasive tests assessing intervertebral disc pathology". Eur Spine J. vol. 8. 1999. pp. 126-131.

Ohnmeiss, DD, Vanharanta, H, Ekholm, J. "Relation between pain location and disc pathology: a study of pain drawings and CT/Discography". Clin J Pain.. vol. 15. 1999. pp. 210-217.

Saifuddin, A, Emanuel, R, White, J. "An analysis of radiating pain at lumbar discography". Eur Spine J.. vol. 7. 1998. pp. 358-362.

Wilke, HJ, Neef, P, Caimi, M. "New in vivo measurements of pressures in the intervertebral disc in daily life". Spine.. vol. 24. 1999. pp. 755-762.

Aprill, C, Bogduk, N. "High intensity zone: a diagnostic sign of painful disc on magnetic resonance imaging". Br J Radiol.. vol. 65. 1992. pp. 361-369.

Saifuddin, A, Braithwaite, I, White, J. "The value of lumbar spine magnetic resonance imaging in the demonstration of annular tears". Spine.. vol. 23. 1998. pp. 453-457.

Smith, BM, Hurwitz, EL, Solsberg, D. "Interobserver reliability of detecting lumbar intervertebral disc high-intensity zone on magneticresonance imaging and association of high-intensity zone on magnetic resonance imaging and association of high-intensity zone with pain and annular disruption". Spine.. vol. 23. 1998. pp. 2074-2080.

Carragee, EJ, Paragioudakis, SJ, Khurana, S. "Lumbar high-intensity zone and discography in subjects without low back problems". Spine.. vol. 25. 2000. pp. 2987-2992.

Zhou, Y, Abdi, S. "Diagnosis and minimally invasive treatment of lumbar discogenic pain: a review of the literature". Clin J Pain.. vol. 22. 2006. pp. 468-481.

Carragee, EJ, Don, AS, Hurwitz, EL, Cuellar, JM, Carrino, J, Herzog, R. "Does discography cause accelerated progression of degeneration changes in the lumbar disc: A ten-year matched cohort study". Spine. vol. 34. 2009. pp. 2338-2345.

Schwarzer, AC, Aprill, CN, Derby, R. "The prevalence and clinical features of internal disc disruption in patients with chronic low back pain". Spine.. vol. 20. 1995. pp. 1878-1883.

Videman, T, Nurminem, M. "The occurrence of annular tears and their relation to lifetime back pain history: a cadaveric study using barium sulfate discography". Spine. vol. 29. 2004. pp. 2668-2676.

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