Snapshot A 46-year-old male presents with lower back pain. His symptoms began approximately 3 weeks ago and has not subsided. The pain does not radiate, and he cannot recall what caused this. He denies night sweats, unexpected weight loss, bowel, or bladder symptoms. He does not use illicit drugs and does not smoke. On physical exam, no saddle anesthesia, muscle weakness, or sensory changes are noted. There is tenderness over the ileolumbar ligament. Introduction Low back pain affects 50-80% of population in lifetime second only to respitatory infection as the main cause to visit doctors office Etiology muscle strain most common cause of low back pain most common degenerative disorders lumbar spinal stenosis lumbar disc herniation discogenic back pain in the pediatric population spondylolisthesis forward slip of vertebrae, usually L5 over S1 in children Risk factors obesity, smoking, and gender lifting, vibration, and prolonged sitting job dissatisfaction Red flags infection (IV drug user and h/o fever and chills) tumor (h/o cancer) trauma (h/o car accident or fall) cauda equina syndrome (bowel/bladder changes) family history of AAA Outcomes 90% of low back pain resolves within one year Presentation Symptoms axial pain musculogenic most common cause of back pain associated with activity characterized by stiffness and difficulty bending mechanical pain caused by degenrative spine disease with facet and disc degeneration sacroiliac symptoms pain originating from sacroiliac joint peripheral/neruogenic radicular pain unilateral leg pain usually dermatomal referred pain buttocks posterior thighs inguinal region (think L5-S1) neurogenic claudication pain in buttock and legs that is worse with prolonged standing and improves with sitting fairly specific for spinal stenosis myelopathy clumsiness in hands gait instability due to injury of spinal cord (~L1 or above) conus medullaris syndrome cauda equina syndrome typically unilateral leg pain LE weakness saddle anesthesia bowel/bladder symptoms spinal cord injury incomplete complete Wadell signs system to evaluate non-organic back pain symptoms Symptoms Conus Medullaris Cauda Equina Syndrome Lesion Conus medullaris of the spinal cord Cauda equina - the peripheral nerves that leave the spinal cord Presentation Sudden Bilateral Gradual Unilateral Low back pain More Less Reflexes Knee jerk - preserved Ankle jerk - affected Knee & ankle jerk - affected Sensory symptoms Perianal numbness Symmetric and bilateral Saddle area numbness Asymmetric and unilateral Motor symptoms Symmetric Lower limb hyperreflexic distal paresis (less marked) Asymmetric Areflexic paraplegia (more marked) Atrophy Evaluation Radiographs indications for radiographs pain lasting > one month and not responding to nonoperative management red flags are present MRI highly sensitive and specific high rate of abnormal findings on MRI in normal people Differential Neck and arm pain metastatic disease/infection cervical radiculopathy cervical myelopathy ankylosing spondylitis trauma Thoracic back and rib pain metastatic disease/infection thoracic disc herniation compression fracture trauma Low back pain muscles strain disc herniation/discogenic pain degenerative spondylolithesis spinal stenosis lumbar radiculopathy abdominal aortic aneurism Sacroiliac pain SI infection ankylosing spondylitis Sacral pain coccydynia sacral insufficiency fracture Treatment In the absence of 'red-flag' symptoms, treat conservatively with NSAIDs/acetaminophen and activity continuation avoid bed-rest Otherwise, treatment is dictated by cause of pain Conus Medullaris Syndrome Cauda Equina Syndrome Presentation · Sudden; bilateral · Gradual; unilateral Low back pain · More · Less Reflexes · Knee jerk – preserved · Ankle jerk - affected · Knee & ankle - affected Low back pain · More · Less Sensory symptoms · Perianal numbness · Symmetric and bilateral · Saddle area numbness · Asymmetric and unilateral Motor symptoms · Symmetric · Lower limb hyperreflexic distal paresis (less marked) · Asymmetric · Areflexic paraplegia (more marked) · Atrophy