Low Back Pain (5)
(ĐTĐ) - Sciatica can be a difficult condition to pin down, and confusing the issue there is also a condition that is commonly called “pseudo-sciatica.” The condition is called piriformis Syndrome. It has different causes from sciatica, but it mimics the symptoms so it won’t be a surprise if you and your doctor believe that it’s sciatica.
Sciatica is caused by the compression of the sciatic nerve by a slipped or herniated disc. This nerve runs from the lower back, through the buttocks and all the way down to the feet and toes. This means that you will experience pain throughout your lower body from this condition.
Piriformis syndrome is uncommon, but causes the same kind of compression. The piriformis is a flat muscle just above the buttocks. This muscle spasms and pinches the sciatic nerve, causing the same sort of pain as sciatica. However, it only seems to be sciatica. Sciatica is generally caused by compression caused by the discs in the back, so when the piriformis muscle is the culprit, it may cause some confusion.
Despite the name, there is nothing imaginary about “pseudo” sciatica. The sciatic nerve is being pinched and compressed in the same manner, just from a different cause. The pain is just as real and the “pseudo” in the name just refers to the fact that the syndrome falsely appears like sciatica.
Despite how similar the syndrome is to sciatica, there are two simple physical manoeuvres that can be used to distinguish between the two. This, of course, depends on a patient only having one or another of the conditions. If you have both conditions at the same time, these will not work. The first position is done this way: from a seated position, straighten the leg in which you are having pain, so that your leg is parallel with the floor. If the symptoms increase, there is a good chance that what you have is true sciatica.
The second position is achieved in two steps. Again, take a sitting position. Then, in the leg in which you have pain, bring the knee up to the shoulder on the same side. While this may sound painful, it generally isn’t except in the most severe cases. Once you have done this, move your knee over toward the opposite shoulder. If there is an increase in pain, there is a good chance that you are suffering with piriformis syndrome.
As the name implies, the symptoms are very similar to regular sciatica. The major symptom is pain and burning down the length of the nerve, from the buttocks to the feet. It usually affects only one side of the body, and can be more intense when you are sitting, or after sitting for a long time.
The main difference between regular sciatica and piriformis syndrome is that it often causes more intense pain in the hip, to the point where it can actually cause the patient to limp or have other difficulty walking. Conversely, people with pseudo-sciatica generally don’t have pain in the thigh. Unfortunately, these differences can appear very slight and may not be enough to give doctors a clue what is causing the pain.
Pseudo sciatica can be caused by poor posture or exercise related injury. This is very unlike the causes of regular sciatica, which are often being overweight or not being active enough. Regular sciatica is also often a side-effect of pregnancy.
Pseudo sciatica can also be caused by sitting too long at a computer with your head protruding to look at the screen. It can also be caused by muscular overuse, as in when a parent repeatedly lifts a child into a car seat in the rear of a car. Men can also develop this syndrome by sitting to long on a hard seat with a wallet in the back pocket.
The options for treatment of the syndrome will generally be very similar to the options available for regular sciatica. These include painkillers, anti-inflammatory medicines and physiotherapy. There are exercises you can do to help relieve pain and lessen the nerve compression that you piriformis muscle is causing.
Leg and Knee Stretch
One of the simplest and easiest ways to relieve pain is through a very basic leg stretch. Lie down on the floor with your legs straight. Then bring one knee up to your chest and hug it to you. Then slowly move it toward your opposite shoulder, so that your leg is stretched across your body diagonally. You should be feeling a stretch in your hip and buttock. Hold the stretch for a few seconds, then release it and repeat the stretch on the other side. Lie on the floor with your legs straight. Bend one knee into your chest, hugging it with your arms. Slowly bring the knee up towards your opposite shoulder, stretching it across your body. You should feel a decent stretch through your hip and buttock area. Hold the stretch for several breaths, then release and repeat on the opposite side.
A yoga pose called Parivrtta Trikonasana, also known as the revolved triangle pose, is able to stretch the piriformis muscle. This is a little more intense than a leg stretch and it will be important to consult with your doctor before you attempt it. However, once you have gotten the go-ahead, you’re ready to work on your yoga.
To perform this pose, come into a push-up position with your arms straight. Lift your buttocks towards the ceiling, coming into an inverted “V” shape pose. Step your right foot up between your hands. Keeping your left hand on the ground, revolve your chest towards the ceiling, bringing your arm straight up over your head so that it is pointing toward the ceiling. Don’t support your body with your left arm, rather support it with the muscles in your back. This position is meant to stretch your back and buttocks, so it’s important that you are using those muscles. Hold the pose for 30 seconds, then return to downward-facing dog pose and repeat on the opposite leg.
As with any condition, it is important to know what the root cause of your pain is. Treatment for regular sciatica is not going to be useless, but obviously it will be more effective if you and your doctor understand what you have before you begin with treatment measures.
(ĐTĐ) - Lower back pain is the leading cause of disability worldwide, according to a large new study published in the Annals of the Rheumatic Diseases.
Researchers in the U.K., Australia and the U.S. studied data from the Global Burden of Disease study, which assessed the health of people in 187 countries. They found that almost one out of ten people (9.4%) suffers from lower back pain – a number likely to rise as the population ages.
Back Pain“Governments, health service and research providers and donors need to pay far greater attention to the burden that low back pain causes,” wrote lead author Dr. Tony Woolf from the Royal Cornwall Hospital in the UK.
“With aging populations throughout the world, but especially in low and middle income countries, the number of people living with low back pain will increase substantially over coming decades.”
Lower back pain was most common in Western Europe, where 15% of the population suffers from it; followed by North Africa and the Middle East. It was least common in the Caribbean and Latin America.
Lower back pain is not usually linked to any serious disease. It can be triggered by any number of everyday activities, including bad posture, bending awkwardly, lifting incorrectly or standing for long periods of time.
“Many people develop back pain for no obvious reasons, and research suggests that it’s impossible to identify a specific cause of pain for around 85 per cent of people in the early stages,” a spokeswoman for Arthritis Research UK told the Daily Express.
“Treatment such as physiotherapy, pain relief and exercise to keep the muscles supporting the spine strong can all help.”
Men (10.1%) are more likely to suffer from lower back pain than women (8.7%).
The study was funded by the Bill and Melinda Gates Foundation, the Australian Commonwealth Department of Health and Ageing, the Australian National Health and Medical Research Council, and the Ageing and Alzheimer’s Research Foundation.
(ĐTĐ) - Perhaps you bent the wrong way while lifting something heavy. Or you're dealing with a degenerative condition like arthritis. Whatever the cause, once you have low back pain, it can be hard to shake. About one in four Americans say they've had a recent bout of low back pain. And almost everyone can expect to experience back pain at some point in their lives.
Sometimes it’s clearly serious: You were injured, or you feel numbness, weakness, or tingling in the legs. Call the doctor, of course. But for routine and mild low back pain, here are a few simple tips to try at home.
Chill it. Ice is best in the first 24 to 48 hours after an injury because it reduces inflammation, says E. Anne Reicherter, PhD, PT, DPT, associate professor of Physical Therapy at the University of Maryland School of Medicine. "Even though the warmth feels good because it helps cover up the pain and it does help relax the muscles, the heat actually inflames the inflammatory processes," she says. After 48 hours, you can switch to heat if you prefer. Whether you use heat or ice -- take it off after about 20 minutes to give your skin a rest. If pain persists, talk with a doctor.
Keep moving. "Our spines are like the rest of our body -- they're meant to move," says Reicherter. Keep doing your daily activities. Make the beds, go to work, walk the dog. Once you're feeling better, regular aerobic exercises like swimming, bicycling, and walking can keep you -- and your back -- more mobile. Just don't overdo it. There's no need to run a marathon when your back is sore.
Stay strong. Once your low back pain has receded, you can help avert future episodes of back pain by working the muscles that support your lower back, including the back extensor muscles. "They help you maintain the proper posture and alignment of your spine," Reicherter says. Having strong hip, pelvic, and abdominal muscles also gives you more back support. Avoid abdominal crunches, because they can actually put more strain on your back.
Stretch. Don't sit slumped in your desk chair all day. Get up every 20 minutes or so and stretch the other way. "Because most of us spend a lot of time bending forward in our jobs, it's important to stand up and stretch backward throughout the day," Reicherter says. Don't forget to also stretch your legs. Some people find relief from their back pain by doing a regular stretching routine, like yoga.
Think ergonomically. Design your workspace so you don't have to hunch forward to see your computer monitor or reach way out for your mouse. Use a desk chair that supports your lower back and allows you to keep your feet planted firmly on the floor.
Watch your posture. Slumping makes it harder for your back to support your weight. Be especially careful of your posture when lifting heavy objects. Never bend over from the waist. Instead, bend and straighten from the knees.
Wear low heels. Exchange your four-inch pumps for flats or low heels (less than 1 inch). High heels create a more unstable posture, and increase pressure on your lower spine. According to research, nearly 60% of women who consistently wear high-heeled shoes complain of low back pain.
Kick the habit. Smoking can increase your risk for osteoporosis of the spine and other bone problems. Osteoporosis can lead to compression fractures of the spine. One study found that smokers are about a third more likely to have low back pain compared with nonsmokers.
Watch your weight. Use diet and exercise to keep your weight within a healthy range for your height. Being overweight puts excess stress on your spine.
Try an over-the-counter pain reliever. Anti-inflammatory drugs such as aspirin, ibuprofen (Advil, Motrin, Nuprin), and naproxen sodium (Aleve, Anaprox, Naprosyn) can help reduce back pain. Acetaminophen (Actamin, Panadol, Tylenol) is another over-the-counter option for pain management. Be sure to check with your doctor or pharmacist about any interactions over-the-counter pain relievers may have with other medications you are taking. People with a history of certain medical conditions (such as ulcers, kidney disease, and liver disease) should avoid some medicines.
Call your doctor if:
- Your low back pain doesn't go away after a few days, and it hurts even when you're at rest or lying down.
- You have weakness or numbness in your legs, or you have trouble standing or walking
- You lose control over your bowels or bladder
- These could be signs that you have a nerve problem or another underlying medical condition that needs to be treated.
Reviewed By Louise Chang, MD - Source WebMD.com
A thorough history and physical examination is paramount to arrive at a diagnosis, and initially imaging is often unnecessary.
- Patients most often complain of pain in the lumbosacral area.
- Determine whether pain is exacerbated by movement or by prolonged sitting or standing.
- Determine the duration of pain.
- Determine if pain is relieved by lying down.
- Establish if pain was sudden in onset or gradual over days or months.
- Determine if pain is worse in the morning or at night.
- Find out if the patient can identify a precipitating event such as lifting or moving furniture.
- Explore the presence of systemic symptoms such as fever, weight loss, dysuria, cough, and bowel or bladder problems.
- Inquire about current medications that may produce symptomatology.
- Chronic steroids may predispose to infection or compression fractures.
- Anticoagulants may result in a bleed or hematoma.
- Any history of new-onset bowel or bladder dysfunction (eg, urinary hesitancy, overflow incontinence) with back pain is suggestive of cauda equina syndrome. This is particularly true if other, new neurologic deficits are also present.
- Physical examination of a patient with back pain should include range of motion and a thorough neurologic examination, including assessment of peripheral motor function, sensation, and deep tendon reflexes.
- Perform straight leg testing with the patient in a supine position. Record response to raising each leg. An approximation of the test may also be performed with the patient sitting and each leg straightened at the knee. An elevation of the leg to less than 60° is abnormal. The straight leg test result is positive only if the pain radiates to below the knee and not merely in the back or the hamstrings. This is the single best test for determining radiculopathy due to disc herniation with a high sensitivity and moderate specificity.
- Perform an abdominal examination to exclude intra-abdominal pathology.
- Perform a rectal examination on men older than 50 years to assess prostate size and exclude prostatitis. Also perform a rectal examination on any patient who may have cauda equina syndrome to assess rectal tone and perineal sensation. If cauda equina syndrome is suspected, urinary catheterization for a postvoid residual or bedside ultrasonography of the bladder may be helpful to assess for urinary retention.
- Perform a rectal examination, if necessary, in younger males who are febrile and have urinary complaints.
- Perform a pelvic examination, if necessary, in females complaining of menstrual abnormalities or vaginal discharge.
- Patients with true herniated discs may not present with any findings other than a positive straight leg raising test. Classic presentation includes numbness in a dermatomal distribution corresponding to the level of disc involved, with findings of motor weakness and reflex loss as described below. Herniated discs have different presentations depending on the location as follows:
- At L4: Pain along the front of the leg; weak extension of the leg at the knee; sensory loss about the knee; loss of knee-jerk reflex
- At L5: Pain along the side of the leg; weak dorsiflexion of the foot; sensory loss in the web of the big toe; no reflexes lost
- At S1: Pain along the back of the leg; weak plantar flexion of the foot; sensory loss along the back of the calf and the lateral aspect of the foot; loss of ankle jerk
- L5 and S1: These nerve roots are involved in approximately 95% of all disc herniations.
- Spinal stenosis may be present when evidence of degenerative joint disease is present on radiographic studies.
- Patients with this disease process often complain of progressive pain down the lateral aspect of the leg during ambulation (pseudoclaudication). This pain results from neurologic compression rather than actual arterial insufficiency, which produces true claudication. In cases of spinal stenosis, the straight leg test result is often negative.
- The stoop test helps distinguish true claudication from pseudoclaudication. Patients with true claudication sit down to rest when pain occurs, while patients with pseudoclaudication attempt to keep walking by stooping or flexing the spine to relieve the stretch on the sciatic nerve.
- Sacroiliitis usually presents with pain over the involved joints and no peripheral neurologic findings.
- Osteomyelitis may be subacute or acute.
- Clinical findings are nonspecific, and the patient may be afebrile on presentation.
- Classic presentation includes pain on palpation of the vertebral body, elevated sedimentation rate, and complaints of pain out of proportion to physical findings.
- Patients particularly at risk for development of osteomyelitis include patients who have undergone recent back surgery, intravenous (IV) drug users, patients with immunosuppression, and those with a history of chronic pelvic inflammatory disease (PID).
Please refer to Pathophysiology, which describes specific causes of back pain in detail. Certain clinical clues can help differentiate between causes. Generally, impingement syndromes produce positive straight leg raising tests, whereas pure irritation does not. To assess for a functional disorder as the cause of low back pain, consider the following:
- Mechanical low back pain is a common complaint in patients with functional disorders. In addition, a functional overlay or component of secondary gain may be present in some patients with true organic pathology. The degree of psychosocial issues affecting the patient's condition may be assessed by the following:
- Patient may receive compensation for injury.
- Patient has pending litigation.
- Patient dislikes job.
- Patient has symptoms of depression.
- Patient caused the accident resulting in back pain.
- Physical clues that help identify patients with significant functional overlay or component of secondary gain include the following:
- Findings of nonanatomic motor or sensory loss
- Nonspecific tenderness or generalized tenderness over the entire back
- Overly dramatic behavior and loss of positive straight leg raising test when patient is distracted
- A particularly useful test is to have patients hold their wrists next to their hips and turn their body from side to side. This test gives the illusion that you are testing spinal rotation, but no actual stress is placed on any muscles or ligaments. Any complaint of pain during this maneuver is strongly suggestive of a functional overlay or component of secondary gain in the presentation.
- Consider performing urinalysis if the problem is not clearly musculoskeletal or an exacerbation of chronic back pain.
- Perform a complete blood count (CBC) and erythrocyte sedimentation rate (ESR) if the patient is febrile or if an epidural or spinal abscess, or osteomyelitis is suspected. While ESR has moderate specificity, the sensitivity is relatively high in cases of abscess, and it can be used as a screening test.
- Other laboratory studies are rarely needed unless a disorder other than back pain is strongly suspected.
- Lumbosacral spine series are expensive and expose the reproductive organs to significant radiation. Annually, 7-8 million such tests are obtained, but most have little value in directing therapy, particularly among adults younger than 50 years.
- Osteophytes are the most frequently seen abnormality of plain films followed by intervertebral disc space narrowing. Both increase with age. Disc space narrowing appears to be more frequent in women. Disc space narrowing at 2 or more levels is strongly associated with back pain pathology.
- Unless a history of traumatic injury or systemic illness is present, such films should be obtained only for suspicion of malignancy or infection. Malignant involvement of vertebral bodies can be evident on plain film when as little as 30% of the vertebral body has been replaced.
- Other indications that suggest the need for radiographic imaging include chronic steroid use and acute onset of pain in patients older than 50 years or in the pediatric age group.
- The physician may also consider obtaining radiographs in patients whose cases involve (or potentially involve) litigation or for patients seeking compensation.
- CT and MRI
- CT and MRI are generally considered the studies of choice for more precise imaging of the vertebrae, paraspinal soft tissues, discs, or spinal cord. CT images cortical bone with higher resolution and can delineate some fractures better than MRI.
- MRI is generally the preferred imaging modality for detecting disc, cord, or soft tissue abnormalities.
- Ultrasonography may be useful if the differential diagnosis includes appendicitis, a pathologic pelvic process, or abdominal aneurysm.
- True emergencies that necessitate imaging include the following:
- Patients with a history of malignancy and new evidence of nerve entrapment
- Patients with back pain associated with paralysis or gross muscle weakness
- Patients with bilateral neurologic deficits associated with bowel or bladder function loss
- Patients in whom an epidural hematoma or epidural abscess is suspected
- Postoperative patients with a recent lumbar laminectomy or hip replacement
Improvement occurs in almost all patients within 4-6 weeks, except those with infection, occult malignancy, or systemic illness. If pain fails to significantly improve or resolve in this time frame, imaging is always indicated.
- Perform the straight leg raising test with the patient in a supine position. Record the response to raising each leg. An approximation of the test may be performed with the patient sitting and each leg straightened at the knee. The examiner should take care to make sure that the quadriceps muscle is relaxed while passively raising the leg to ensure that the sciatic nerve is being adequately stretched during the testing. If the quadriceps is contracted, it will take the pressure off the sciatic nerve and may give a false-negative result.
- The stoop test helps distinguish true claudication from pseudoclaudication. Patients with true claudication sit down to rest when pain occurs, while patients with pseudoclaudication attempt to keep walking by stooping or flexing the spine to relieve the stretch on the sciatic nerve.
Mechanical low back pain is one of the most common patient complaints expressed to emergency physicians in the United States accounting for more than 6 million cases annually. Approximately two thirds of adults are affected by mechanical low back pain at some point in their lives, making it the second most common complaint in ambulatory medicine and the third most expensive disorder in terms of health care dollars spent surpassed only by cancer and heart disease.
Low back pain reportedly occurs at least once in 85% of adults younger than 50 years, and 15-20% of Americans have at least one episode of back pain per year. Of these patients, only 20% can be given a precise pathoanatomic diagnosis. Low back pain affects men and women equally. The onset most frequently occurs in people aged 30-50 years. Low back pain is the most common and most expensive cause of work-related disability in the United States. Smokers appear to have an increased incidence of back pain compared with nonsmokers. Furthermore, the incidence of current smoking and the association with low back pain is higher in adolescents than in adults.
Many causes of mechanical low back pain exist. The most common causes are age-related degenerative disc and facet processes and muscle- or ligament-related injuries. Discussion in this article is limited to musculoskeletal causes. These can be divided into nerve root syndromes, musculoskeletal pain syndromes, and skeletal causes.
Nerve root syndromes
Classic nerve root syndrome is characterized by radicular pain arising from nerve root impingement due to herniated discs. A similar syndrome can also be produced by inflammation and irritation, which may explain why patients whose presentation is consistent with this diagnosis respond to conservative therapies.
Impingement pain tends to be sharp, well localized, and can be associated with paresthesia, whereas irritation pain tends to be dull, poorly localized, and without paresthesia. Impingement is associated with a positive straight leg raising sign (ie, shooting pain down contralateral leg with leg raising), while irritation is not. Neurologic deficits and pain radiation below the knee are rarely seen in irritation alone and are most commonly found with impingement.
The cause of impingement syndrome is most commonly herniated discs, but it may also be caused by spinal stenosis, spinal degeneration, or cauda equina syndrome.
Herniated discs are produced as spinal discs degenerate. After growing thinner, the nucleus pulposus herniates out of the central cavity against a nerve root. Intervertebral discs begin to degenerate by the third decade of life, and herniated discs are found on autopsy in one third of adults older than 20 years. Only 3% of these, however, are symptomatic. The most common locations for herniation are L4, L5, and S1.
Spinal stenosis occurs when disc spaces decrease as intervertebral discs lose moisture and volume with age. Even minor trauma under these circumstances can cause inflammation or nerve root impingement, which can produce classic sciatica pain without disc rupture. The pain can often be bilateral.
Spinal degeneration is caused by alterations in the hygroscopic quality of the nucleus pulposus. This process progresses to annular degeneration. Coupled with progressive posterior facet disease, this process leads to spinal canal or foraminal encroachment. These retrogressive and proliferative changes in the disc anteriorly and the joints posteriorly produce clinical symptoms and radiographic findings termed 3-joint complex degeneration. Spinal degeneration has 3 distinct stages, as follows:
- Dysfunction with complaints of pain only
- Instability with advanced degeneration, pseudospondylolisthesis, and neurologic abnormalities
- Stabilization with morning stiffness and with prolonged standing or walking, producing radicular pain
Cauda equina syndrome is produced by massive midline extrusion of nuclear material or tumor into the spinal canal, which compresses the caudal sac. The classic presentation is bilateral sciatica, with lower extremity bowel or bladder dysfunction present in 90% of patients. Urinary retention is initially observed and followed by overflow incontinence. Perineal or perianal anesthesia is present in 60-80% of patients.
Musculoskeletal pain syndromes
Musculoskeletal pain syndromes that produce low back pain include myofascial pain syndromes and fibromyalgia.
Myofascial pain is characterized by pain and tenderness over localized areas (trigger points), loss of range of motion in the involved muscle groups, and pain radiating in a characteristic distribution but restricted to a peripheral nerve. Relief of pain is often reported when the involved muscle group is stretched.
Fibromyalgia results in pain and tenderness on palpation of 11 of 18 trigger points, one of which is the low back area, as classified by the American College of Rheumatology. Generalized stiffness, fatigue, and muscle ache are reported.
Other skeletal causes
Other skeletal causes of low back pain include osteomyelitis, sacroiliitis, and malignancy.
Osteomyelitis results from infectious processes involving the bones of the spine, while sacroiliitis results from inflammatory changes in the sacroiliac joints. This pain presents over the sacroiliac joints and radiates to the anterior and posterior thighs. This pain is usually worse at night and is exacerbated by prolonged sitting or standing.
Malignant tumors of the spine can be primary or metastatic. Most primary spinal tumors are found in patients younger than 30 years and usually involve the posterior vertebral elements. Metastatic tumors are found mostly in patients older than 50 years and tend to occur in the anterior aspects of the vertebral body.
Mechanical low back pain is one of the most common patient complaints expressed to emergency physicians in the United States accounting for more than 6 million cases annually.
- Most etiologies of mechanical low back pain are not life threatening; however, significant morbidity is associated with chronic low back pain syndromes.
- A significant number of patients are unable to return to their normal daily routines or function in a productive work environment secondary to low back pain.
- Most cases of back pain treated in the emergency department are not true emergencies, with the exception of cauda equina syndrome. Patients who have cauda equina syndrome must undergo surgical decompression as soon as possible or face permanent neurologic damage.
No differences exist in incidence of back pain between racial groups.
Both male and female populations are affected; however, there is a tendency towards a higher incidence in male patients.
Low back pain is a common complaint in adults of all ages, and it is becoming an increasing complaint in children and adolescents.