Assessment of Dorso-Lumbar Spine: Low Back Pain

Low Back Pain

• Pain and discomfort localized below the costal margins and above the inferior gluteal folds, with or without referred leg pain.

Global Diagnostic Triage (International Guidelines)

• Serious pathology (red flags) prioritized over radicular syndrome and non-specific/mechanical low back pain.

Non-Specific/Mechanical Low Back Pain

• Not attributable to a objectively recognizable, known specific pathology (e.g., infection, tumor, osteoporosis).
• Different underlying causes, including:
  • Myofascial
  • Discogenic
  • Sacroiliac

Red Flags

Spinal Fractures

• Major trauma
• Osteoporotic fracture
• Osteoporosis

Cancer

• History of cancer
• Multiple cancer risk factors
• Strong clinical suspicion

Infection

• Immunocompromised status
• Urinary tract infection
• Intravenous drug use

Neurophatic Pain

• Pain arising from injury or disease directly affecting the nerve roots that innervate the spine and lower limbs.
• No gold-standard approach for diagnosis.
• Distribution of pain and associated sensory or motor signs, including:
  • Sensory loss
  • Hyperalgesia, allodynia
  • Weakness
  • Numbness, tingling, electricity type pain

Nerve Roots Disorders

• Dorsal flexion worsens pain, plantar flexion makes it better.
• Flexion of head worsens pain, extension relieves it.

Mechanical Low Back Pain

• Sacroiliac joint pain suggested when 3 or more of 6 positive tests (Gaenslen's left and right, thigh thrust, sacral thrust, distraction, and iliac compression).
• Estimated sensitivity of 93.8%, specificity of 78.1%.
• Discogenic pain:
  • 26%-42% of patients with low back pain
  • Annular disruption and inflammatory response
  • Centralization of symptoms: progressive resolution, reduction, or retreat of pain toward midline

Low Back Pain

• Pain and discomfort localized below the costal margins and above the inferior gluteal folds, with or without referred leg pain.

Global Diagnostic Triage (International Guidelines)

• Serious pathology (red flags) prioritized over radicular syndrome and non-specific/mechanical low back pain.

Non-Specific/Mechanical Low Back Pain

• Not attributable to a objectively recognizable, known specific pathology (e.g., infection, tumor, osteoporosis).
• Different underlying causes, including:
  • Myofascial
  • Discogenic
  • Sacroiliac

Red Flags

Spinal Fractures

• Major trauma
• Osteoporotic fracture
• Osteoporosis

Cancer

• History of cancer
• Multiple cancer risk factors
• Strong clinical suspicion

Infection

• Immunocompromised status
• Urinary tract infection
• Intravenous drug use

Neurophatic Pain

• Pain arising from injury or disease directly affecting the nerve roots that innervate the spine and lower limbs.
• No gold-standard approach for diagnosis.
• Distribution of pain and associated sensory or motor signs, including:
  • Sensory loss
  • Hyperalgesia, allodynia
  • Weakness
  • Numbness, tingling, electricity type pain

Nerve Roots Disorders

• Dorsal flexion worsens pain, plantar flexion makes it better.
• Flexion of head worsens pain, extension relieves it.

Mechanical Low Back Pain

• Sacroiliac joint pain suggested when 3 or more of 6 positive tests (Gaenslen's left and right, thigh thrust, sacral thrust, distraction, and iliac compression).
• Estimated sensitivity of 93.8%, specificity of 78.1%.
• Discogenic pain:
  • 26%-42% of patients with low back pain
  • Annular disruption and inflammatory response
  • Centralization of symptoms: progressive resolution, reduction, or retreat of pain toward midline

Centralization

• Defined as the phenomenon where a movement or position leads to the abolition of pain or the migration of symptoms from a more distal or lateral area in the buttocks and lower extremity to a more proximal location near the midline of the lumbar spine.
• Indicates a good prognosis.

Myofascial Pain

• Can be a contributing factor to other sources of low back pain (LBP) or a primary cause in itself.
• No gold standard for evaluating myofascial pain.
• Characterized by the presence of trigger points.

Lumbopelvic Instability

• Results from dysfunction in one or more of the stabilizing subsystems, leading to an increase in the size of the neutral zone.
• Comprises three subsystems:
  • Passive subsystem
  • Active subsystem
• Clinical instability is defined as the clinical signs and symptoms created by dysfunction of one or more of the stabilizing subsystems of the spine.

Functional Instability

• Associated with altered intervertebral discs and ligamentous support of the spine.
• Can be identified using the positive passive lumbar extension test (also known as the Prone instability test).

Centralization

• Defined as the phenomenon where a movement or position leads to the abolition of pain or the migration of symptoms from a more distal or lateral area in the buttocks and lower extremity to a more proximal location near the midline of the lumbar spine.
• Indicates a good prognosis.

Myofascial Pain

• Can be a contributing factor to other sources of low back pain (LBP) or a primary cause in itself.
• No gold standard for evaluating myofascial pain.
• Characterized by the presence of trigger points.

Lumbopelvic Instability

• Results from dysfunction in one or more of the stabilizing subsystems, leading to an increase in the size of the neutral zone.
• Comprises three subsystems:
  • Passive subsystem
  • Active subsystem
• Clinical instability is defined as the clinical signs and symptoms created by dysfunction of one or more of the stabilizing subsystems of the spine.

Functional Instability

• Associated with altered intervertebral discs and ligamentous support of the spine.
• Can be identified using the positive passive lumbar extension test (also known as the Prone instability test).