Dr. Ebraheim’s educational animated video describes the condition of low back pain - simple or complicated.
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low back pain, can be simple or complicated. It is hard to imagine anything simple associated with a disease or sickness, but low back pain can be simple. I am going to try to explain the difference between a simple low back pain situation and a complicated situation. 80% of the population will experience low back pain during their lifetime. About 3% will experience lower extremity radiculopathy. Radiculopathy could mean shooting pain down to the buttock, the posterior thigh, and the posterior leg.
It is important to ask a low back pain patient a few questions:
1. Do you have bladder and bowel symptoms?
If the answer is no, then this is good! If the answer is yes, then this could be bad, because it means the patient could have cauda equina syndrome. If the answer is yes, then you need to get an emergency MRI and you need to make sure that there is no compression of the cauda equina. If there is compression of the cauda equina then this is an emergency and you need to do an urgent surgery, otherwise the bladder function may not recover.
2. Do you stagger when you walk? Do you have unsteady gait?
If the answer is no, then this is good! If the answer is yes, "I have unsteady gait and also clumsiness in the hands ", then you should start looking at the cervical spine of the patient for another associated lesion that may cause cervical myelopathy.
3. Does the pain radiate down the leg?
If the answer is yes, then this is radiculopathy (nerve irritation associated with lumbar disc herniation). This radicular pain is usually unilateral leg pain and dermatomal.
If the patient has low back pain, 50% of the patients resolve their pain in 1 week, and 95% of the patients resolve their pain in 3 months. If you have radiculopathy, 50% of the patients recover in 1 month and 75% recover in 1 year. If you have nerve irritation and radiculopathy, then it is really more complex than if you have low back pain by itself. This radiculopathy may take a longer time to get better.
4. Ask the patient about neurogenic claudication (pain in the buttock and leg, worse with prolonged standing). If the answer is yes, then this patient probably has spinal stenosis. When the patient stands for a long time, the hyperextension of the spine makes the pain worse, and flexion of the spine improves the pain.
5. Does the patient have pain from movement of the spine?
If the answer is yes, then this is mechanical pain. This is probably better than pain that happens at rest and at night, especially if the patient has weight loss or fever, which can be associated with a tumor or infection. 50% of the new patient visits to physicians are due to low back pain, so it is a very common thing. Back pain can be idiopathic or nonspecific. In the 85% of cases, you will find no cause. Reaching a definitive, conclusive diagnosis may be difficult and 85% of patients because they may have idiopathic low back pain that does not have a cause, that will go away and the majority will get better in 3 months.
This is one of the questions that you will ask the patient, if there is more leg pain than back pain? If the patient has leg pain greater than the back pain, then the patient will have sciatica. In sciatica or lumbar radiculopathy, leg pain is greater than the back pain, especially if the disc is large or extruded. If the patient has more back pain than leg pain, then you can successfully treat the patient conservatively. Sciatica can be self-diagnosed by the patient. Sciatica means nerve root irritation probably due to a herniated disc. The disc herniation sometimes is resolved with time. The pain will be worse with sitting, coughing, sneezing, and forward flexion. The pain associated with disc herniation is less by lying down and rest. If the patient has a painful lumbar flexion, then you have a disc problem. If the patient has a painful lumbar extension, then the patient has a facet problem. When you do the examination for the patient with sciatica, you do the straight leg raise test. If the test is positive, it may indicate that the patient has a disc herniation compressing the nerve root. Disc herniation and leg pain is more complicated than low back pain alone. Another good thing that you will note from the history is that you will figure out about the risk factors. Usually, the patient is 30 to 50 years old. The cause may be occupational, with repetitive heavy lifting and driving. Be aware of things that increase the disc pressure and cause more pain. Actually, the disc pressure is the lowest in a supine position followed by standing. The worst disc pressure is when the patient is sitting and leaning forward.