Section 4
Issues in Specific Diagnoses
Chapter Low Back Pain
41 Karen P. Barr and Mark A. Harrast
Low back pain has become a costly burden to society and a
leading cause of disability and loss of productivity. This chapter
outlines the anatomy and biomechanics of the lumbar spine,
and our current understanding of the physiology of low back
pain. We discuss the clinical evaluation and treatment of various
etiologies of low back pain and leg pain caused by lumbar spine
disease.
Epidemiology
Low back pain is a symptom, not a disease, and has many
causes. It is generally described as pain between the costal
margin and the gluteal folds. It is extremely common. About
40% of people say that they have had low back pain within the
last 6 months.213 Studies have shown a lifetime prevalence as
high as 84%.220 Onset usually begins in the teens to early forties.
Most patients have short attacks of pain that are mild or moder-
ate and do not limit activities, but these tend to recur over
many years. Most episodes resolve with or without treatment.
The median time off work for a back injury is 7 days, and many
people with low back pain never alter their activity. However,
a small percentage of low back pain becomes chronic and causes
significant disability. In most studies, about half the amount of
sick days used for back pain are accounted for by the 15% of
people who are home from work for more than a month.
Between 80 and 90% of the healthcare and social costs of back
pain are for the 10% who develop chronic low back pain and
disability. Just over 1% of adults in the USA are permanently
disabled by back pain, and another 1% are temporarily
disabled.140
The percentage of patients disabled by back pain, as well as
the cost of low back pain, has steadily increased over the past
25 years. This appears, however, to be more from social causes
than from a change in the conditions that cause low back pain.
The two most commonly cited factors are the increasing soci-
etal acceptance of back pain as a reason to become disabled,
and changes in the social system that pay benefits to patients
with back pain.
Anatomy and biomechanics of
the lumbar spine
General concepts
The lumbar spine has a dichotomous role in terms of function,
which is strength coupled with flexibility. The spine performs
Ch041-X2610.indd 883
a major role in support and protection (strength) of the spinal
canal contents (spinal cord, conus, and cauda equina) but also
give us inherent flexibility, allowing us to place our limbs in
appropriate positions for everyday functions.
The strength of the spine results from the size and arrange-
ments of the bones, as well as from the arrangement of the
ligaments and muscles. The inherent flexibility results from the
large number of joints placed so closely together in series. Each
vertebral segment can be thought of as a three-joint complex
(one intervertebral disk with vertebral end plates, and two
zygapophyseal joints). The typical lordotic framework of the
lumbar spine assists with this flexibility but also increases the
ability of the lumbar spine to absorb shock, which is an impor-
tant role due to the amount of forces that travel through the
spine on a regular basis.
The vertebrae
The bony anatomy of the lumbar spine consists of five lumbar
vertebrae. A smaller percentage of the population has four (the
fifth vertebrae is sacralized) or six (the first sacral segment is
lumbarized). There are also anatomic variants consisting of a
partially lumbarized S1, where there can be a pseudoarthrosis
between the transverse process of the lowest lumbar vertebrae
and the sacral alae, or the articulation might be entirely united
through bony fusion. It is important to recognize this articula-
tion, when it exists, as it has been hypothesized to be a potential
source of pain.
The lumbar vertebrae have distinct components, which
include the vertebral body, the neural arch, and the posterior
elements (Fig. 41-1). The vertebral bodies increase in size as
you travel caudally in the spine. The lower three are typically
more wedge-shaped (taller anteriorly), which helps create the
normal lumbar lordosis. The structure of these large vertebral
bodies serves its weight-bearing function well to support axially
directed loads; however, they would fracture more routinely
were it not for the shock-absorbing intervertebral disks placed
strategically between the vertebral bodies.
The sides of the bony neural arch are the pedicles, which are
thick pillars that connect the posterior elements to the vertebral
bodies. They are designed to resist bending, and to transmit
forces back and forth from the vertebral bodies to the posterior
elements. The posterior elements consist of the laminae, the
articular processes, and the spinous processes. The superior and
inferior articular processes of adjacent vertebrae create the
A
zygapophyseal joints. Finally, the pars interarticularis is a part
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 884 Section 4 Issues in Specific Diagnoses

Pedicle

Superior
articular
facet Vertebral
body
Transverse
process
(a)
Spinous
process
Inferior Lamina Inferior
articular vertebral
facet notch
Figure 41-1  Lateral view of the lumbar vertebrae. (From Parke 1999,154
with permission.)
(b)

Figure 41-3  The mechanism

of weight transmission in an
intervertebral disk. (a) Compression
raises the pressure in the nucleus
pulposus. This is exerted radially on
to the annulus fibrosus, and the
2 tension in the annulus rises. (b) The
1 (c) tension in the annulus is exerted
3 on the nucleus, preventing it from
expanding radially. Nuclear pressure
is then exerted on the vertebral end
plates. (c) Weight is borne, in part,
by the annulus fibrosus and by
the nucleus pulposus. (d) The radial
pressure in the nucleus braces the
annulus, and the pressure on the
Figure 41-2  An oblique dorsal view of an L5 vertebra, showing the
end plates transmits the load from
parts of the vertebral arch: 1, pars interarticularis (crosshatched area);
one vertebra to the next. (From
2, pars laminaris; and 3, pars pedicularis. The dotted line indicates the
(d) Bogduk 1977,26 with permission.)
most frequent site of mechanical failure of the pars interarticularis. (From
Parke 1999,154 with permission.)

collagen, and less proteoglycans and water, than the inner

of the lamina between the superior and inferior articular
processes (Fig. 41-2). The pars is the site of stress fractures
(spondylolysis), because it is subjected to large bending forces
as the forces transmitted by the vertically oriented lamina
undergo a change in direction into the horizontally oriented
pedicle.23
The joints
The intervertebral disk
The intervertebral disk and its attachment to the vertebral end
plate are considered a secondary cartilaginous joint, or symphy-
sis. The disk consists of the internal nucleus pulposus and the
outer annulus fibrosus. The nucleus pulposus is the gelatinous
inner section of the disk. It consists of water, proteoglycans,
and collagen. At birth, the nucleus pulposus is 90% water. Disks
desiccate and degenerate as we age, and lose some of their
height, which is one reason we are slightly shorter in our
geriatric years.
The annulus fibrosus consists of concentric layers of fibers at
oblique angles to each other, which help to withstand strains in
A
any direction. The outer fibers of the annulus comprise more
fibers.19 The varying composition supports the outer fibers’
functional role in acting more as a ligament to resist flexion,
extension, rotation, and distraction forces.
The main function of the intervertebral disk is shock absorp-
tion (Fig. 41-3). However, it is primarily the annulus that acts
as the shock absorber, and not the nucleus, which is primarily
a liquid (and incompressible). When an axial load occurs, the
increase in force in the incompressible nucleus pushes on the
annulus and stretches its fibers. If the fibers break, then a
herniated nucleus pulposus results.
The zygapophyseal joints
The zygapophyseal joints (or Z joints) are paired synovial joints,
i.e. they have a synovium and a capsule (Fig. 41-4). Their align-
ment or direction of joint articulation determines the direction
of motion of the adjacent vertebrae. The lumbar zygapophyseal
joints lie in the sagittal plane, and thus primarily allow flexion
and extension, although some lateral bending and very little
rotation are allowed, which limit torsional stress on the lumbar
disks. Rotation is more a component of thoracic spine motion.
The majority of flexion and extension (90%) occurs at the L4–5

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C C
AC
Figure 41-4  A posterior view of the L3–4 zygapophysial joints. On
the left, the capsule of the joint (C) is intact. On the right, the posterior
capsule has been resected to reveal the joint cavity, the articular
cartilages (AC), and the line of attachment of the joint capsule (dashed
line). The upper joint capsule (C) attaches further from the articular
margin than the posterior capsule does. (From Bogduk 1977,27 with
permission.)
Nerve root
compression
in the lateral
recess
Pasterolateral
herniated
nucleus
pulposus
Nucleus
pulposus
Figure 41-5  Posterolateral intervertebral disk herniation.
to S1 levels, thus contributing to the high prevalence of disk
problems at these levels.
Biomechanics
Because flexion loads the anterior disk, the nucleus is displaced
posteriorly.102 If the forces are great enough, the nucleus can
herniate through the posterior annular fibers. The lateral fibers
of the posterior longitudinal ligaments are thinnest, however,
making posterolateral disk herniations the most common
(Fig. 41-5). The posterolateral portion of the disk is most at
risk, with forward flexion accompanied by lateral bending
(i.e. bending and twisting). Finally, when in flexion the zygapo-
physeal joints can no longer resist rotation. This increases tor-
sional shear forces in the lumbar spine, making rotary movements
in a forward-flexed posture probably the most risky for lumbar
disks.
The ligaments
There are two main sets of ligaments of the lumbar spine: lon-
gitudinal ligaments and segmental ligaments. The two longitu-
dinal ligaments are the anterior and posterior longitudinal
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Chapter 41
Low Back Pain 885
ligaments. They are named according to their position on the
vertebral body. The anterior longitudinal ligament acts to resist
extension, translation, and rotation, whereas the posterior lon-
gitudinal ligament acts to resist flexion. Disruption of either
ligament primarily occurs with rotation rather than with flexion
or extension. The anterior longitudinal ligament is twice as
strong as the posterior longitudinal ligament.
The main segmental ligament is the ligamentum flavum,
which is a paired structure joining adjacent laminae and is the
ligament that is pierced when performing lumbar punctures. It
is a very strong ligament but also elastic enough to allow flexion.
Flexing the lumbar spine puts this ligament on stretch, decreas-
ing its redundancy and making it easier to pierce during a
lumbar puncture.
The other segmental ligaments are the supraspinous, inter-
spinous, and intertransverse. The supraspinous ligaments
deserve mention, as they are the strong ligaments that join the
tips of adjacent spinous processes and act to resist flexion.
These ligaments, along with the ligamentum flavum, act to
restrain the spine and prevent excessive shear forces in forward
Cauda bending. This is supported by electromyographic studies that
equina have shown that there is no active contraction of the erector
spinae and hip extensor muscles when resting in lumbar
flexion.
Defect
The muscles
in anulus
fibrosus
Muscles with origins on the lumbar spine
These muscles can be divided anatomically into posterior and
anterior muscles. The posterior muscles include the latissimus
Anulus dorsi and the paraspinals. The lumbar paraspinals consist of the
fibrosus erector spinae (iliocostalis, longissimus, and spinalis), which act
as the chief extensors of the spine, and the deep layer (rotators
and multifidi) (Figs 41-6 and 41-7). The multifidi are tiny seg-
mental stabilizers that act to control lumbar flexion, because
they cannot produce enough force to truly extend the spine.
Their more important function has been hypothesized as more
of a sensory organ to provide proprioception for the spine, given
the predominance of muscle spindles seen histologically in
these muscles.
The anterior muscles of the lumbar spine include the psoas
and quadratus lumborum. Because of the direct attachment of
the psoas on the lumbar spine, tightening this muscle accentu-
ates the normal lumbar lordosis. This can increase forces on the
posterior elements and can contribute to zygapophyseal joint
pain. The quadratus lumborum acts in side bending and can
assist in lumbar flexion.
Abdominal musculature
The superficial abdominals include the rectus abdominis and
external obliques (Fig. 41-8a). The deep layer consists of
internal obliques and the transversus abdominis (Fig. 41-8b).
The transversus abdominis has received significant attention
over the recent past as an important muscle to train in treating
low back pain. Its connection to the thoracolumbar fascia
A
(and consequently its ability to act on the lumbar spine) has
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 886 Section 4 Issues in Specific Diagnoses

Semispinalis capitis

Semispinalis cervicis

Iliocostalis thoracis

Longissimus thoracis

Spinalis thoracis

Iliocostalis thoracis Spinalis thoracis

Longissimus lumborum

Iliocostalis lumborum

Multifidus

Figure 41-6  The intermediate layer of back muscles: the erector spinae. Figure 41-7  The deep back muscles: the multifidi.

Serratus Pectoralis
anterior major

Anterior Rectus
layer of abdominis
rectus
Serratus 5th costal sheath Posterior
anterior cartilage layer of
rectus
Anterior layer External sheath
Anterior layer of oblique
of rectus sheath
rectus sheath (cut edges)
Transversus
Rectus
abdominis
External abdominis
Internal
oblique
oblique Internal
External
oblique oblique
Anterior
Anterior superior superior Rectus
iliac spine iliac spine abdominis
(a) (b)
Figure 41-8  (a) The superficial abdominal muscles. (b) The deep abdominal muscles.

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probably been the major reason it has received such attention
of late.
Thoracolumbar fascia
The thoracolumbar fascia, with its attachments to the transver-
sus abdominis and internal obliques, acts as an abdominal and
lumbar ‘brace’. It decreases some of the shear forces that other
muscles and lumbar motions create. This abdominal bracing
mechanism results from contraction of these deep abdominal
muscles, which creates tension in the thoracolumbar fascia,
which then creates an extension force on the lumbar spine
without increasing shear forces.71
Pelvic stabilizers
The pelvic stabilizers are considered ‘core’ muscles due to their
indirect effect on the lumbar spine, even though they do not
have a direct attachment to the spine. The gluteus medius
stabilizes the pelvis during gait. Weakness or inhibition of this
muscle results in pelvic ‘instability’, which introduces lumbar
side bending and rotation, creating increased shear or torsional
forces on the lumbar disks.
The piriformis, as a hip and sacral rotator, can cause excessive
external rotation of the hip and sacrum when it is tight. This
can result in increased shear forces at the lumbosacral junction
(i.e. the L5–S1 disk).
Biomechanical lifting in relation to muscular activity and
disk loads
The activity of the lumbar muscles correlates well with intra­
diskal pressures (i.e. when back muscles contract, there is an
associated rise in disk pressure). These pressures change depend-
ing on spine posture and the activity undertaken. Figure 41-9
demonstrates these changes in L3 disk pressure under various
%
%
25 75 100 150 220 140 185 275
(a)
Figure 41-9  (a) Relative change in pressure (or load) in the third lumbar disk in various positions in living subjects. (b) Relative change
in pressure (or load) in the third lumbar disk during various muscle-strengthening exercises in living subjects. Neutral erect posture is considered
100% in these figures; other positions and activities are calculated in relationship to this. (From Nachemson with permission of
Lippincott Williams & Wilkins.)
Ch041-X2610.indd 887
Chapter 41
Low Back Pain 887
positions and exercises.141,142 Adding rotation to the already
flexed posture increases the disk pressure substantially. Com-
paring lifting maneuvers, it has been shown that there is not a
significant difference in disk pressure when lifting with the legs
(i.e. with the back straight and knees bent) versus lifting with
the back (i.e. with a forward-flexed back and straight legs).6,7
What decreases the forces on the lumbar spine is lifting the
load close to your body, as the farther the load is from the
chest, the greater the stress on the lumbar spine.7
The nerves
The conus medullaris ends at about bony level L2, and below
this level is the cauda equina. The cauda equina consists of the
dorsal and ventral rootlets, which join together in the interver-
tebral neuroforamen to become the spinal nerves (Fig. 41-10).
The spinal nerve gives off the ventral primary ramus, which,
together from the other levels, forms the lumbar and lumbo­
sacral plexus to innervate the limbs. The dorsal primary ramus,
with its three branches (medial, intermediate, and lateral),
innervates the posterior half of the vertebral body, the paraspi-
nal muscles, and the zygapophyseal joints, and provides sensa-
tion to the back. The medial branch is the most important to
remember, as it innervates the zygapophyseal joints and lumbar
multifidi and is the target during radiofrequency neurotomy for
presumed zygapophyseal joint pain (Fig. 41-11).25
Biochemistry and pathophysiology
Radiculitis and radiculopathy
Many patients with radicular pain have no neural impingement
noted on magnetic resonance imaging (MRI). Studies have
shown that disk herniations can cause an inflammatory
response.121,124,174 The mechanism stems from the fact that the
150 180 210 100 140 130 35
(b)
A
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 888 Section 4 Issues in Specific Diagnoses

Dura Multiple inflammatory mediators have been identified at the

site of disk injury, indicating their role in the pathogenesis
Arachnoid of chemical radiculitis. These mediators include phospholipase
A2, cyclooxygenase-2, prostaglandin E2, nitric oxide, cytokines,
Subarachnoid
interleukins, and immunoglobulins.62,70,136,174 Although these
Dural sleeve
space inflammatory mediators have all been implicated in the bio-
chemical pathogenesis of radicular symptoms, the role of the
Pia
inflammatory cells, including macrophages and neutrophils, has
Spinal nerve not yet been elucidated.74,97
The mechanism of mechanical compression of the nerve
Dorsal root
roots has been studied as well.13,171,172 Compression of nerve
Ventral ramus
roots can induce structural and vascular changes as well as
Ventral root inflammation.142 Neural compression can result in impairment
of intraneural blood flow, subsequently decreased nutrient
Dorsal root supply to the neural tissue, local ischemia, and formation of
ganglion Dorsal ramus intraneural edema. This can set off an inflammatory cascade
Figure 41-10  A lumbar spinal nerve, its roots and meningeal coverings. similar to that described above. Mechanical stimulation of
The nerve roots are invested by pia mater, and covered by arachnoid lumbar nerve roots has also been shown to stimulate production
and dura as far as the spinal nerve. The dura of the dural sac is of substance P, the neuropeptide known to modulate sensory
prolonged around the roots as their dural sleeve, which blends
with the epineurium of the spinal nerve. (From Bogduk 1977,24 nociceptive feedback.13 With these biochemical reactions, the
with permission.) local structural effects of mechanical compression (demyelina-
tion and axonal transport block) just compound the sympto-
matic response.

Transverse Superior The degenerative spine cascade

process articular Kirkaldy-Willis et al. have supplied us with the most accepted
facet theory describing the cascade of events in degenerative lumbar
spine disease that results in spondylotic changes, disk hernia-
Spinal tions, and eventually multilevel spinal stenosis (Fig. 41-12).100
nerve Medial
branch At the heart of this theory is the fact that, although the poste-
rior zygapophyseal joints and the anterior intervertebral disks
Ventral are separated anatomically, forces and lesions affecting one
Zygapo-
primary physeal certainly alter and affect the other. For example, axial com-
ramus joint pressing injuries can damage the vertebral end plates, which can
lead to degenerative disk disease, which eventually stresses the
Dorsal Inferior
posterior joints, leading to the common degenerative changes
primary articular seen in them over the course of time. Torsional stress can injure
ramus facet the posterior joints and/or the disks, which in turn leads to
Figure 41-11  Observe that the innervation of the zygapophyseal joints increased stress on both these elements, resulting in further
derives from the medial branch off the dorsal primary ramus. degenerative changes over time. When these degenerative
changes affect one level, say L4–5, a chain reaction occurs,
placing stress on the levels above and below the currently
affected level, and eventually resulting in more generalized
multilevel spondylotic changes.
In studying lumbar degenerative disease, the question of
nucleus pulposus, being in an immunoprotected setting in which came first (disk degeneration or zygapophyseal joint
non-pathologic states, is highly antigenic. When the fluid of the degeneration) always arises. Fujiwara has answered this by
nucleus pulposus is exposed to neural tissue of the spinal canal studying multiple MRIs of aging spines.63 He hypothesizes that
and neuroforamen through a defect in the annular fibers, disk degeneration precedes zygapophyseal joint osteoarthritis,
an autoimmune-mediated inflammatory cascade begins. The and that it might take 20 years for zygapophyseal joint disease
inflammatory mediators generated can cause swelling of the to occur after the onset of disk degeneration.
nerves. This can alter their electrophysiologic function, sensitiz- To describe the degenerative cascade in more detail, we will
ing these neurons and enhancing pain generation without separate our discussion of the changes that occur in the poste-
specific mechanical compression. rior joints from those in the disk, but fully realizing that they
A

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 Chapter 41
Low Back Pain 889

Posterior Three joint Intervertebral A similar process is occurring anteriorly at the disk level from
joints complex disk repetitive microtrauma of primarily shearing forces. Tears in
the annulus are thought to be the first anatomic sign of degen-
erative wear. When the annulus is weakened enough, typically
Synovial Circumferential posterolaterally, the internal nucleus pulposus can herniate.
reaction tears However, internal disk disruption can occur without herniation
as age and repeated stresses acting on the spine cause the gelati-
nous nucleus to become more fibrous over time. Tears in the
Cartilage Radial annulus can progress to tears in the fibrous disk material, result-
Herniation
destruction tears
ing in ‘internal disk disruption’ without frank herniation. All
this results in a loss of disk height, which causes instability (as
the end-plate connection to the disk is degenerated), as well as
Osteophyte Internal
lateral recess and foraminal narrowing, and potential nerve root
formation disruption
impingement. The loss of disk height also places new stresses
on the posterior elements, resulting in further instability of the
Capsular Loss disk zygapophyseal joints and further degeneration and nerve root
Instability
laxity height impingement.
The above description is a well-accepted theory of how
mechanical compression of lumbar nerve roots and the cauda
Subluxation Lateral nerve Disk equina occurs to result in the neurogenic claudication symp-
entrapment resorption toms of lumbar stenosis. More recently, there are newer theo-
ries that support a spinal vascular role in stenosis symptoms.
Because there are many people with anatomic stenosis on
Enlargement One-level Osteophytes imaging studies without symptoms, the following vascular
articular process Central at back of
stenosis theories have credence.
(and laminae) vertebral
bodies If mechanical compression were the sole problem in spinal
stenosis, decompressive surgeries would be the only needed
Effect of recurrent strains cure. We know that this is untrue, and consequently alternative
at levels above and theories on the pathogenesis of symptomatic spinal stenosis
below the original lesion have been studied. Two theories supporting a vascular compo-
nent to symptoms of spinal stenosis are the venous engorge-
ment and arterial insufficiency theories.1
Multilevel degenerative lesions In the venous engorgement theory, the spinal veins of patients
with stenosis dilate, causing venous congestion and stagnating
blood flow.42 This pooling of blood in the spinal veins increases
Multilevel spinal stenosis epidural and intrathecal pressures, leading to a microcircula­-
tory, neuroischemic insult (i.e. an ischemic neuritis), which in
Figure 41-12  The spectrum of degenerative change that
leads from minor strains to marked spondylosis and stenosis.
turn leads to the typical neurogenic claudication symptoms of
(From Kirkaldy-Willis et al. 1978,100 with permission of stenosis.
Lippincott Williams & Wilkins.) The arterial insufficiency theory of spinal stenosis is based on
the arterial dilatation of the lumbar radicular vessels during
lower limb exercise to provide increased blood flow and nour-
ishment to the nerve roots. In patients with spinal stenosis,
this reflex dilatation might be defective.14 As patients with
both can occur simultaneously and affect each other (Fig. spinal stenosis are typically elderly, they are also at higher risk
41-12). The degenerative changes that occur in the zygapophy- for atherosclerosis, which in turn just amplifies the arterial
seal joints from aging and repetitive microtrauma are similar to insufficiency.
those that occur in the appendicular skeletal joints. Initially, the
synovium hypertrophies, which eventually results in cartilage
degeneration and destruction. With lessened and weakened Pain generators of the lumbar spine
cartilage and capsular laxity, the joint can become unstable. The low back is an anatomically diverse set of structures, and
With the repetitive abnormal joint motion that results from this there are many potential sources of pain. This makes low back
instability, the bony joint hypertrophies. This narrows the pain often complex and confusing for those inexperienced in
central canal and lateral recesses, potentially impinging nerve spine medicine. One particularly useful strategy to clarify these
roots. potential sources of pain is learning what low back structures
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 890 Section 4 Issues in Specific Diagnoses
Box 41-1  Potential pain generators of the back
A useful classification system to understand the potential sources
of low back pain depends on knowing what structures are
innervated (and can transmit pain) and what structures have no
innervation.
Innervated structures
• Bone: vertebrae
• Joints: zygapophyseal
• Disk: only the external annulus and potentially diseased disk
• Ligaments: anterior longitudinal ligament, posterior longitudinal
ligament, interspinous
• Muscles and fascia
• Nerve root
Non-innervated structures
• Ligamentum flavum
• Internal annulus
• Disk: nucleus pulposus
are innervated (and thus can transmit pain through neural pain
fibers) and what structures have no innervation (Box 41-1).
The sinuvertebral nerve innervates the anterior vertebral
body, the external annulus, and the posterior longitudinal liga-
ment. The posterior longitudinal ligament is a highly innervated
structure, and can play a significant role in low back pain per-
ception with lumbar disk herniations. The medial branch of the
dorsal primary ramus innervates the zygapophyseal joints and
interspinous ligaments, as well as the lumbar multifidi. The
other small branches of the dorsal primary ramus innervate the
posterior vertebral body and other lumbar paraspinal muscula-
ture and fascia. The anterior longitudinal ligament is innervated
by the gray rami communicans, which branch off the lumbar
sympathetic chain. The internal annulus fibrosus and nucleus
pulposus do not have innervation and in non-disease states
cannot transmit pain.
The history and physical examination
of the low back
A complete history and physical examination is important in
the evaluation of low back pain to determine the cause of the
symptoms, rule out serious medical pathology, and determine
if further diagnostic evaluation is needed.
The history
The causes of back pain are often very difficult to determine.
For as many as 85% of patients, no specific cause for back pain
is found.46 A common rule of thumb quoted in medicine is that
85% of a diagnosis is made using the history alone. There is no
reason to think that back pain should be significantly different.
Therefore a thorough history is very important for the patient
A
with back pain.
Ch041-X2610.indd 890
Box 41-2 Most common indications from history and
examination for pathologic findings needing
special attention and sometimes immediate
action (including imaging)
• Back pain in children <18 years old with considerable pain, or
onset in those > 55 years old
• History of violent trauma
• Constant progressive pain at night
• History of cancer
• Systemic steroids
• Drug abuse, HIV infection
• Weight loss
• Systemic illness
• Persisting severe restriction of motion
• Intense pain with minimal motion
• Structural deformity
• Difficulty with micturition
• Loss of anal sphincter tone or fecal incontinence, saddle
anesthesia
• Widespread progressive motor weakness or gait disturbance
• Inflammatory disorders (ankylosing spondylitis) suspected
• Gradual onset <40 years
• Marked morning stiffness
• Persisting limitation of motion
• Peripheral joint involvement
• Iritis, skin rashes, colitis, urethral discharge
• Family history
(From Nachemson and Vingard 2001,138 with permission of Lippincott
Williams & Wilkins.)
As with any pain history, features of back pain that should
be explored include location; character; severity; timing, includ-
ing onset, duration, and frequency; alleviating and aggravating
factors; and associated signs and symptoms. Each of these
features can assist the clinician in obtaining a diagnosis and
prognosis, and determining the appropriate treatment.
A careful pain history such as this can identify serious medical
pathology that can cause back pain, such as metastatic cancer,
infection, and rheumatologic disease. Elements of historical
information that suggest a serious underlying condition as the
cause of the pain are called red flags (Box 41-2). When these
are present, further work-up is necessary. Specific questions
should be asked to clarify if any red flags are present. The sen-
sitivity and specificity of the history in identifying red flags has
been perhaps the best studied aspect of the low back pain
history (Tables 41-1 to 41-3).
Besides determining specific facts about the pain, a purpose
of the history is to explore the patient’s perspective and illness
experience. Certain psychosocial factors are valuable in deter-
mining prognosis (Box 41-3). Factors such as poor job satisfac-
tion, catastrophic thinking patterns about pain, the presence of
depression, and excessive rest or downtime are much more
common in patients in whom back pain becomes disabling.
These are called yellow flags, because the clinician should
proceed with caution, and further psychologic evaluation or
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 Chapter 41
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Table 41-1 Sensitivities and specificities of different elements of the history and examination for some specific causes of low
back pain

Disease or group of diseases Symptom or sign Sensitivity Specificity

Spinal malignancy Age > 50 years 0.77 0.71

Previous history of cancer 0.31 0.98
Unexplained weight loss 0.15 0.94
Pain unrelieved by bed rest 0.90 0.46
Pain lasting > 1 month 0.50 0.81
Failure to improve with1 months’ conservative therapy 0.31 0.90
Erythrocyte sedimentation rate > 20 mm 0.78 0.67
Spinal infection Intravenous drug abuse, urinary tract infection, skin infection 0.4 —
Fever 0.27–0.83a 0.98
Vertebral tenderness ‘Reasonable’ ‘Low’
Age > 50 years 0.84 0.61
Compression fracture Age > 70 years 0.22 0.96
Corticosteroid use 0.66 0.99
Herniated intervertebral disk Sciatica 0.95 0.88

a
The sensitivity of ‘fever’.
(From Nachemson and Vingard 2001,138 with permission.)

Table 41-2  Patterns of back pain

Pattern Where pain is worst Aggravating Relieving Onset Duration Probable

movement movement cause

Back-dominant pain 1 Back or buttocks Flexion; stiff Extension Hours to days Days to Disk involvement
  or mechanical   (<90% back pain);   in morning   months   (minor
  cause   myotomes seldom   (sudden or   herniation,
  affected;   slow)   spondylosis),
  dermatomes   sprain, strain
  not affected  
2 Back or buttocks; Extension or Flexion Minutes to Days to weeks Facet joint
  myotomes   rotation   hours   (sudden)   involvement,
  seldom affected;   strain
  dermatomes not
  affected
Leg pain dominant 3 Leg (usually below Flexion Extension Hours to days Weeks to Nerve root
  or non-mechanical   knee); myotomes   months   irritation (most
  cause   commonly affected   likely cause is
    (especially in   disk herniation)
  chronic cases);
  pain in dermatomes
4 Leg (usually below Walking Rest (sitting) With walking — Neurogenic
  knee); (may be   (extension)   and/or   intermittent
  bilateral); myotomes   postural   claudication
  commonly affected   change   (stenosis)
  (especially in
  chronic cases); pain
  in dermatomes

(From Magee 2002,115 with permission.)

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 892 Section 4 Issues in Specific Diagnoses

Table 41-3  Some implications of painful reactions

Activity Reaction of pain Possible structural and pathologic implications

Lying sleeping ↓ Decreased compressive forces: low intradiskal pressures

Absence of forces produced by muscle activity
↑ Change of position: noxious mechanical stress
Decreased mechanoreceptor input
Motor segment ‘relaxed’ into a position compromising affected structure
Poor external support (bed)
Non-musculoskeletal cause
First rising (stiffness) ↑ Nocturnal imbibition of fluid, disk volume greatest
Mechanical inflammatory component (apophyseal joints)
Prolonged stiffness, active inflammatory disease (e.g. ankylosing spondylitis)
Sitting ↑ Compressive forces
High intradiskal pressure
With extension ↓ Intradiskal pressure reduced
Decreased paraspinal muscle activity
↑ Greater compromise of structures of lateral and central canals
Compressive forces on lower apophyseal joints
With flexion ↓ Little compressive load on lower apophyseal joints
Greater volume, lateral and central canals
Reduced disk bulge posteriorly
↑ Very high intradiskal pressures
Increased compressive loads, upper and midapophyseal joints
Mechanical deformation of spine
Prolonged sitting ↑ Gradual creep of tissues
Sitting to standing ↑ Creep, time for reversal, difficulty in straightening up
Extension of spine, increase disk bulge posteriorly
Walking ↑ Shock loads greater than body weight
Compressive loads (vertical creep)
Leg pain
Neurologic claudication
Vascular claudication
Driving ↑ Sitting: compressive forces
Vibration: vibro creep repetitive loading, decreased hysteresis loading, decreased hysteresis
Increased dural tension sitting with legs extended
Short hamstrings: pull lumbar spine into greater flexion
Coughing, sneezing, straining ↑ Increased pressure in subarachnoid space (increased blood flow, Batson’s plexus,
  compromises space in lateral and central canal)
Increased intradiskal pressure
Mechanical ‘jarring’ of sudden uncontrolled movement

(From Magee 2002,115 with permission.)

treatment should be considered if they are present. Some of
these psychosocial factors are addressed by specific questions,
and some become evident through statements that patients
make during the history as they describe their illness experi-
ence. Questions about, for example, what patients believe is
causing the pain, their fear and feelings surrounding this belief,
their expectations about the pain and its treatment, and how
back pain is affecting their lives (including work and home life)
can yield valuable information. Many of these yellow flags are
better prognostic indicators than the more traditional medical
diagnoses.214
A
The physical examination
Table 41-4 outlines a thorough examination of the lumbar
spine.
Observation
Observation should include a survey of the skin, muscle mass,
and bony structures, as well as observation of overall posture
(Fig. 41-13), and the position of the lumbar spine in particular
(Fig. 41-14). Gait should also be observed for clues regarding
etiology and contributing factors.

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Table 41-4  Physical examination for low back pain

Examination component Specific activity Reason for this part of the examination

Observation Observation of overall posture Determine if structural abnormality or muscle

  imbalances are present
Observation of lumbar spine Further define muscle imbalance and habitual posture
Observation of the skin Search for diagnoses such as psoriasis, shingles, or
  vascular disease as cause of the pain
Observation of gait Screen the kinetic chain and determine if muscular,
  neurologic, or joint problems are contributing to
  symptoms
Palpation Bones Search for bony problems such as infection or fracture
Facet joints Identify if specific levels are tender
Ligaments and intradiskal spaces Determine if these are tender
Muscles Search for trigger points, muscle spasms, muscle
  atrophy
Active range of motion Forward flexion Amount, quality if painful
Extension —
Side bending Same, also side to side differences
Rotation —
Neurologic examination Manual muscle testing of L1–S1 myotomes Determine weakness
Pinprick and light touch sensation, L1–S1 Determine sensory loss
  dermatomes
Reflexes: patellar, hamstring, Achilles Test injury to L4, L5, or S1 roots if diminished,
  upper motor neuron disease if brisk
Balance and coordination testing Signs of upper motor neuron disease
Plantar responses Same
Straight leg raise Neural tension at L5 or S1
Femoral nerve arch Neural tension at L3 or L4
Orthopedic special tests Abdominal muscle strength Determines weakness and deconditioning
Pelvis stabilizer strength, i.e. gluteus Determines weakness and deconditioning
  medius, maximus, etc.
Tightness or stiffness of hamstrings Determines areas of poor flexibility
Tightness or stiffness of hip flexors —
Tightness or stiffness of hip rotators —
Prone instability test Signs of instability

Box 41-3  Some common ‘yellow flags’
• The presence of catastrophic thinking: there is no way the
patient can control the pain, that disaster will occur if the pain
continues, etc.
• Expectations that the pain will only worsen with work or activity
• Behaviors such as avoidance of normal activity, and extended
rest
• Poor sleep
• Compensation issues
• Emotions such as stress and anxiety
• Work issues, such as poor job satisfaction and poor relationship
with supervisors
• Extended time off work
Palpation
Palpation should begin superficially and progress to deeper
tissues. It can be done with the patient standing, or to ensure
that the back muscles (Fig. 41-15) are fully relaxed, this is often
done with the patient lying prone, perhaps with a pillow under
the abdomen to slightly flex the spine into a position of comfort.
It should proceed systematically to determine what structures
are tender to palpation. Sometimes pressure over isolated
vertebrae is applied to look for the painful level; this is known
as prone instability testing.
Range of motion
Quantity of range of motion  There are several ways to
measure spinal range of motion (ROM). These include using a
A

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 894 Section 4 Issues in Specific Diagnoses

(a) (b) (c) (d)

(a) (b) (c) (d)

Ideal Kyphosis- Flat back Sway-back
alignment lordosis posture posture
posture
Figure 41-13  The four types of postural alignment: (a) ideal alignment,
(b) kyphosis–lordosis posture, (c) flat back posture, (d) sway-back
posture. (From Kendall and McCreary 1983,97a with permission.)
<30° 30° >30°

single or double inclinometer; measuring the distance of finger-

tips to floor; and, for forward flexion, the Schober test (measur-
ing distraction between two marks on the skin during for­-
ward flexion). Of these methods, the double inclinometer has
been shown to correlate the closest to measurements on radio-
(e) (f) (g)
graphs.73,192 The literature varies on inter- and intrarater reliabil-
Figure 41-14  Faulty pelvic alignment as a result of weak and long
ity and the use of inclinometers. Fingertip to floor has good
abdominal muscles (a), short and stiff hip flexors (b), apparent anterior tilt
inter- and intrarater reliability, but this takes into account the (c), and posterior tilt (d). The effect of pelvic tilting on the inclination of
movement of the pelvis, and is affected by structures outside the base of the sacrum to the transverse plane (sacral angle) during
the spine such as tight hamstrings.158 The Schober test is com- upright standing is shown. (e) Tilting the pelvis backward reduces the
sacral angle and flattens the lumbar spine. (f) During relaxed standing,
monly used to assess a decrease in forward flexion in ankylosing the sacral angle is about 30°. (g) Tilting the pelvis forward increases the
spondylitis. It is sensitive for this condition but is not specific. sacral angle and accentuates the lumbar spine. (From Sahrmann
General figures for normal ROM are forward flexion, 40–60°; 2002,176 with permission.)
extension, 20–35°; lateral flexion, 15–20°; and rotation, 3–18°.
Studies to determine normal ROM in asymptomatic adults have
found large variations within the normal range.155 The normal
extension can signify spondylolisthesis, zygapophyseal joint
ROM of people without back pain, and the ROM in patients
disease, or spinal stenosis.
with back pain, overlap. It is unclear what the significance of
decreased ROM is in patients with back pain, because many
The neurologic examination
people without back pain also have limited range. ROM can
The neurologic examination of the lower extremities can rule
also change depending on the time of day, the effort the patient
out clinically significant nerve root impingement and other neu-
expends, and many other factors.230
rologic causes of leg pain (Tables 41-5 and 41-6). The physical
Quality of range of motion  The examiner should record if examination should logically proceed to discover if a particular
there are abnormalities in the patient’s movement pattern root level is affected by combining the findings of weakness,
during ROM, such as a ‘catch’ in the range or whether it causes sensory loss, diminished or absent reflexes, and special tests
pain. This can give clues to the diagnosis. For example, pain such as straight leg raise. In addition, an upper motor neuron
A
with forward flexion can signify disk disease, and pain with condition should be ruled out. The accuracy of the neurologic

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Table 41-5  Factors that affect posture

Reason for abnormality Clinical example

Bone structure Compression fractures

Scheuermann disease
Ligamentous laxity Hyperextension of the knees, elbows
Muscle and fascial length Tight hamstrings that cause a posterior pelvic tilt
Weak and long abdominal muscles that allow an anterior pelvic tilt
Body habitus Obesity or pregnancy causes changes in force and increased lumbar lordosis
Neurologic disease Spasticity causes an extension pattern of the lower limb
Mood Depression causes forward slumped shoulders
Habit Long-distance cyclists have increased thoracic kyphosis and flat spine from prolonged positioning while riding

control. Kendall recommends two tests to grade abdominal

Erector spinae L4–5 intervertebral
muscles joint
Iliac Sacroiliac
crest joint
Figure 41-15  Anatomy of the low back surface anatomy.
examination in diagnosing herniated disk is moderate. However,
combinations of findings increase the accuracy considerably.46
The sensitivity and specificity of different findings for lumbar
radiculopathy have been well studied (Table 41-7).
Orthopedic special tests to assess for relative strength
and flexibility
Back pain can be caused by deconditioning, poor endurance,
and muscle imbalances. Therefore, any inefficient or abnormal
movement patterns of muscles that control the movement of
the spine and the position of the pelvis should be identified.
Because of their stabilizing effect on the spine, abdominal
muscle strength and endurance is important. There are several
different ways to measure abdominal muscle strength and
muscles: the curl trunk sit up (Fig. 41-16), and holding the low
back flat during leg lowering (Fig. 41-17).
Because of the great amount of strength needed for both
these tests, and the inability of many patients with back pain
even to perform the lowest grades, other tests have been devel-
oped to test abdominal strength. One grading system assesses
whether the patient is able to maintain a neutral spine position
while adding increasingly more challenging leg movements
(Fig. 41-18).
Besides determining the strength of the abdominals, strength
testing of the hip abductors and the ability to activate the
gluteus maximus are often assessed to examine pelvic stability.
Assessing for areas of relative inflexibility is also important.
Commonly performed tests are hip flexor flexibility, hamstring
flexibility, other hip extensors’ length, and gastrocnemius/
soleus length. Balance challenges, such as the ability to maintain
single-footed stance, are also helpful to determine a patient’s
baseline status.
Orthopedic special tests for lumbar segmental instability
Many clinicians and researchers believe that one cause of
mechanical low back pain is segmental instability that responds
to specific stabilization treatments. Therefore accurately iden-
tifying this group from other forms of mechanical low back pain
is important. These special tests include passive intervertebral
motion testing and the prone instability test.
Passive intervertebral motion testing  The patient lies prone.
The examiner applies a firm steady pressure over the spinous
process anteriorly, and assesses the amount of vertebral motion
and whether pain is provoked.85
Prone instability test  The patient lies prone, with the torso
on the examining table and the legs over the edge of the table
with the feet resting on the floor. The examiner performs
A
passive intervertebral motion testing at each level and notes

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 896 Section 4 Issues in Specific Diagnoses

Table 41-6  Lumbar root syndromes

Root Dermatome Muscle weakness Reflexes or special tests affected Paresthesias

L1 Back, over trochanter, groin None None Groin, after holding posture,
which causes pain
L2 Back, front of thigh to knee Psoas, hip abductor None Occasionally front of thigh
L3 Back, upper buttock, front Psoas, quadriceps–thigh Knee jerks sluggish, protein Inner knee, anterior lower leg
of thigh and knee, medial wasting kinase B-positive, pain on
lower leg full straight leg raise
L4 Inner buttock, outer thigh, Tibialis anterior, extensor Straight leg raise limited, neck Medial aspect of calf and ankle
inside of leg, dorsum of hallucis flexion pain, weak knee jerk;
foot, big toe side flexion limited
L5 Buttock; back and side of Extensor hallucis, peroneals, Straight leg raise limited to one Lateral aspect of leg, medial
thigh; lateral aspect of leg; gluteus medius, ankle side, neck flexion pain, ankle three toes
dorsum of foot; inner half dorsiflexors, hamstrings– jerk decreased, crossed leg
of sole and first, second, calf wasting raising pain
and third toes
S1 Buttock, back of thigh, and Calf and hamstrings; Straight leg raise limited Lateral two toes, lateral foot,
lower leg wasting of gluteals, lateral leg to knee, plantar
peroneals; plantar flexor aspect of foot
S2 Same as S1 Same as S1, except Same as S1 Lateral leg, knee, heel
peroneals
S3 Groin, inner thigh to knee None None None
S4 Perineum: genitals, lower Bladder, rectum None Saddle area, genitals, anus,
sacrum impotence

(From Magee 2002,115 with permission.)

Table 41-7  Lumbosacral radiculopathy in patients with sciaticaa

Findingb Sensitivity (%) Specificity (%) Positive lumbosacral Negative lumbosacral

radiculopathy radiculopathy

Motor examination
Weak ankle dorsiflexion 54 89 4.9 0.5
Ipsilateral calf wasting 29 94 5.2 0.8

Sensory examination
Leg sensation abnormal 16 86 NS NS

Reflex examination
Abnormal ankle jerk 48 89 4.3 0.6

Other tests
Straight leg-raising maneuver 73–98 11–61 NS 0.2
Crossed straight leg–raising maneuver 23–43 88–98 4.3 0.8

NS, Not significant.

a
Diagnostic standard: for lumbosacral radiculopathy, surgical finding of disk herniation compressing the nerve root.
b
Definition of findings: for ipsilateral calf wasting, maximum calf circumference at least 1 cm smaller than on contralateral side; for straight leg raising
maneuvers, flexion at hip of supine patient’s leg, extended at the knee, causes radiating pain in affected leg (pain confined to back or hip is a negative
response); for crossed straight leg raising maneuver, raising contralateral leg provokes pain in the affected leg.
(From McGee 2001,125 with permission.)
A

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 Chapter 41
Low Back Pain 897

50%
60%
70%

90°

75°
80%

°
60

°
45
90%
°
30
(a)
15° 100%

0°

(b) (a)

(c)
Figure 41-16  Trunk raising forward: grading. The curl trunk sit up is
performed with the patient lying supine and with the leg extended.
The patient posteriorly tilts the pelvis and flexes the spine, and slowly
completes a curled trunk sit up. Kendall states that the ‘crucial point in (b)
the test for the abdominal muscle strength is at the moment the hip
flexors come into strong action. The abdominal muscle at this point must
be able to oppose the force of the hip flexors in addition to maintain the
trunk curl’. At the point where the hip flexors strongly contract, patients
with weak abdominal muscles will tilt the pelvis anteriorly and extend the
low back. (a) A 100% or normal grade is the ability to maintain spinal
flexion and come into the sitting position with the hands clasped behind
the head. (b) An 80% or good grade is the ability to do this with the
forearms folded across the chest. (c) A 60% or fair grade is the ability to (c)
do this with the forearms extended forward. A 50% or fair grade is the Figure 41-17  Leg lowering: grading. In the second test, the patient
ability to begin flexion but not maintain spinal flexion with the forearms raises the legs one at a time to a right angle, and then flattens them
extended forward. (From Kendall and McCreary 1983,97a with back on the table. The patient slowly lowers the legs while holding the
permission.) back flat. A 100% or normal grade is the ability to hold the low back flat
on the table as the legs are lowered to the fully extended position. An
80% or good grade is the ability to hold the low back flat and lower the
legs to a 30° angle. (a) A 60% or fair plus grade is the ability to lower
provocation of pain. Then the patient lifts the legs off the floor, the legs to 60° with the low back flat. (b) The pelvis tilted anteriorly and
and the painful levels are repeated. A positive test is when the the low back arched as the legs were lowered. (c) The final position.
Kendall notes that this second test is more important than the first (Fig.
pain disappears when the legs are lifted off the table. This is
41-16) in grading muscles essential to proper posture, and that often
because the extensors are able to stabilize the spine in this patients who do well on the first test do poorly on the second. (From
position.85,126 Kendall and McCreary 1983,97a with permission.)

Examining the area above and below the lumbar spine

Generally, in musculoskeletal medicine, the joint above and the
joint below the painful area should be assessed to make sure
nothing is missed. This is a good idea for the examination of
the lumbar spine as well. ROM of the hip joints should be
assessed, and a quick screen of the knee and ankle joint can
determine if pathology in these areas is contributing to the back
problem. The thoracic spine can be quickly screened as well
during ROM and palpation.
Illness behavior and non-organic signs seen on physical
examination
There are multiple reasons why patients with back pain might
display symptoms out of proportion to injury. Illness behaviors
are learned behaviors, and are responses that some patients use
to convey their distress. Several studies have found that patients
with chronic low back pain and chronic pain syndrome experi-
A
ence significant anxiety during the physical examination, even

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 898 Section 4 Issues in Specific Diagnoses

(a)

(b) (c)

(d) (e)
Figure 41-18  Abdominal strength grading. (a) The patient lies supine with the knees bent (supine crook lying). The physician cues the patient to
activate the transversus abdominis (‘Pull your belly button toward your backbone’), and a very slight lumbar lordosis is maintained in a neutral
position in which the spine is neither flexed nor extended. The ability to maintain the neutral spine is progressively challenged by loading the spine via
lower extremity movements. Grading is as follows. (b) Grade 1: the patient is able to maintain a neutral spine while extending one leg by dragging the
heel along the table; the other leg remains in the starting position. (c) Grade 2: the patient is able to maintain a neutral spine while holding both legs
flexed 90° at the hip and 90° at the knee, and touching one foot to the mat and then the other. (d) Grade 3: the patient is able to maintain a neutral
spine while extending one leg by dragging the heel along the table. The other leg is off the mat and flexed 90° at the hip and 90° at the knee. (e)
Grade 4: the patient is able to maintain a neutral spine while extending one leg hovered an inch or two above the table, while the other leg is off the
mat and flexed 90° at the hip and 90° at the knee. Grade 5: the patient is able to extend both legs a few inches off the mat and back again while
maintaining the spine in neutral.

to the level experienced during panic attacks. This complicates
the assessment by altering the clinical presentation of the condi-
tion. This anxiety is generally manifest as avoidance behavior,
such as decreased ROM or poor effort with muscle testing.77
Other reasons for illness behavior include a desire to prove to
physicians how disabling the pain is and malingering. One way
to assess for illness behavior on physical examination is to
perform parts of the examination to search for Waddell’s signs.
Waddell’s signs are forms of illness behavior.219 They are non-
organic findings on physical examination that correlate with
psychologic distress. They are as follow.
• Inappropriate tenderness that is widespread or superficial.
• Pain on testing that only simulates loading the spine, such
as light pressure applied to the top of the head, which
reproduces back pain, or rotating the hips and shoulders
together to simulate twisting without actually moving the
spine, which reproduces back pain.
• Inconsistent performance when testing the same thing in
different positions, such as a difference in outcome of the
straight leg-raising test with the patient supine versus
A
sitting.
• Regional deficits in strength or sensation that do not have
an anatomic basis.
• Overreaction during the physical examination.
Findings in three out of these five categories are suggestive of
psychologic distress.
Clinical evaluation: diagnostics
Imaging studies
Imaging of the lumbar spine should be used in the evaluation
of low back pain if specific pathology needs to be confirmed
after a thorough history and physical examination.
Plain radiography
Conventional radiographs are indicated in trauma to evaluate
for fracture, and to look for bony lesions such as tumor when
red flags are present in the history. As an initial screening tool
for lumbar spine pathology, however, they have very low sensi-
tivity and specificity.68 Anterior–posterior and lateral views are
the two commonly obtained views. Oblique views can be
obtained to examine for a spondylolysis by visualizing the pars

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interarticularis and the ‘Scottie dog’ appearance of the lumbar
spine (Fig. 41-19). Lateral flexion–extension views are obtained
to check for dynamic instability, although the literature does
not support their usefulness.51 They are potentially most helpful
from a surgical screening perspective when evaluating a
spondylolisthesis. They are commonly obtained in posttrauma
and postsurgical patients.
Magnetic resonance imaging
Magnetic resonance imaging is the preeminent imaging method
for evaluating degenerative disk disease, disk herniations, and
radiculopathy (Fig. 41-20) (see also Ch. 7). On T2-weighted
imaging, the annulus can be differentiated from the internal
nucleus, and annular tears can be seen as high-intensity zones.
These zones are of unclear clinical significance but are thought
to be potential pain generators.
Superior articular process
(ear of Scotty dog)
Transverse process
(nose)
Pedicle
(eye)
Defect at pars interarticularis
(collar or broken neck)
Inferior articular process
(foot)
Figure 41-19  Oblique drawing of the lumbosacral junction, outlining the
‘Scottie dog’ and the area of spondylolysis.
a b
Figure 41-20  Disk protrusion in a 48-year-old woman with back and right leg pain. (a and b) Sagittal T2- and T1-weighted magnetic resonance
imaging (MRI), showing L4–S1 disk protrusion and type 2 marrow change. (c) Axial T2-weighted MRI, showing L4–5 disk protrusion deforming the
thecal sac. No root compression is evident. (From Maus 2002,122 with permission.)
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Low Back Pain 899
Adding gadolinium contrast enhancement helps to identify
structures with increased vascularity. Contrast is always indi-
cated in evaluating for tumor or infection, or to determine scar
tissue (vascular) versus recurrent disk herniation (avascular) in
postsurgical patients with recurrent radicular symptoms.
The downside of MRI is that, although it is a very sensitive
test, it is not very specific in determining a definite source of
pain. It is well established that many people without back pain
have degenerative changes, disk bulges, and protrusions on
MRI. Boden demonstrated that one-third of 67 asymptomatic
subjects were found to have a ‘substantial abnormality’ on MRI
of the lumbar spine.21 Of the subjects younger than 60, 20%
had a disk herniation, and 36% of those older than 60 had a
disk herniation and 21% had spinal stenosis. Bulging and degen-
erative disks were even more commonly found. In another
study of lumbar MRI findings in people without back pain,
Jensen demonstrated that only 36% of 98 patients had normal
disks.91 They found that bulges and protrusions were very
common in asymptomatic subjects, but that extrusions were
not. In a more recent study in 2001, Jarvik confirmed these
findings.90 In studying 148 asymptomatic subjects, he concluded
that the less common findings on MRI of moderate or severe
central stenosis, root compressions, and disk extrusions are
likely to be clinically relevant. MRI is rarely appropriate in an
initial work-up unless there has been a major acute injury or
there are symptoms of infection, tumor, or progressive neuro-
logic loss.84
Computed tomography
Because of the resolution of anatomic structures in MRI, it has
essentially replaced computed tomography (CT) scanning as
the imaging study of choice for low back pain and/or radicu-
lopathy. However, CT scanning is still more useful than MRI in
evaluating bony lesions. CT scans are also useful in the postsur-
gical patient with excessive hardware that can obscure magnetic
resonance images, and in patients with implants (aneurysm clips
or pacemakers) that preclude MRI.
c
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 900 Section 4 Issues in Specific Diagnoses
a b
Figure 41-21  Anteroposterior (a) and lateral (b) myelograms of a 59-
year-old woman with severe L4–5 central stenosis due to a large left
L4–5 zygapophyseal joint synovial cyst. Note the obvious filling defect at
the L4–5 level. She had symptoms of cauda equina syndrome and
regained full neurologic function after decompression surgery.
Myelography
In myelography, contrast dye is injected into the dural sac and
plain radiographs are performed to produce images of the
borders and contents of the dural sac (Fig. 41-21). CT images
can also be obtained after contrast injection to produce axial
cross-sectional images of the spine that enhance the distinction
between the dural sac and its surrounding structures. This is
typically reserved as a potential presurgical screening tool but
has been utilized less with the advancement of MRI.
Scintigraphy
Radionuclear bone scanning is a fairly sensitive but not specific
imaging modality that can be used to detect occult fractures,
bony metastases, and infections. To increase anatomic specifi-
city, single-photon emission computed tomography (SPECT)
bone scanning is used to obtain bone scans with axial slices. This
allows the diagnostician to differentiate uptake in the posterior
elements from more anterior structures of the spine. The diag-
nostic utility of this study with regard to altering clinical deci-
sion making is controversial and has not been well studied.
Electromyography
Electromyography is useful in evaluating radiculopathy, as it
provides a physiologic measure for detecting neurogenic changes
and denervation with good sensitivity and high specificity. It
can help to provide information as to which anatomic lesions
found in imaging studies are truly physiologically significant.169
See Chapters 10, 11, and 12 for further details.
Laboratory studies
Bloodwork is rarely used in isolation as a diagnostic strategy
for low back pain. It is helpful as an adjunct in diagnosing
inflammatory disease of the spine (with such markers of
in­flammation as sedimentation rates and C-reactive proteins)
and some neoplastic disorders, such as multiple myeloma
with a serum protein electrophoresis and urine protein
A
electrophoresis.
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Differential diagnosis and treatment:
the prototype of back pain greater
than leg pain
Mechanical low back pain
Nearly 85% of those who seek medical care for low back pain
do not receive a specific diagnosis.46 The majority of these
patients most probably have a multifactorial cause for back
pain, which includes functional instability; deconditioning;
abnormal posture; poor muscle recruitment; emotional stress;
and changes associated with aging and injury such as disk degen-
eration, arthritis, and ligamentous hypertrophy. This type of
back pain can be given many names; simple backache, non-
specific low back pain, lumbar strain, and spinal degeneration
are a few of the common names for this condition. The name
given to a condition sends certain messages to the patient who
receives the diagnosis. For example, the term simple backache
may cause a patient to think that the physician misunderstands
because, from the patient’s perspective, the pain is not simple
if it has not resolved in a few days. The label non-specific low
back pain can cause the patient to continue to seek care from
multiple providers in order to receive a specific diagnosis.
Lumbar strain suggests that the condition was caused by over-
activity, which is often not the case, and that further physical
activity would cause it to recur, which is not true. Spinal degen-
eration sends the message that the changes are permanent and
will probably worsen.214 The term mechanical low back pain is
perhaps the best term for this multifactorial axial backache. It
suggests the mechanism of injury better than terms such as
strain or sprain. It does not imply permanence. It is precise,
and it suggests that, by changing biomechanics, improvement
can occur.
The biomechanics of the spine are not unlike the biomechan-
ics of other systems, in that longevity of the components and
efficiency of the system depend on precise movements of each
segment. In the spine, this means both an alignment in sus-
tained postures and movement patterns that reduce tissue
strain and allow for efficient muscle action without trauma to
the joints or soft tissue.176 The biomechanical model for the
treatment of mechanical low back pain is that movement pat-
terns which are altered because of faulty strength and flexibility,
fatigue from poor endurance, or abnormal neural control can
eventually cause tissue damage. Tissue damage can also lead to
abnormal movement patterns and further damage, which is
the basis for the Kirkaldy-Willis degenerative cascade.115 One
of the goals of rehabilitation is to categorize faulty alignment
and abnormal movement patterns so that specific treatment can
be given. Clinicians and researchers alike theorize that, when
alignment and movement patterns deviate from the ideal,
degeneration and tissue overload is more likely, just like abnor-
mal tire wear occurs on a car out of alignment. Unlike machin-
ery, the body can adapt with time to stress on the segments.
This adaptation can be the healthy response of tissue to loading
(as is seen with exercise), such as muscle hypertrophy or
increased bone density, or it can begin a cycle of microtrauma
that can lead to macrotrauma.115,128,176 The theoretic model for
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this approach is strong, and research is beginning to validate
many of these concepts, although this is not easy given the
complex nature of the system.
Physical factors associated with mechanical If these three things can be shown, then the next step will be
low back pain
Segmental instability  The biomechanical model is particu-
larly complex in the spine, because of the presence of global
movement patterns and segmental movement patterns. Two
interrelated muscular tasks must be carried out at the same
time: maintaining overall posture and position of the spine, and
control of individual intersegmental relationships. Sufficient
joint stiffness is required at the segmental level to prevent
injury and allow for efficient movement. This stiffness is
achieved with specific patterns of muscle activity, which differ
depending on the position of the joint and the load on the spine.
The inability to achieve this stiffness, and the resulting segmen-
tal instability, is thought to be a common factor in mechanical
low back pain.166
Instability can be a result of tissue damage, poor muscular
endurance, or poor muscular control, and is usually a combina-
tion of all three factors. Structural changes from tissue damage,
such as strained or failed ligaments that cause joint laxity,
vertebral end-plate fractures, and loss of disk height, can lead
to segmental instability because of the altered anatomy.
However, muscles provide the most critical component of
spinal stability. A cadaver spine in which the bones and liga-
ments are intact but the muscles have been removed will buckle
under only 20 lbs of compressive load. The human spine with
muscles functioning properly, however, can handle many times
that load.127
In normal situations, only a small amount of muscular
coactivation, about 10% of maximal contraction, is needed to
provide segmental stability. In a segment damaged by ligamen-
tous laxity or disk disease, slightly more might be needed.
Because of the gentle force required to perform activities of
daily living, muscular endurance is more important than abso-
lute muscle strength for most patients, although some strength
reserve is needed for unpredictable activities such as a fall, a
sudden load to the spine, or quick movements. In sports and
heavy physical work, both strength and endurance needs
increase. For example, in rapid breathing caused by exertion,
there is rhythmic contraction and relaxation of the abdominal
wall. A fit person can simultaneously provide spine support with
abdominal wall muscles, and meet breathing demands, but a
less fit person might not be able to and therefore could more
easily become injured or have pain.127
Muscular imbalances and neural processing problems  It
has been known for many years that disk disease, ligamentous
injury, and arthritis can cause low back pain. More recently, a
significant amount of research is emerging with the following
aims.
• To determine what muscular abnormalities exist in patients
with back pain.
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Chapter 41
Low Back Pain 901
• To ascertain if exercise training can lead patients with low
back pain to develop more normal firing patterns,
endurance, and strength ratios.
• To see whether this in turn will improve pain.
determining if patients at risk for back pain can be identified
and treated before they develop problems.
There appear to be consistent muscular problems in patients
with persistent low back pain. Some of these factors might exist
preinjury and make the spine more susceptible to injury, and
some are adaptations to injury. Just as is seen in other areas of
the body such as the knee, muscle function and strength around
the spine is altered after injury. Studies of patients with back
pain have found significant muscle recruitment abnormalities.
For example, a group working at the University of Queensland
in Australia studied patients with no history of low back pain,
and found that contraction of the transversus abdominis pre-
ceded contraction of muscles that move the arms and legs when
subjects were instructed to move their limbs in a certain direc-
tion in response to a stimulus. These contractions happened
without conscious effort by the pain-free subjects to stabilize
the spine before limb contractions began, so that unwanted
trunk movements would not occur with limb movement.
However, in patients with low back pain, firing of the transver-
sus abdominis is delayed, often occurring after the limb move-
ment is completed.165 Other studies have also uncovered
abnormal firing patterns in the deep stabilizers of the spine with
activities such as accepting a heavy load and responding to
balance challenges. Other researchers have found strength ratio
abnormalities and endurance deficits in patients with low back
pain, such as abnormal flexion to extension strength ratios and
lack of endurance of torso muscles.128
Lumbar paraspinal abnormalities  Studies of lumbar para­
spinals have found several abnormalities in patients with low
back pain. Multiple imaging studies have demonstrated para­
spinal muscle atrophy, particularly multifidi atrophy, in patients
with chronic low back pain. In a study using ultrasound to
measure the multifidi in patients with unilateral acute and
subacute low back pain compared to subjects without low back
pain, the side to side difference in multifidi size was 3 ± 4% in
the normal subjects and 31 ± 8% in the patients with low back
pain. The atrophy was found on the same side as the symptoms,
and was usually confined to one vertebral level. One subject
was measured within 24 h of developing pain and displayed
asymmetry, and the researchers interpreted this as the result
of segmental inhibition of the multifidus.166
Recovery of the multifidi does not appear to occur spontane-
ously with the resolution of back pain. The same researchers
performed a randomized trial of 39 subjects with acute first-
episode unilateral low back pain with multifidus atrophy. Sub-
jects were randomized to a control group and a treatment group.
The treatment group received specific exercises for multifidus
activation and strengthening; the control group received educa-
tion and usual care. Both groups had near resolution of back pain
A
and return to baseline function at 4 weeks. However, in the
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 902 Section 4 Issues in Specific Diagnoses
control group, the multifidi remained almost unchanged at 4 and
10 weeks, while in the treatment group the multifidus cross-
sectional area was restored to normal within 4 weeks of treat-
ment. Long-term follow-up revealed that 30% in the treatment
group suffered a recurrence of back pain within a year, and 80%
of the control group suffered a recurrence. After 3 years, people
in the control group were 12.4 times more likely to have further
episodes of pain than those in the exercise group.86
Biopsies of multifidi in patients with low back pain also show
abnormalities. Atrophy of type 2 muscle fibers is found, and
internal structural changes of type 1 fibers that give them moth-
eaten appearance are seen. In a study of patients undergoing
surgery for lumbar disk herniations with duration of symptoms
from 3 weeks to 1 year, multifidi biopsies collected at the time
of surgery revealed type 2 muscle atrophy and type 1 fiber
structural changes. Biopsies were repeated 5 years postopera-
tively. Type 2 fiber atrophy was still found in all patients, both
those who had improved with surgery and those who had
not. However, in the positive outcome group, the percentage
of type 1 fibers with abnormal structures had decreased, and in
the negative outcome group there was a marked increase in
abnormal type 1 fibers.161
There is increasingly strong scientific support for the multi-
factorial nature of low back pain, which includes both structural
and dynamic factors. This gives a theoretic basis for treatment
aimed at improving spine biomechanics as a means of treating
mechanical low back pain, along with other treatments aimed
at pain management. The research in this area is intriguing but
not yet conclusive. As is further discussed in the Prevention of
back pain section, it is unclear whether these muscular abnor-
malities are the result of back pathology that leads to pain, or
the cause of back pain. Study results conflict regarding consist-
ent deficits in patients with back pain. This again reflects the
heterogeneous nature of the group of patients classified as
having mechanical low back pain, and that different factors
predominate for different patients.
Psychosocial factors and low back pain
Pain is an individual experience, and biomechanical factors
alone do not explain much of the variance seen clinically in
patients with back pain. Multiple psychosocial factors have
been found to play a role in low back pain. This is briefly dis-
cussed here, and more thoroughly discussed in the chapter on
chronic pain, as these issues are shared by multiple painful
conditions and not just low back pain.
Depression and anxiety  It appears that between 30 and 40%
of those with chronic back pain also have depression.107 This
rate is so high because depressed patients are more likely to
develop back pain and to become more disabled by pain, and
because some patients with persistent pain become depressed.
Patients who are depressed are at increased risk of developing
back and neck pain. In a recent analysis of factors leading to
the onset of back and neck pain, those in the highest quartile
for depression scores had a fourfold increased risk of developing
A
low back pain than those in the lowest quartile for depression
Ch041-X2610.indd 902
scores.37 There is also strong evidence that psychosocial factors
are closely linked to the transition from acute pain to chronic
pain and disability. In a study of 1628 patients with back pain
seen at a pain clinic, those with a comorbid diagnosis of depres-
sion were over three times more likely to be in the worst
quartiles of physical and emotional functioning on the 36-Item
Short-Form Health Survey than those who were not depressed.65
Multiple other studies have found that depression, anxiety, and
distress are strongly related to pain intensity, duration, and
disability.110
Patient beliefs about pain and pain cognition  Beliefs about
back pain can be highly individual and are often not based on
facts. Some patients with back pain, especially those with
chronic low back pain that keeps them from working, have a
great deal of fear about back pain. These include fears that their
pain will be permanent, that it is related to activity, and that
exercise will damage their back. This set of beliefs is labeled
fear-avoidance. For example, studies have found that patients
with chronic low back pain who perform poorly on treadmill
exercise tests,178 walk slower on treadmill tests,3 and perform
more poorly on spinal isometric exercise testing4 were the ones
with more anticipation of pain than those who did well on these
tests. Fear-avoidance beliefs rather than actual pain during
testing predicted their performance. Fear-avoidance levels
explain self-reported disability and time off work more accu-
rately than actual pain levels or medical diagnosis do.117 This
has led Waddell and other experts to state that ‘the fear of pain
may be more disabling than pain itself’.219
A large, population-based study found that subjects with
high levels of pain catastrophizing, characterized by excessively
negative thoughts about pain, and high fear of movement and
injury or reinjury (kinesophobia), who had back pain at baseline
were much more likely to have especially severe or disabling
pain at follow-up compared to those who did not catastrophize.
For those without back pain at the initial questionnaire, cata-
strophizers were more likely to have developed low back pain
with disability at follow-up than non-catastrophizers.159 Thought
processes, such as the presence of catastrophizing, are not
limited to back pain and are often part of a larger pattern of
relationships and thought processes.
Patients’ beliefs about pain and their approach to dealing with
pain have been consistently found to affect outcomes. Fortu-
nately, changes in these beliefs and cognitive patterns are pos-
sible. Multidisciplinary pain programs have proven effective
in decreasing fear-avoidant beliefs and catastrophizing (see
Ch. 43).188
These changes in beliefs can also improve function. For
example, a study in which a group of patients with chronic low
back pain underwent a cognitive behavioral treatment program
found that, although there were not significant changes in pain
intensity, those with reductions of fear-avoidance beliefs had
significant reductions in disability. Changes in fear-avoidant
beliefs accounted for 71% of the variance in reduction in
disability in this study.229
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History, physical examination, and diagnostic tests in
mechanical low back pain
The history and physical examination in mechanical low back
pain is variable. There are no specific diagnostic tests for
mechanical low back pain. Tests and imaging are used to exclude
other diagnoses.
Treatment of mechanical low back pain
Reassurance and patient education  Education should
include providing as much of an explanation as patients need
in terms they can understand. In addition, the physician should
provide empathy and support, and impart a positive message.
Reassurance that there is no serious underlying pathology, that
the prognosis is good, and that the patient can stay active and
get on with life despite the pain can help counter negative
thoughts and misinformation that the patient might have about
back pain.214
There is strong evidence from systematic reviews that the
advice to continue ordinary activity as normally as possible
fosters faster recovery and can lead to less disability than the
advice to rest and ‘let pain be your guide’.215 It is controversial
whether patients with low back pain fare better with a specific
diagnosis or not. Education and explanations, however, should
be adequate. As Waddell states in his book The Back Pain Revo-
lution, ‘Simply saying that “I can’t find anything wrong” may
imply that you are not sure and make patients worry more!’214
On the other hand, some diagnoses carry negative messages to
patients that suggest permanent damage and the need to ‘get
fixed’, such as degenerative disk disease or arthritis.214 Mechani-
cal low back pain is a useful diagnostic term, because it implies
the mechanism of the pain and the way it is best treated
without suggesting permanence.
Beyond a diagnosis, there is other information that patients
want about low back pain. In a study of patients who presented
with low back pain to their primary care doctors in a health
maintenance organization setting, the information that patients
wanted from their doctor included the likely course of their
back pain, how to manage their pain, how to return to usual
activity quickly, and how to minimize the frequency and sever-
ity of recurrences. They ranked each of these areas of education
a higher priority than finding a cause or receiving a diagnosis for
their pain.214 Providing this information in an amount and in a
way that patients can understand helps build a therapeutic
doctor–patient relationship and, it is hoped, help reduce anxiety
and speed recovery.
Back schools  The term back school is generally used for group
classes that provide education about back pain. The content and
length of these classes varies a great deal, but generally they
include information about the anatomy and function of the
spine, common sources of low back pain, proper lifting tech-
nique and ergonomic training, and sometimes advice about
exercise and remaining active. In general, studies have found
back school to be effective in reducing disability and pain for
chronic low back pain.203
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Chapter 41
Low Back Pain 903
Exercise  There are no well-controlled studies that show that
exercise is effective for the treatment of acute low back pain.
Many practitioners believe that exercise for patients with acute
low back pain is appropriate to prevent deconditioning, to
reduce the chance of recurrence of symptoms, and to reduce
the risk of the development of chronic pain and disability. This
is consistent with rehabilitation principles for other acute
injuries, such as sports-related injuries or rehabilitation after
joint replacement surgery.218 Perhaps because of problems with
long-term exercise compliance, however, the overall favorable
prognosis for each episode of acute back pain, or the outcome
measures used, this principle is not yet supported by scientific
research.
In contrast, multiple high-quality studies have found that
exercise results in positive outcomes in the treatment of chronic
low back pain.205 This includes a wide variety of exercises used,
although the most common type studied is a combination of
strengthening and flexibility exercises.86 This is not surprising,
because it is generally believed that the purpose of exercises for
the treatment of low back pain is to strengthen and increase
endurance of muscles that support the spine and improve flex-
ibility in areas where this is lacking. This is combined with
motor retraining to establish normal patterns of muscle activity,
and treatment of deficits of the kinetic chain that interfere with
biomechanical efficiency.
Adverse effects of exercise for low back pain are rarely
reported, so it is generally a very safe treatment. One reason
that studies have not been able to determine what exercises
are best could be that multiple forms of exercise can achieve
the goal of restoring full function and regaining physical
fitness.108,204,218 Because endurance is a big problem with many
patients with persistent back pain, activity levels should be
increased by planned, fixed increments based on realistic goals
rather than symptoms, because it is the normal course of low
back pain that there will be temporary exacerbations of pain
along the way. Beyond the physiologic benefits of exercise,
increasing activity has positive effects on beliefs and behaviors
about pain. Small doses of exercise that are not sufficient to
cause physiologic change have been found to increase function
and decrease pain. When specifically studied, this appeared to
be from decreased fear-avoidance beliefs and reduced anxiety.
By exposing fearful patients to physical activity through gradu-
ally increasing activity levels despite pain, they receive positive
reinforcement by meeting goals, and personal experience can
reduce fear of movement, reinjury, and catastrophizing.22
Specific exercise treatment for low back pain  Postural
retraining Exercise prescriptions for mechanical low back pain
generally begin with the goal of improving alignment and
posture. Although researchers have not been able to consist-
ently identify which specific postural faults are associated with
chronic low back pain,52 the correction of posture is important
for at least two reasons. One is that exercises are more effective
if they are done from a position of proper alignment that
promotes optimal joint function and movement patterns. The
A
second is that, for virtually all patients, much more time will
5/9/2006 3:20:02 PM
 904 Section 4 Issues in Specific Diagnoses
be spent in habitual postures such as sitting and standing than
will ever be spent exercising. If these habitual postures can
reduce abnormal tissue strains, there is a better chance of
reducing pain and promoting healing.175
Posture should be evaluated in both sitting and standing, and
faulty positions corrected. Common faulty postures in standing
include either excessive lumbar lordosis or a flat back. In sitting,
common faults include patients who tend to lean to one side,
often leaning on an armrest that is too low. This causes pro-
longed lateral flexion of the trunk that can lead to pain, espe-
cially if the lateral flexion is abnormally occurring at only a few
segments. Short patients whose feet do not reach the floor
when they sit can overuse hip flexors to hold the legs in posi-
tion, which can increase forces on the spine. Tall patients might
sit with the knees higher than the hips, causing increased lumbar
flexion.176 Some of these postural faults are habitual and can be
improved with education, cuing, and practice. Some postural
faults are structural problems that do not change with exercise,
such as the kyphosis of Scheuermann disease or idiopathic
scoliosis, and should be addressed with aids such as higher
armrests or a chair with increased lumbar support. Many
postural faults begin as habitual, and then become structural
as tight muscles and tendons do not allow immediate correc­-
tion with cuing, and weak muscles cannot maintain the proper
position even if it can be reached. This is what is seen with
typical postural faults such as long standing lordosis, in which
hip flexors and lumbar paraspinals become tight from prolonged
positioning in lordosis, and abdominal muscles become long and
weak from disuse and their prolonged lengthened position.
These types of faults can be addressed with the proper exer-
cises to stretch tight areas and strengthen weak areas. However,
this is harder to achieve in patients with persistent back pain.
Multiple studies have shown that subjects with chronic low
back pain have deficits in spinal proprioception and make repo-
sitioning errors. For example, in a study in which asymptomatic
patients were compared with patients with chronic low back
pain in an activity in which participants were assisted into
neutral spine posture and then asked to reproduce this position
after periods of relaxed full lumbar flexion, the group with back
pain had significantly more repositioning errors.152 This has
important implications for treatment, as those with back pain
may need extensive training by a physical therapist to change
their posture, rather than just education regarding posture or a
few simple demonstrations.
Lumbar stabilization  Either after or at the same time as pos-
tural therapy and retraining, exercise training is added that
addresses the issues of decreased muscular endurance, abnor-
mal strength ratios, and poor motor control in patients with low
back pain. Generally, this includes lumbar stabilization exer-
cises. This is also called core strengthening. It includes training
in the proper use of muscles to increase stiffness and support
in areas that are weak and deconditioned, and improving flexi-
bility in areas of excessive stiffness. One of the principles of
physics is that movement occurs along the path of least resist-
A
ance. In the case of the body, the greatest degree of motion
Ch041-X2610.indd 904
occurs at the most flexible segment. In the spine, pathology is
often seen at the most flexible segments. Increasing muscular
strength, endurance, and neural firing patterns around these
segments can stiffen them and decrease abnormal flexibility.
Proper treatment also addresses the issue, however, that some-
times segments or areas with reduced flexibility can be the
problem. The reduced flexibility of some segments contributes
to compensatory motion at the most flexible segments and leads
to injury.
Many exercises can be stabilizing exercises. The key is prac-
ticing these exercises so that optimal or at least improved motor
patterns can be learned that ensure a stable spine. Achieving
stability is not just a matter of activating a few targeted muscles.
It is the ability to continually change motor strategies as needed
to support posture, to endure unexpected loads, to prepare for
moving quickly, and to provide sufficient stiffness in any degree
of freedom of the joint so that it is not subjected to further
injury. This end result is achieved by approaching the problems
in stages. The usual stages of a lumbar stabilization exercise
program are outlined below. For patients currently experiencing
back pain, exercises should be chosen that impose low loads on
the spine so that pain is not increased.
Awareness of spine position and muscle contraction in various
positions and with different activities  This begins with the
postural training as discussed above, and progresses to include
movement patterns and activities of daily living. This is key for
further training. Patients need to be able to appreciate the posi-
tion of their bodies while bending, reaching, moving the arms
and legs, and doing activities such as washing dishes or working
on the computer. They also need to be able to determine motor
patterns of movement. For example, patients should be able to
distinguish lumbar flexion from hip flexion when bending
forward, and need to assess whether the spine is moving exces-
sively or abnormally during exercises. This type of training can
be accomplished with a combination of simple exercises and
education.
Obtaining and maintaining mild abdominal contraction and
multifidi activation  Some patients with low back pain learn
this step easily and can contract the proper muscles for stabili-
zation, such as the transversus abdominis, very easily. For them,
simple cuing such as ‘Bring your belly button toward your
backbone’ will activate the proper muscles. For other patients,
this can be a long process of training that can take significant
effort by the physical therapist and might even need further
techniques such as biofeedback. This step is essential, however,
before moving to the next step, which demands further strength
and endurance of the muscles and more sophisticated motor
strategies.165
Stabilization exercises to establish motor patterns and build
endurance  Many exercises can be stabilization exercises. A
balanced program addresses the need for sufficient anterior
abdominal strength with exercises such as curl-ups, leg lifts,
oblique strengthening, bridging, and other exercises chosen
based on baseline strength, ability to maintain the appropriate
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position while doing the exercises, and reducing spinal forces
in those with back pain. The quadratus lumborum is an impor-
tant lateral stabilizer of the spine, and can be strengthened with
exercises such as side bridging. Extensor strengthening can be
accomplished by various extension patterns in quadruped as
well as other exercises. Pelvic floor exercises and appropriate
breathing patterns are also addressed.
Modifications for those in whom exercises aggravate pain  McGill
and colleagues have done extensive research evaluating spinal
forces generated during exercise. For example, sit ups cause
over 3000 N of compressive loads on the spine because of psoas
activity, about the same as moderately heavy lifting. Leg raises
also cause relatively high compressive forces. Curl-ups cause
lower forces on the spine, so are a better choice for anterior
abdominal strengthening in the early stages of rehabilitation, or
in those who have increased pain and cannot tolerate exercises
with increased spinal loading. Lying prone and extending the
spine while extending the arms and legs causes over 6000 N of
compression to the spine, and might be much too intense for
those with back injuries. The quadruped position with the leg
extended, however, also activates spinal extensors but causes
less than half the amount of spinal compression if done properly
with the abdominal muscles engaged and the spine in neutral.126
These examples show how modification of exercises can reduce
spinal forces and increase exercise tolerance.
Some patients, especially those with persistent pain, can have
high fear-avoidant behavior and develop kinesophobia, a fear of
movement and a belief that movement will increase pain or
cause them to be injured. This fear of pain, rather than forces
on the spine or spinal pathology, leads to poor exercise toler-
ance. If this is the reason for poor exercise tolerance, it can be
addressed by graded reactivation and gradual increases in activ-
ity. A positive experience with this might decrease fears. For
more severe cases, a multidisciplinary approach that includes
psychologic counseling to explore these dysfunctional thought
processes can be needed. The physician should emphasize to
patients that exercise needs to become a daily habit. Lack of
compliance is one of the main reasons why exercise treatments
fail. The health benefits of the stabilization program should be
discussed, and patients should be reminded that exercising
needs to continue even after symptoms decrease.
Flexion exercises for low back pain  Once popular for the
treatment of acute low back pain, using a series of flexion exer-
cises has not been found to be more helpful for acute low back
pain than other interventions, such as spinal manipulation, in
several studies. No research has been done on the effectiveness
of flexion exercises for chronic low back pain.202
Extension exercises for low back pain  Still commonly used
by therapists in the treatment of low back pain, and in particu-
lar back pain accompanied by radicular leg pain, extension-
based exercises are often done using the principles of the
McKenzie method of physical therapy. This therapy approach
divides the diagnosis for back pain into three categories: derange-
ment, dysfunction, and postural syndrome. The most common
Ch041-X2610.indd 905
Chapter 41
Low Back Pain 905
of these are derangements, and exercises are chosen that cen-
tralize the pain, i.e. move the pain from the leg or buttock into
the low back. Although early studies were very promising, later
studies have found this type of physical therapy to be helpful
for low back pain but no more effective than other types of
exercise.38,202
Aerobic activity  Increasing aerobic activity is a cornerstone
of most exercise programs for low back pain. Studies in this
area are often difficult to interpret because, both in the clinical
setting and in research studies, aerobic activity is usually com-
bined with strengthening and flexibility exercise. Studies have
found that group classes that combine low-impact aerobics with
strengthening and stretching floor exercises can be as effective
in reducing pain and decreasing disability as individualized
physical therapy and strengthening with weight machines.118
Many clinicians have found that patients with chronic low back
pain tend to have very low fitness levels, but research in this
area has had conflicting results. For example, one study, in
which prediction equations to estimated Vo2max (a measure of
aerobic fitness) in patients with chronic low back pain were
compared with normal values, found that values for chronic
low back pain patients did not differ from age-matched normal
values for sedentary men and women.227,228 This could be
because those who agreed to participate in the study were not
representative of all patients with chronic low back pain, or it
might simply demonstrate the poor aerobic fitness of sedentary
people in general. Perhaps this poor fitness level is related more
to lifestyle than to back pain.
No particular type of aerobic activity has been found to be
more effective for gaining fitness or decreasing pain than another
for patients with back pain. A willingness to regularly partici-
pate in the activity at an intensity level to improve fitness is a
more important factor than the specific type of exercise. One
small study that compared symptom-limited exercise tests per-
formed on the treadmill, stationary bicycle, or upper extremity
ergometer by patients with low back pain found that pain scores
were higher at the end of the treadmill test than the test on
the other two pieces of equipment. However, this appeared to
be because patients prematurely stopped the bicycle and arm
ergometer tests because of muscular fatigue, and patients were
able to reach significantly higher heart rates and peak Vo2 on
the treadmill test despite pain complaints.228 If increasing
aerobic fitness in a commonly used activity is the goal, then
walking might be the best way to achieve this, despite pain
complaints in patients with back pain. Patients with chronic low
back pain tend to walk slower during gait analysis than those
without pain. This is linked more with fear of pain and high
scores on fear-avoidance and catastrophic thinking scales than
with pain ratings.4 Interestingly, a slow stroll reduces spine
motion and causes almost static loading of tissues, overall higher
spine loading, and therefore more pain than faster walking with
arm swings. Faster walking causes cyclic loading of tissues and
results in lower spine torques, muscle activity, and loading.
Swinging the arms facilitates efficient storage and use of elastic
A
energy, which reduces the need for concentric muscle con­
5/9/2006 3:20:02 PM
 906 Section 4 Issues in Specific Diagnoses
tractions with each step.128 Fast walking has been shown
to be therapeutic for low back pain, as has other aerobic
activity.128,181
Aquatic exercises for mechanical low back pain  Patients
who have not tolerated land-based exercises are often able to
participate in pool exercises. There are several benefits to exer-
cising in the water. One is buoyancy and reduction of gravita-
tional stress. The greater the amount of the body that is
submerged, the greater the effect. For example, there is a 90%
reduction in gravitational stresses when exercising in the verti-
cal position when the patient is immersed to the neck.101 Water
can also decrease pain via the gate theory, in which the sensory
input from the water temperature, hydrostatic pressure, and
turbulence cause the patient to feel less pain. Muscle guarding
and muscle overactivity might also be decreased in warm water.
For those patients fearful of movement and reinjury, moving
in the pool can increase their confidence as they see that they
can progress without pain. The same principles for progressing
therapy apply to aquatic exercise as to land-based exercise.
Patients can learn neutral position, stabilizing, and other
strengthening exercise, and by walking, jogging (these can be
done in deep water using a buoyancy belt or vest), or swimming
can add an aerobic component.101 There has not been a great
deal of research in this area, but small case series have found
it an effective exercise form for patients with low back
pain.11,101
Exercise after spine surgery  Most of the research in this area
has been done on patients who have undergone lumbar disk
surgery. One systematic review of this subject found no evi-
dence that exercising after disk surgery increases injury rate or
need to reoperate.148 Overall, exercise appears effective to
decrease pain and increase return to work rates. Those who
used high-intensity exercise compared with low-intensity exer-
cise found significantly better short-term pain relief, functional
status, and faster return to work with the high-intensity program.
However, there was no difference between the high- and
low-intensity groups at 1-year follow-up, perhaps because of
long-term compliance issues with the high-intensity exercises.
Another study found home exercise programs equally effective
to a supervised exercise program when all patients are given the
same exercises.148
Overall, exercise has been found to be one of the most effec-
tive treatments for decreasing pain and increasing function in
chronic low back pain. The many other health benefits of exer-
cise, along with the low risk of causing harm, make it a first-line
treatment for mechanical low back pain.
Medication 
Non-steroidal antiinflammatory drugs  Multiple studies
provide strong evidence that NSAIDS prescribed at regular
intervals provide pain relief for both acute and chronic low back
pain. Studies comparing the effectiveness of NSAIDs have not
A
found any particular NSAID to be superior to others.204,208
Ch041-X2610.indd 906
NSAIDS are associated with some risk, especially gastrointes-
tinal bleeding. Other side effects include decreased hemostasis
and renal dysfunction or failure in patients with abnormal renal
function or hypovolemia.16 The deleterious cardiovascular
effects of the cyclooxygenase-2 inhibitors have received much
attention as of late.
Muscle relaxants  The use of muscle relaxants remains contro-
versial. One reason is that it is unclear what role muscle ‘spasms’
play in mechanical low back pain. Some object to the term
muscle spasm for skeletal muscle, because only smooth muscles
have the syncytial innervation pattern needed to actually spasm.
They prefer the term muscle guarding. Other experts do not
believe that pain in the low back is generally caused by muscle
spasms. Others think that, if muscle spasms are present, they
can contribute to the healing process by immobilizing the back
and are therefore efficacious in acute low back pain. Despite
this controversy, 35% of patients who visit a primary care physi-
cian for low back pain are prescribed muscle relaxants.207 These
medications fall into three classes of drug: the benzodiazepines,
the non-benzodiazepines that are antispasmodics, and antispas-
ticity medication.
The mechanism of action for benzodiazepines is the enhance-
ment of GABA inhibitory activity. The limited research done
on this class of medication has found them to be effective for
both acute and chronic low back pain for short-term pain relief
and decrease of muscle spasm. However, they have significant
adverse effects, such as sedation, dizziness, and mood distur-
bances. Rapid withdrawal can cause seizures. These medica-
tions have serious abuse and addiction potential, and they are
not recommended for mechanical low back pain except in
unusual cases for a short time.41,207
Non-benzodiazapine antispasmodics include medications
with multiple mechanisms of action. Cyclobenzaprine has a
structure similar to that of tricyclic antidepressants and is
believed to act in the brain stem. Carisoprodol blocks interneu-
ronal activity in the spinal cord and descending reticular forma-
tion. The mechanism of action of methocarbamol is not known
but may be due to central nervous system depression.8 There
are multiple high-quality studies showing that these medica-
tions are effective for patients with acute low back pain for
short-term pain relief. The most common side effects are drow-
siness and dizziness. There is not currently any evidence that
one is more efficacious than another. Carisoprodol is metabo-
lized to meprobamate, an antianxiety agent. It has significant
potential for abuse and can result in psychologic and physical
dependence.207 Because of this risk, and the fact that it is not
more efficacious than other muscle relaxants, it should not be
used except in rare cases. There is not much literature on the
use of muscle relaxants for chronic pain, and the drug manu-
facturers in this class state that they are not for long-term
use.8,41
Antispasticity medication has also been used to treat low
back pain. Baclofen is a GABA derivative that inhibits transmis-
sion at the spinal level and brain. One study has shown this
medication to be effective for short-term pain relief in acute
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low back pain. Dantrolene works on the muscle, blockading the
sarcoplasmic reticulum calcium channels. A small study of 20
patients found it to be effective for acute low back pain. It does
not have the drowsiness side effect of the other muscle relax-
ants, but there is a risk of severe hepatotoxicity.207
Antidepressants  Tricyclic antidepressants are an effective
treatment for many painful conditions, such as diabetic neu-
ropathy, postherpetic neuralgia, fibromyalgia, and headaches.
There are no adequate studies to show if they are effective for
the treatment of acute low back pain. Multiple studies and
reviews have shown their effectiveness, however, for chronic
low back pain. Staiger and colleagues did a best evidence syn-
thesis of randomized, placebo-controlled trials on this topic,
which included 440 patients.189 They found that the tricyclics
and tetracyclics had significant effects in reducing pain. These
reductions were seen in studies in which depressed patients
were excluded, so the mechanism is independent of any treat-
ment of underlying depression. The doses used in almost all
these studies were within the Agency for Health Care Policy
and Research guidelines for treatment of depression. The most
common side effects seen with the use of tricyclic antidepres-
sants are dry mouth, blurry vision, constipation, dizziness,
tremors, and urinary disturbances.
The selective serotonin reuptake inhibitors and trazodone are
not effective in treating chronic low back pain, which is consist-
ent with the findings in studies for other painful conditions,
such as diabetic neuropathy.189
Opioids  Many providers use short-acting opioids to treat
acute low back pain. The use of opioids for chronic non-
malignant pain is much more controversial. Randomized con-
trolled trials in this area are lacking. Most studies on opioid use
and pain include pain in many sites of the body, although back
pain generally makes up a large percentage of the pain com-
plaints. These studies also tend to suffer from high dropout
rates, because of either medication side effects or lack of effi-
cacy. Studies with long-term follow-up are lacking.
In one randomized controlled trial of pain relief with oral
sustained-release morphine versus placebo, in which 44% of the
patients had low back pain, the morphine group had less pain
but no psychologic or functional improvement.17 In a rand-
omized open-label trial of 36 patients with chronic low back
pain, one-third of the subjects were treated with naproxen,
one-third with set doses of oxycodone, and one-third with as-
needed doses of oxycodone plus sustained-relief morphine
titrated for pain intensity. Both opioid groups had significantly
less pain but no improvement in sleep or activity levels. In a
larger, non-randomized, open-label trial, about half of patients
treated with opioids had 50% or more pain relief, about 25%
had less than 50%, and about 25% did not respond. It is not
clear what percent had changes in function.17
Side effects are substantial, and in many studies occur in well
over half the participants. These effects include nausea, consti-
pation, somnolence, dizziness, and pruritis.17
In studies that have compared long-acting with short-acting
opioids, the long-acting medications appear to generally give
Ch041-X2610.indd 907
Chapter 41
Low Back Pain 907
better pain relief, are better tolerated, and are thought to have
less abuse potential.
Generally, because of side effects, abuse potential, tolerance,
and unknown long-term effects on pain and neuronal function-
ing, opioid medications are avoided, and a more global approach
to mechanical low back pain is used. As with other treatments,
long-term opioid treatment should be used only after careful
analysis of the positive and negative impacts on function and
quality of life. Outcomes beyond simple pain reduction should
be used, and a rational end point of treatment and criteria for
tapering and discontinuing the medications should be deter-
mined. Opioid medications should not be used without regular
follow-up (see Ch. 43).16,17
Anticonvulsants  The anticonvulsants, particularly gabapentin,
are widely used for neuropathic pain. Large, randomized, con-
trolled trials have not yet been conducted with these medica-
tions for the treatment of mechanical low back pain. Some pain
experts believe that chronic back pain is maintained long after
the acute noxious stimuli have ceased by processes similar to
neuropathic pain, such as central sensitization in the spinal cord
and a disinhibition of inhibitory neurotransmitters. If this is the
case, then it is a type of neuropathic pain and should respond
to treatment by anticonvulsants. This has not yet been proved
or disproved in the medical literature.
Topical treatments  Lidocaine (lignocaine) patches have been
found effective by some patients for the treatment of back pain.
No large studies have proved or disproved its efficacy. A variety
of creams and lotions are used by patients, including irritants
and antiinflammatory creams. Some people find them effective,
but they have not been subjected to extensive research. These
treatments carry little risk and have low incidence of side
effects.
Injections and needle therapy for mechanical low
back pain
Myofascial pain and trigger point injections  The theory that
irritable foci in skeletal muscle can cause both local and referred
pain is generally accepted, although some physicians doubt the
diagnosis of myofascial pain because, in general, the research
supporting the biochemical and mechanical basis of trigger
points is inconclusive (see Ch. 44). In regard to mechanical low
back pain, it is thought that acute trauma or overload, chronic
overwork and fatigue, or altered neurologic input causes trigger
points to develop. They are treated by a combination of tech-
niques, which include reducing biomechanical stress in the area
by avoiding tissue overload and making postural changes,
ischemic compression, stretching, and injections.198,199 Of this
treatment approach, the injection component has been most
studied. A Cochrane review of injection therapy for low back
pain pooled the results of multiple studies that have found
injections of trigger points to be effective in the treatment
of low back pain. These included studies that evaluated dry
needling, lidocaine (lignocaine) alone, and lidocaine with steroid
A
injections. The reviewers concluded that trigger point injections
5/9/2006 3:20:02 PM
 908 Section 4 Issues in Specific Diagnoses
are better than placebo injections for long-term pain relief
based on these studies.143
Acupuncture  Acupuncture has been used for the treatment of
pain conditions for thousands of years (see Ch. 23). From a
western medicine perspective, it appears to have multiple
mechanisms of action, including effects on the endogenous
opioid peptide system, an effect on the sympathetic nervous
system, and alterations in pain processing in the spinal cord and
brain.83 The efficacy of acupuncture in the treatment of low
back pain is difficult to determine. Like other physical treat-
ments, it is difficult to perform blinded studies. When compar-
ing acupuncture with other standard treatments for low back
pain, such as exercise, the results are difficult to interpret,
because the placebo effect is thought to increase with more
invasive procedures. There are great variations in the diagnosis
and treatment of low back pain by acupuncturists. Much like
other treatments for low back pain, such as physical therapy
and medication regimens, treatments are patient- and provider-
specific, and acupuncture treatments vary from one another by
the points chosen, what type of needle stimulation is done, and
the duration of the treatment.87,93
Despite these difficulties, the effectiveness of acupuncture
to treat low back pain is increasingly being studied. It has also
been the subject of multiple systematic reviews and metaanalyses
(more than 45 from the late 1980s to 2004). Most of these
reviews comment primarily on the quality of studies done, and
most studies are considered to be of poor quality, so only
limited conclusions on the efficacy of acupuncture can be made.
There seems to be general consensus in multiple reviews,
however, that the evidence for acupuncture in relieving low
back pain is either positive or inconclusive. For example, the
British Medical Association’s rigorous analysis in 2002 of acu-
puncture found it to be effective for low back pain, whereas
the Canadian/Alberta Health Authorities report’s rigorous
analysis done the same year found the results inconclusive
for low back pain.20
More high-quality definitive studies and clinical experience
is obviously needed to reach a final conclusion in this area.
Acupuncture is safe for the treatment of low back pain, with
very low complication rates and side effects. The most common
side effects are bruising and pain at the site of needle
insertion.20
Experimental injection procedures  Botulinum toxin injections
are increasingly being used to treat low back pain. The mecha-
nism of action could be through changes in sympathetic tone,
reduction of muscle spasms, or another unknown mechanism.
Studies in this area are currently small, and the results are
inconclusive as to whether this will be an effective treatment
for back pain.
Prolotherapy is another controversial procedure gaining pop-
ularity in certain parts of the country. It consists of a series of
injections into spinal ligaments to cause inflammation and thick-
ening of the ligaments. Based on the scientific literature, the
ability of this procedure to treat low back pain has not yet been
A
validated.
Ch041-X2610.indd 908
Steroid injections and other spinal procedures  See Chapter 25
for other specific spinal procedures used in the treatment of
low back pain.
Manual mobilization or manipulation  Historical references
to manual medicine go back over 4000 years. In the nineteenth
century, an increased interest in manual medicine began in
Great Britain and the USA. There are multiple theories as to
how manual medicine works. One theory is that it restores
normal motion to restricted segments. Another is that it changes
neurologic control via reflex mechanisms, especially the inter­
action between the autonomic nervous system and the spinal
cord.72
Multiple randomized controlled trials and systematic reviews
have been done to assess the efficacy of manual therapy. In most
countries with national guidelines for the treatment of low back
pain, spinal manipulation is recommended for acute low back
pain,216 although this is not universal. The recommendations for
chronic back pain are much more varied. Assendelft and col-
leagues performed a metaanalysis of the effectiveness of this
treatment for low back pain and found many high-quality
studies.12 This metaanalysis had weaknesses common to all
metaanalyses, including the variety in quality of the studies, the
possibility of publication bias, and statistical issues. Its strengths
were the size of the patient pool, thoroughness, and inclusion
of the most recent available data up to 2002. The metaanalysis
included a total of 5486 patients. For both acute and chronic
low back pain, the authors found spinal manipulation more
effective than placebo (which was either sham manipulation or
treatments judged to be ineffective) for short-term pain relief.
There was an improvement in function noted, but this did not
reach statistical significance. When spinal manipulation was
compared with other treatments known to be effective, such
as analgesics, exercise, and physical therapy, the authors could
find no statistically significant benefits as compared with other
therapies. Results did not change when they looked at studies
in which only manipulation and not mobilization was used.
They also could not identify any particular subgroup of patients
for whom manipulation was particularly effective, although
they theorized that, if such a group existed, it would be
small.
Of note, the authors also did not find other commonly used
treatments, such as physical therapy and medication, to be
statistically more effective than spinal manipulation, so their
conclusion was that spinal manipulation is more effective than
placebo, and is one of several options of modest effectiveness
for patients with low back pain.
Traction  The literature in this area has been criticized because
of disagreement as to whether studies done have used the
appropriate weight of traction, frequency of treatment, and
length of treatment session. For example, many studies have
been of traction used once per week, while some practitioners
believe traction should be done daily and that outcomes of
studies with frequency less than this are invalid.81 Multiple
randomized controlled trials using different doses of traction
have been done, however, and most have not found traction to
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be effective for the treatment of back pain. No well-done study
has shown that a specific weight or frequency of traction is
effective over sham treatment.204,208
Heel lifts and correction of leg length discrepancy  There is no
consensus in the literature as to whether small differences in
leg length lead to increased back pain. Part of the controversy
stems from the multiple reasons that legs can appear to be of
different length. Limb length discrepancy can be secondary to
either anatomic limb length inequality (in which there is a true
difference in length between the head of the femur and the
ankle), or to functional or apparent limb length inequality,
which may be from many diverse causes. The apparent limb
length inequality sources range from foot biomechanics (e.g.
increased pronation and decreased arch height causing a func-
tionally shorter limb) to imbalances of soft tissue around the
pelvis (e.g. quadratus lumborum shortening causes hiking of the
pelvis so that the legs appear a different length). There is little
consensus on what level of leg length discrepancy is clinically
significant, or how prevalent leg length discrepancies are.
Studies range from a 4% to 95% prevalence based on different
populations, measurement techniques, and cutoffs for clinical
significance from 5 mm to 11 mm. Small, unblinded studies
have found that correction of leg length discrepancy decreases
low back pain, but this has not yet been evaluated in large,
controlled trials.29
Lumbar supports  Lumbar supports are used to both treat and
prevent low back pain. There are multiple types of lumbar
support. They vary from a simple elastic wrap to custom-
molded plastic braces. High-quality studies comparing the
effectiveness of different braces are generally lacking, although
one study showed that patients who wore a lumbar support plus
a rigid insert in the back had more subjective improvement than
those who wore a brace without a rigid support.134
Several mechanisms of action have been proposed as to why
lumbar supports would be effective. One hypothesis is that
they prevent excessive spinal motion, either by physically block-
ing extremes of motion or by providing sensory feedback to
remind the patient not to bend excessively. Another theory is
that they increase intraabdominal pressure without increasing
abdominal muscle activity, and therefore could reduce muscle
force, fatigue, and compressive loading on the spine.160 A review
of the literature regarding the mechanisms of action of lumbar
supports showed that neither of these theories has been proven.
In general, lumbar supports decrease ROM, but the results are
not consistent. Decreases in ROM vary between subjects, with
some subjects even showing increased range while wearing a
brace, and the plane of motion that is reduced varies between
subjects and the types of braces tested. For example, some
types of brace reduce rotation, while others reduce flexion and
extension. There is no evidence that lumbar supports actually
increase intraabdominal pressure or decrease muscle forces and
fatigue.160 Regarding the efficacy of lumbar supports, there is
limited evidence that lumbar supports provide some pain relief
for low back pain when compared with no treatment, but when
compared with other treatments they are no more effective.
Ch041-X2610.indd 909
Chapter 41
Low Back Pain 909
Studies also show that overall there is poor compliance for
subjects to consistently wear lumbar supports. There is no
consistent evidence that lumbar supports prevent the occur-
rence of back pain.205
Transcutaneous electrical nerve stimulation  The development
of TENS was based on the gate theory of pain of Melzack and
Wall. In this theory, the stimulation of large afferent fibers
inhibits small nociceptive fibers, and so the patient feels less
pain. There are multiple types of TENS applications, such as
high frequency moderate intensity, low frequency high inten-
sity, and burst frequency (see Ch. 22). Clinically, many patients
find TENS helpful for temporary relief of low back pain.
Evaluating the research in this area is difficult because of the
difficulty of an equivalent placebo and the different types of
TENS applications used between studies, and because most
studies use patients’ memory of their pain, which is frequently
inaccurate, as an outcome measure.30 Metaanalyses of TENS
outcomes show trends toward better pain reduction, better
function, and satisfaction with treatment as compared with
placebo, but these trends do not reach statistical significance
and, given the small changes, are of unclear clinical significance.
Larger, methodologically sound studies are still needed to
evaluate the efficacy of this treatment.135
Massage  Massage is one of the most commonly used com­
plementary therapies for low back pain. The mechanism of
action is thought to include relaxation and stress reduction, the
therapeutic benefits of touch, and beneficial effects on the
structure or function of tissues and pain sensation.64 Research
that included massage has generally fallen into two categories:
studies that measure the effect of massage, and studies that
assess the effectiveness of other interventions and use massage
as a control with hands-on effects. Interestingly, in studies in
which massage was used as the control, massage was not gener-
ally found to be more beneficial. This could be because of the
effectiveness of both interventions, explaining why no differ-
ences were found, or it could have been due to publication bias.
In studies in which massage was one of the main interventions,
massage has been found to be effective for pain relief and in
restoring function. For example, Cherkin and colleagues per-
formed an interesting study that compared massage, acupunc-
ture, and self-care education for chronic low back pain.39 After
10 weeks in which up to 10 treatments were allowed, the
massage group showed improvements on disability scales, had
decreased medication use, and had less time with restricted
activity than the control group. After 1 year, many of these
gains were maintained.39 Other high-quality studies have also
found massage to be effective for improving symptoms and
functions in subacute and chronic low back pain. High-quality
studies on the effects of massage on acute low back pain have
not yet been done (see also Ch. 20).
Complementary movement therapies  There are many move-
ment therapies being used in the treatment of low back pain.
A few of the most commonly used therapies are listed below.
A
These therapies have been found helpful in case series but have
5/9/2006 3:20:02 PM
 910 Section 4 Issues in Specific Diagnoses
not been subjected to stringent randomized controlled trials
(see also Ch. 23).
• Yoga: both an exercise system and philosophy that
promotes relaxation, acceptance, and breathing techniques
while various stretching and strengthening exercises are
done.
• Pilates: a form of core-strengthening exercises that stress
alignment and proper form.
• Alexander technique: an educational approach to posture
and normalizing movement patterns.
• Feldenkrais: a combination of classes and hands-on
work with therapeutic exercise to promote natural and
comfortable movement patterns and improve body
awareness.
Multidisciplinary pain treatment programs  There is strong
evidence that a multidisciplinary program with a goal of func-
tional restoration is helpful for severe chronic pain.204 This is
discussed further in Chapter 42 on chronic pain.
Treatment of comorbidities  Multiple comorbidities are often
seen with back pain. Issues commonly associated with low back
pain include depression, anxiety, and sleep disturbances. Treating
these conditions often diminishes pain and increases function.
Those who suffer from low back pain often also have other
illnesses associated with an unhealthy and sedentary lifestyle,
such as obesity, non-insulin-dependent diabetes, and cardiovas-
cular disease. This must be taken into account when formulat-
ing a rehabilitation plan.
Other causes of back pain greater than leg pain
Lumbar spondylosis
The degenerative cascade of Kirkaldy-Willis has already been
described above. Because degenerative disease of the zygapo-
physeal joints generally coexists with degenerative disk disease,
it is difficult to separate the two entities. Both can cause axial
back pain. Both can also cause referred pain into the buttocks
and legs. Mooney and McCall have studied the sclerotomal
distribution of zygapophyseal joint pain in detail.123,137 Zygapo-
physeal joint pain has even been described to refer below the
knee in some cases.
Delineating a degenerative zygapophyseal joint as the primary
pain generator in axial low back pain, however, is difficult.
Imaging studies are not particularly useful, because many
asymptomatic people have spondylotic changes in their spines.
This diagnosis is also made more commonly in older patients.
Those in the older population have multiple findings in their
history, in their physical examination, and on imaging studies
that complicate arriving at specific diagnoses or specific pain
generators as the cause of their complaints. Spondylotic zygapo-
physeal joints are seen quite commonly with other potential
sources of low back pain such as degenerative disks and lumbar
stenosis. On physical examination, patients with these imaging
findings commonly have postural abnormalities, poor pelvic
girdle mechanics, and potentially multiple myofascial sources
A
Ch041-X2610.indd 910
for pain. They typically have an accentuated lumbar lordosis,
in part due to tight hip flexors, which exacerbates the problem
by increasing stress on the posterior elements.
From biomechanical studies and knowledge of anatomy, we
know that lumbar extension and rotation increase forces placed
on the posterior zygapophyseal joints. This specific maneuver,
however, has not been shown to be diagnostic for zygapophyseal
joint pain in clinical settings (by either history or examination).
There actually are no unique identifying features in the history,
physical examination, or radiologic imaging that are diagnostic
for zygapophyseal joint pain. The only diagnostic maneuvers for
zygapophyseal joint pain are fluoroscopically guided zygapophy-
seal joint injections with local anesthetic, and medial branch
blocks (i.e. local anesthetic blocks of the medial branches of
the dorsal primary rami that innervate the zygapophyseal
joints).48,120 Using these injection techniques, the prevalence
of facet-mediated pain has been estimated to be 15% in
the younger population and 40% in older age groups.179,180
Schwarzer’s 1994 study demonstrated that the vast majority of
lumbar zygapophyseal joint pain originates from the L4–5 and
L5–S1 zygapophyseal joints. Consequently, if injections are
used as treatment, most can be directed to those two lumbar
levels.
There are more conservative management options for the
spondylotic spine and facet-mediated pain that should be trialed
before resorting to invasive procedures such as intraarticular
zygapophyseal joint corticosteroid injections or medial branch
neurotomies. The conservative treatments are similar to treat-
ments for osteoarthritic joints, and can be categorized as life-
style and activity modification, medications, and exercise.
Lifestyle and activity modifications include weight control,
relative rest, and initially limiting activities that result in
increased pain (e.g. sleeping prone generally is to be avoided).
Medications used include analgesics such as acetaminophen
(paracetamol) and NSAIDs. There might be a role for glucos­
amine, because it has demonstrated a good response for pain
relief with knee osteoarthritis. Exercise programs are generally
designed to decrease the forces acting on the zygapophyseal
joints. This can include improving postural control by reducing
any exaggerated lumbar lordosis through hip flexor stretching
and pelvic tilts, but also developing the spine’s supportive mus-
culature, including the deep abdominals, quadratus lumborum,
and gluteal muscles, to stabilize the pelvis and lessen potential
shearing forces in the lumbar spine. There is no single proven
exercise program, however, for standardized treatment with an
exercise protocol for zygapophyseal joint-mediated pain. If
land-based exercise is initially too aggravating, aquatic therapy
can be the best starting place. Finally, lumbar braces or corsets
have not proven useful in the long term, but for an overweight
patient with a protuberant abdomen or large pannus (which can
certainly increase zygapophyseal joint stress by increasing the
lordotic posture) it could be the best alternative.
Interventional treatments for zygapophyseal joint pain have
been briefly mentioned above. A more detailed discussion can
be found in Chapter 26.
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Lumbar disk disease
Diskogenic causes of low back pain generally fall into three
categories: degenerative disk disease, internal disk disruption,
and disk herniation. Diskogenic pain is classically described as
bandlike and exacerbated by lumbar flexion, but this is not
always the case. It can be unilateral, can radiate to the buttock,
and can even be worsened by extension or side bending (depend-
ing on the site of disk pathology).
Internal disk disruption
Bogduk defines internal disk disruption as a condition in which
the internal architecture of the disk is disrupted, but its exter-
nal surface remains essentially normal (i.e. there is no bulge or
herniation).23 It is characterized by degradation of the nucleus
pulposus and radial fissures that extend to the outer third of
the annulus (high-intensity zone areas on MRI).9 It can be
diagnosed only by postdiskography CT, which shows the
degradation of the nucleus and the presence and extent of the
annular fissures. Although the use of diskography is controver-
sial, most believe that annular tears (especially those that reach
the outer third of the annulus, i.e. the innervated fibers) can be
a source of low back pain. It must be remembered, however,
that, like most abnormalities on lumbar spine imaging, annular
tears or high-intensity zone areas are seen commonly in asymp-
tomatic subjects.
The proposed mechanisms for pain generation from internal
disk disruption are similar to those previously described for disk
herniation and radiculopathy; that is, chemical nociception
from inflammatory mediators and mechanical stimulation.
Similar to other general causes of low back pain, treatment
generally encompasses NSAIDs and non-opiate analgesics,
relative rest, and exercise programs designed to strengthen the
lumbar supportive musculature. Epidural steroids might have a
potential role in treatment as well. Recently, Butterman sup-
plied us with some potential criteria for the role of epidural
steroid injections in degenerative disk disease.36 There are many
novel, interventional treatment approaches that are discussed
in detail in Chapters 25 and 26, including intradiskal steroids
and intradiskal electrothermal annuloplasty. However, it should
be kept in mind that these interventional treatments are still
awaiting rigorous scientific studies. Fusion surgery is another
controversial treatment for degenerative disk disease. Because
of the variable and controversial results of fusion surgery, much
hype is being generated about disk replacement surgery, which
has gained popularity in Europe and was, in October 2004,
approved in the USA.
Disk herniation
The terminology used to describe disk material that extends
beyond the intervertebral disk space is confusing. Herniated
disk, herniated nucleus pulposus, disk protrusion, disk bulge,
ruptured disk, and prolapsed disk are all commonly used terms,
and sometimes are used (incorrectly) synonymously. Displaced
disk material can be initially classified as a bulge (disk material
is displaced >50% of its circumference) or as a herniation
Ch041-X2610.indd 911
Chapter 41
Low Back Pain 911
Normal disk Diffuse bulge Broad-based
protrusion (25–50%
circumference)
a
b
Focal protrusion Extrusion Sequestration
(<25% circumference) (b>a) (loss of contact
with parent disk)
Figure 41-22  Disk herniation, protrusion, and extrusion. (From Maus
2002,122 with permission.)
(<50% of its circumference) (see Fig. 41-22).53 Disk herniations
can then be subclassified into protrusions or extrusions. A disk
protrusion is defined as a herniation with the distance of the
edges of the herniated material less than the distance of the
edges at its base. A disk extrusion occurs when the distance of
the edges of the herniated material is greater than the distance
of the edges at its base. A disk extrusion can be further sub­
classified as a sequestered or sequestrated disk if the extruded
disk material has no continuity with the disk of origin. Finally,
disk herniations can be described as contained or uncontained
depending on the integrity of the outer annular fibers. If the
outer annular fibers are still intact, it is described as a contained
disk herniation. This classification has no relevance to the
integrity of the posterior longitudinal ligament.
Over 95% of lumbar disk herniations occur at the L4–5 and
L5–S1 levels.45,187 Next most common is L3–4, followed by
L2–3. The most common lumbosacral radiculopathies are con-
sequently L5 and S1. Posterolateral disk herniations are most
common because the annulus fibrosus is weakest posterolater-
ally. Posterolateral disks can affect the nerve root as it descends
in the lateral recess or just before it enters the neural foramen.
Far lateral or extraforaminal herniations can affect the nerve
root as it exits the neural foramen, and central disk herniations
may affect any part of the cauda equina depending on the
level.
As noted above, disk herniations can cause an inflammatory
response that can affect the nerve root, or there can be mechan-
ical compression, both of which can cause radicular symptoms.
However, disk herniations can cause solely axial pain. Diagnos-
ing diskogenic low back pain is a challenge, because we know
asymptomatic subjects can have disk herniations present on
MRI.21,90,91 Diskography is a controversial diagnostic tool for
diskogenic pain (see Ch. 26). It is typically used as a presurgical
screening tool.
The mainstay of treatment for diskogenic back pain is con-
servative. The literature is rather poor for discerning effective
conservative management for diskogenic low back pain or, for
that matter, axial low back pain in general. The primary reason
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5/9/2006 3:20:03 PM
 912 Section 4 Issues in Specific Diagnoses

is that most studies do not have a well-defined patient popula- for instability (say, in patients with significant multilevel degen-
tion, because it is quite difficult to discern the exact etiology erative disease), spinal fusion is sometimes considered. Only
of low back pain (e.g. diskogenic, facet, ligamentous, or mus- recently have prosthetic disk replacements been given consider-
cular). Studies evaluating conservative measures (such as reha- able thought to replace spinal fusion as a motion-sparing
bilitation programs and exercise) might have different patients procedure.
who would respond to different forms of exercise and not all
be suitable for the one standardized exercise program used in Spondylolysis
the study. Many other studies do not even define the exercise Spondylolysis is a defect of the pars interarticularis, and is a
program well enough to truly make any appropriate conclusions common cause of back pain in children and adolescents. The
about one form of exercise over another. most common hypothesized mechanism of injury is repetitive
Even when it is agreed that the etiology of low back pain is hyperextension loading in the immature spine, and is commonly
diskogenic, patients still respond differently to various exercise reported in adolescent gymnasts and football linemen.56,89 Acute
regimens, primarily because the location of the disk herniation fracture from a severe hyperextension injury is also possible but
typically dictates which lumbar spine movements can enhance less commonly reported.55 Pars defects have been reported in
pain and which do not (i.e. posterolateral disks cause more pain non-athletic individuals as well. In growing children, the defect
with flexion, central disks are usually more painful in extension, is rarely seen before walking begins and most commonly occurs
and for lateral disks there is more pain with ipsilateral side at age 7–8 years.144 An increase in incidence occurs during the
bending). It is appropriate to individualize rehabilitation pro- adolescent growth spurt between ages 11 and 15 years. The
grams according to which movements patients can do with little pars defect appears to result from a combination of hereditary
pain, and slowly progress their exercise program or movement dysplasia of the pars and repetitive stressing of the spine by
patterns to include more planes of motion (that might initially walking and extension loading.47 Unilateral or bilateral defects
have been painful) to improve the patients’ functioning with can occur; however, bilateral involvement may result in
less pain. spondylolisthesis. Ninety percent of these lesions occur at
Prior to exercise treatment, some patients need a limited the L5–S1 level.
period of convalescence. During this initial period, these patients Patients typically present with low back pain that is exacer-
have relative rest with avoidance of activities that enhance pain bated by extension and alleviated by rest or activity limitation.
(e.g. lifting, repetitive bending and twisting, and prolonged Physical examination can demonstrate focal tenderness, pain
sitting). It might also be helpful to use pain medications (aceta- with lumbar extension, and hamstring tightness (Fig. 41-23).
minophen [paracetamol], NSAIDs, or a limited prescription of The neurologic examination is usually normal. If a spondylo­
an opiate analgesic) and modalities such as lumbar traction to listhesis is present, a palpable step-off with examination of the
decrease pain prior to initiating a rehabilitation program. Pro- spinous processes might be evident.
longed bed rest greater than 3 days is not indicated, as it has
not been shown to reduce disability from low back pain.44
Getting the patient moving and educated on proper body
mechanics for sitting and standing postures, as well as for lifting,
is important early on in the course of treatment.
Most patients with diskogenic pain do well with conservative
management alone. There are still some patients who do not
respond to these conservative measures. Over the past few
years, there has been an insurgence of interventional procedures
to tackle the problem of diskogenic back pain, in order to
prevent the need for surgical management. There is growing
literature to support epidural steroid injections as a pain man-
agement strategy for disk herniations with radiculitis. Because
it is well accepted that a disk herniation can cause an inflam-
matory response, epidural steroid injections for diskogenic pain
(i.e. without radicular symptoms) have been used and probably
are indicated, although there is no proven literature to support
this. There are many other procedures that are gaining in popu-
larity, including intradiskal steroid injections, annuloplasty, and
nucleoplasty (see Ch. 26).
The literature on surgical management for diskogenic pain is
similar to that regarding epidural steroid injections, i.e. surgery
is most effective in improving radicular leg symptoms and is
less impressive for axial back complaints. The most common Figure 41-23  The standing
A
surgical procedure is diskectomy. However, if there is concern one leg hyperextension test.

Ch041-X2610.indd 912 5/9/2006 3:20:03 PM


Radiologic assessment of a suspected pars injury begins with
plain films to include oblique views of the lumbar spine. Oblique
views demonstrate the typical Scottie dog appearance of the
lumbar vertebrae, and a pars defect will show up as a break in
the dog’s collar or neck (Fig. 41-19).163 Bone scanning is a more
sensitive test for a pars injury, and is indicated if the plain films
are normal or if the plain films show a fracture that could be
old. The bone scan demonstrates increased bony turnover at
the site of a recent fracture, healing fracture, or bony stress
injury. SPECT is even more sensitive and specific for an active
spondylolysis than planar bone scans are.164 Thin-cut CT scan-
ning through the level of the pars injury can be useful to deter-
mine if a fracture is old (sclerotic borders at the fracture edges)
or acute. MRI can sometimes miss a spondylolysis but is very
sensitive for other etiologies of a young athlete’s back pain, such
as disk herniation.
A spectrum of successful management strategies for spondylo­
lysis have been employed. Conservative management is most
common, typically beginning with relative rest and avoidance
of activities that increase pain (repetitive extension). Bracing is
quite common for symptomatic spondylolysis. Micheli advo-
cates use of a modified Boston overlap brace constructed with
0° of lumbar flexion 23 h a day for at least 6 months.131 He
demonstrated that 32% of young athletes healed their fracture,
and 88% were able to resume pain-free activity even if fracture
union did not occur.133 From these data, it is obvious that frac-
ture union should be considered a hope, but it is not a necessary
goal to be asymptomatic and fully functional in sports and
everyday life. Bracing is not an absolute necessity, however, and
some consider it only for those patients who cannot or will not
comply with their activity restrictions, or for those who need
a stigma of disability to show an overzealous coach or intrusive
parent.
In any event, braced or not, the young athlete is at risk for
deconditioning. When pain allows, the patient should be encour-
aged to begin aerobic conditioning and eventually enter a spinal
rehabilitation program before return to a sport. Once the athlete
has mastered a basic core stabilization program, functional pro-
gression back to the specific sport is appropriate, with a focus
on neuromuscular proprioceptive control and sport-specific
drills before full return to play. For the patient with chronic low
back pain and spondylolysis, O’Sullivan et al. demonstrated that
a specific exercise program focused on training the lumbar
multifidi and deep abdominals can be very effective.153 Surgical
treatment is rarely indicated for the patient with spondylolysis
alone, but is more common when spondylolysis is in the setting
of spondylolisthesis and/or radiculopathy.
The natural history of spondylolysis and low-grade (<2)
spondylolisthesis is benign, i.e. it is rare to have progressive
slippage. Saraste demonstrated this in a study of 225 patients
with a 20-year follow-up period.177 Most cases of progressive
slippage occur during the adolescent growth spurt, however,
so for very young athletes monitoring with lateral flexion–
extension plain films during this time is appropriate. Besides
the adolescent growth spurt, a listhesis >50% is considered a
risk factor for progressive slip.
Ch041-X2610.indd 913
Chapter 41
Low Back Pain 913
L5
S1
Figure 41-24  Grade
1 isthmic
spondylolisthesis.
Spondylolisthesis
There are many causes of lumbar spondylolisthesis or anterior
slippage of one vertebra on another. Spondylolisthesis can be
grouped into six different categories by etiology. The most
common is the isthmic spondylolisthesis (Fig. 41-24). The
isthmic slip occurs due to a spondylolysis or ‘stress fracture’ of
the pars interarticularis (as described above). The dysplastic
spondylolisthesis is a congenital slip, and is caused by dysplasia
of the facet joints of the upper sacrum, leading to an inability
to resist shear stresses; consequently forward slippage results.
Degenerative spondylolisthesis is seen in the older spine, and is
related to longstanding intersegmental instability from degen-
erative facet or disk disease. The most common level affected
in a degenerative slip is the L4–5 level. Traumatic spondylo­
listhesis is rare, and is caused by acute fracture secondary to
trauma. Pathologic spondylolisthesis is due to medical causes
of generalized or local bone disease that can cause decreased
bony strength. This form can present as an isthmic defect or an
elongated, intact pars. The final category is postsurgical and is
due to resulting instability from an extensive decompression,
which is quite uncommon now due to the amount of hardware
used for fusions after extensive decompression.
The patient with spondylolisthesis typically presents with
low back pain. Sometimes, there is a complaint of intermittent
radicular symptoms related to a dynamic radiculitis, i.e. nerve
root irritation caused by subtle instability at the listhetic
segment. Physical examination is not different from that seen
in spondylolysis. When imaging a patient with suspected
spondylolisthesis, lateral flexion–extension views are helpful for
presurgical screening. With lateral plain films, the degree of slip
is graded 1–5 (Table 41-8).
The natural history of spondylolisthesis is spontaneous stabi-
lization. It is generally accepted that significant slip progression A
5/9/2006 3:20:03 PM
 914 Section 4 Issues in Specific Diagnoses
Table 41-8 Meyerding’s grading system for
spondylolisthesisa
Grade Percentage slip
1 <25
2 25–49
3 50–74
4 75–99
5 ≥100 (spondyloptosis)
a Anterior column fractures  These are compression fractures
Meyerding divided the anterior–posterior diameter of the superior
surface of the first sacral vertebral into quarters and assigned the
grade accordingly.226
rarely occurs in adults.177,182 There is some controversy regard-
ing slip progression in adolescents. Harris studied youths with
grade 3 or 4 slips in a long-term follow-up study, and noted that
there was a higher incidence of progression of the slip until
skeletal maturity was reached.80 Saraste and Seitsalo had simi-
larly large long-term observational studies that demonstrated
that slip progression in youths and adults was quite small
overall.177,182 Possible factors positively correlating with slip
progression include degree of slip, degenerative disk disease at
the level of slip, adolescent age, and ligamentous laxity that
manifests as hypermobility on imaging (i.e. motion on flexion–
extension views).
Treatment for an isthmic spondylolisthesis in a young patient
is similar to that for the athlete with spondylolysis, as described
in the prior section. Fusion surgery is generally considered in
adolescents if the slip is grade 3 or greater. For the degenerative
spondylolisthesis, non-operative management with a rehabilita-
tion program similar to that described in the section on degen-
erative zygapophyseal joint and disk disease is appropriate,
because both are typical findings with a degenerative slip. Oper-
ative intervention with fusion is generally considered only for
recalcitrant pain after an appropriate rehabilitation program,
persistent radiculopathy, or progressive instability.
Other spinal fractures
There are many other types of spinal fracture, the most common
of which are briefly discussed below. Many are secondary to
trauma. Evidence-based guidelines have not yet been developed
for the treatment of traumatic spine fractures. Current litera-
ture in this area is mainly of retrospective case series. Outcomes
appear to be most dependent on the amount of neurologic
injury at the time of injury, and on the time elapsed between
injury and surgery if a neurologic injury exists.210
The three-column structural concept of Denis is the most
common way to classify spinal fractures. This concept divides
the spine into anterior, middle, and posterior columns. The
anterior column is made up of the anterior longitudinal ligament
A
Ch041-X2610.indd 914
and the anterior half of the vertebral body and disk. The middle
column is made up of the posterior longitudinal ligament and
the posterior half of the vertebral body and disk. The posterior
column is made up of the rest of the bony and soft tissues of
the spine. If two of the three columns are intact, the spine is
stable and treatment with pain management and rehabilitation
is generally indicated.
Posterior column fractures  This includes transverse process
and spinous process fractures. These are stable injuries. They
are treated by pain management techniques and avoiding contact
sports until the fractures have healed.
and generally are caused by flexion injuries. These fractures
usually do not cause neurologic deficits and do not require
surgery. If greater than 50% of the height of the vertebral body
is lost, there is an increased chance that the fracture can be
unstable, because posterior injury might also be involved, and
further investigation can be warranted. The treatment of trau-
matic compression fractures remains controversial.
Anterior and middle column fractures  These are burst frac-
tures and are usually the result of compression and flexion
injuries. Instability and cord compression should be ruled out
with plain films, a CT scan, and a thorough neurologic assess-
ment. If patients are neurologically intact and there is no evi-
dence of posterior instability, they can often be treated with a
brace, usually a thoracic–lumbar–sacral orthosis for 12 weeks.
If there is injury to the posterior longitudinal ligament, then
surgery is usually required. Burst fractures in which there is loss
of 50% or more of the height of the vertebral body, greater than
50% impingement into the spinal canal, or greater than 20° of
kyphosis require surgery to achieve stability.
Anterior and posterior column fractures  These are caused
by flexion and distraction injuries, and are called chance frac-
tures. They are usually caused by seat belt injuries in high-
impact motor vehicle accidents. They are unstable fractures.
They are sometimes treated with bracing but often require
surgery.156
Osteoporotic compression fractures  Osteoporotic compres-
sion fractures are important to diagnose, both because they are
a significant source of morbidity and because they also can
herald the risk for subsequent fractures, particularly hip frac-
tures, which have a high morbidity and mortality. Patients who
have had a previous vertebral fracture have 3.8 times the risk
of suffering a hip fracture compared with those who have not.
The risk of compression fractures increases as bone density
decreases. Genetic factors account for much of the risk, as well
as exercise, calcium intake, smoking, alcohol use, and age at
puberty (see Ch. 42).
Compression fractures can be a significant cause of pain, and
are generally the reason that there is a higher incidence of back
pain in elderly women as compared with in men. Pain is espe-
cially prevalent if three or more fractures are present. These
subjects have twice as much back pain as those without
5/9/2006 3:20:03 PM

compression fractures.61 Fractures can be asymptomatic or
can present with sudden onset of severe pain. Pain can
radiate anteriorly, and usually gradually improves over several
weeks.
Diagnostic evaluation for vertebral fractures  Up to 30% of
those with osteoporotic compression fractures have an under-
lining cause, which is called secondary osteoporosis. Common
causes of secondary osteoporosis are use of oral steroids,
hyperthyroidism, metastases, and multiple myeloma. An
underlying cause should always be ruled out. This can be done
with a complete blood count, sedimentation rate, reactive
protein, thyroid function tests, bone profile, and biochemical
profile (such as liver function test, electrolytes, and albumin).147
Bone mineral density measurements are useful to confirm
the diagnosis of osteoporosis and to assess the efficacy of
treatment.
Treatment  A balance should be found between alleviating pain
and the pain medication side effects. Calcitonin, either subcu-
taneous or intranasal, has been found in multiple studies to
decrease pain without significant side effects. Adjunct treat-
ment and modalities such as TENS might be helpful. Intercostal
nerve blocks are sometimes used to treat the pain.
Vertebroplasty is a procedure in which bone cement is
injected into the bone for pain relief and to strengthen the bone.
Studies so far have mainly been case series or uncontrolled
prospective studies, but it appears that up to 80% of patients
treated obtain significant pain relief, and complications are rare.
The complications can include compression of the spinal nerve
roots and spinal cord, and pulmonary embolism.61
Osteoporosis requires treatment with a combination of
medication, lifestyle modification, and exercise (see Ch. 42).
Cancer and low back pain
Cancer is the second leading cause of death in the USA, and
two-thirds of patients with cancer develop metastases. The
third most common site of metastases is to bone. The spine is
the most common site for bony metastases, and vertebral body
metastases are found in over one-third of cancer patients. The
most common cancers that involve the spine are lung, breast,
prostate, and renal cell.157
Back pain is by far the most common symptom of metastatic
disease. It is caused by stretching of the periosteum and tumor
mass effect. Most commonly, the thoracic region of the spine
is involved, although the lumbar spine is a more common site
for colorectal cancer.162 The pain can start gradually and increase
as the bone is destroyed. It is a constant ache not exacerbated
by movement. Sometimes, the pain has a more sudden onset
because of a pathologic fracture, and this type of pain can be
worse with movement, especially if the spine is unstable. Deyo
found that the most specific historical feature for malignancy
is a previous history of cancer (98% specific), and the authors
considered it prudent to consider new-onset back pain in a
patient with a history of cancer to be malignant disease until
proven otherwise. This historical feature has a sensitivity of only
Ch041-X2610.indd 915
Chapter 41
Low Back Pain 915
0.31, however, so only about one-third of patients with spinal
malignant neoplasm have a history of cancer. Consequently,
other features suggestive of malignancy must be explored in the
history. Back pain unrelieved by bed rest is greater than 90%
sensitive so, if the pain is relieved by bed rest, malignancy is
unlikely. This is not specific, so many patients without malig-
nancy will complain that their pain is not relieved by bed rest.
Other historical features related to cancer include unexplained
weight loss and failure to improve with conservative care. New
onset of back pain after age 50 is suspicious for malignancy,
because many other common causes of back pain begin at an
earlier age. These features can be combined to give the clinician
confidence in determining if cancer should be included in the
differential diagnosis. For example, in Deyo’s study of nearly
2000 patients with back pain, no patient under 50 had cancer
involving the spine without a history of cancer, unexplained
weight loss, and failure to improve with conservative care,
giving a combined sensitivity of 100%.46
Neurologic deficits occur much less commonly than back
pain, but 5–20% of patients with spinal metastases will develop
neurologic deficits either from mechanical pressure of the
tumor or from bone extruded from a collapsed vertebral
body.201 Deficits often occur several months after the back pain
began.67
Imaging for suspected spinal metastasis
Because significant vertebral body destruction must occur
before changes are seen on plain films, the sensitivity of plain
films is low, especially early in the course of the disease. In the
thoracic and lumbar spine, the most common finding on plain
films is pedicle erosion. Compression fractures can also be
seen. Technetium-99 bone scintigraphy is more sensitive for
most types of metastases than plain films are, but the specificity
is low. Trauma or degenerative disease can cause false positives.
Certain highly vascular metastases, such as renal cell
and thyroid, can be missed on bone scans.67,162 CT is the best
imaging modality to examine bone anatomy, but it does not give
nearly as much information about neural compression as MRI
does. It is useful for surgical planning. MRI is the imaging
modality of choice for a full evaluation of spinal metastases.
It is very sensitive and can show early changes in the bone
marrow. It also shows both bony destruction and neural
compression.67,162
Spinal infections
Spinal infections include osteomyelitis, diskitis, pyogenic facet
arthropathy, and epidural infections. These structures are often
all infected at the same time. The incidence of spinal infections
is increasing. Some of the causes of this include the growing
numbers of immunocompromised patients who are at high risk,
drug resistance of some infections, and the recent increases in
tuberculosis.194 It is important to diagnose and treat spinal
infections quickly to prevent increased morbidity and mortality,
and to prevent complications such as epidural abscesses that
can cause paralysis. However, this is not always easy. In Tali’s
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5/9/2006 3:20:03 PM
 916 Section 4 Issues in Specific Diagnoses
review article of spinal infection, he describes the ‘rule of 50’
to assist in the diagnosis of spinal infections: 50% of the patients
are older than 50, 50% will have a fever, and 50% will have a
normal white blood count. The urinary tract is the source in
50%, Staphylococcus aureus is the organism in 50%, the lumbar
spine is affected in 50%, and symptoms are present for greater
than 3 months in 50%.194
Vertebral osteomyelitis can occur from hematogenous spread
or secondary to a contiguous focus of infection. Hematogenous
spread occurs via spinal arteries, and infection can quickly
spread from the end plate of one vertebral body into the disk
and then into the adjacent vertebral body. The most common
source is urinary tract infections, often caused by Escherichia
coli and other enteric bacilli. Hematogenous spread is also seen
from other sources, such as infected intravenous lines or endo-
carditis. Patients with diabetes, those on hemodialysis, intra­
venous drug users, and other immunocompromised patients are
at increased risk.116,194 The most common location is the lumbar
spine, and the most common symptom is back pain, although
15% of patients also have radicular pain. Symptoms can begin
slowly and progress over months. Many patients do not have a
fever or elevated white blood count. The erythrocyte sedimen-
tation rate, however, is usually elevated. The infection can
spread to surrounding tissues, and epidural, paraspinal, and
psoas abscesses can also be present. Epidural abscesses are par-
ticularly serious because of the risk of spinal cord injury. Early
diagnosis is important to prevent bone necrosis and other com-
plications of a spreading infection.98
Plain films are usually normal the first 2 weeks, and then the
first sign is a periosteal reaction. As the infection progresses,
plain films show irregular erosions in the end plates of adjacent
vertebral bodies and narrowing of the disk space. This appear-
ance is nearly pathognomonic for infection, as tumors and other
causes of irregular erosions rarely cross the disk space. Bone
scan shows changes as soon as 24 h after symptoms begin but
is not specific. MRI is as sensitive as bone scan and can give
important anatomic information, so is generally the imaging
technique that should be used.98,100
Treatment for spinal infections is usually a 4- to 6-week
course of intravenous antibiotics. Sensitivity can often be deter-
mined by blood cultures but, if these are negative, samples from
a bone biopsy might be necessary. Following the erythrocyte
sedimentation rate is helpful to determine the effectiveness of
treatment. Surgery is generally necessary only if the spine has
become unstable, there are progressive neurologic deficits, or
medical treatment fails. Spontaneous fusion of the infected
segments often occurs after treatment.98
Osteomyelitis secondary to a contiguous focus of infection is
seen after surgical procedures and with extension of infection
from adjacent soft tissue. The most common organism is
S. aureus.116,194 Risk factors for development of postoperative
osteomyelitis include history of smoking, obesity, poor nutri-
tion, uncontrolled diabetes, administration of steroids, history
of malignancy, and radiation treatment in the area of surgery.98
These infections usually present about 14–30 days after
A
surgery.98 Diagnosis is sometimes difficult, as symptoms such as
Ch041-X2610.indd 916
pain or fever can be attributed to soft tissue infection or the
surgical procedure. Imaging studies can also be less conclusive
because of surgical or soft tissue changes. Erythocyte sedimen-
tation rate is usually elevated after surgery, so is not as useful
in making the diagnosis in the first weeks after surgery.98 Treat-
ment for these types of infection usually requires surgical
debridement and then a course of antibiotics.116,194
Diskitis can occur from contiguous spread of infection, or
iatrogenically from procedures such as diskectomy and diskog-
raphy. The incidence of these types of infection is low, as
studies report a 0–3% incidence with procedures, but morbidity
if infection occurs is significant. One study found that 55–87%
of patients were unable to return to their normal work after
diskitis. One reason for this poor outcome is the difficulty of
using antibiotics to treat the infection because of the relative
avascularity of disks.31
Spondyloarthropathies
Spondyloarthropathies are a group of diseases associated with
the HLA-B27 allele. They include ankylosing spondylitis, Reiter
syndrome, reactive arthritis, psoriatic arthritis, enteropathic
arthritis, and undifferentiated spondyloarthropathy. It is hypoth-
esized that, in genetically susceptible individuals, an interplay
of environmental and immunologic factors leads to clinical
manifestations. Although the diseases are grouped together,
each has unique features on clinical presentation.95
Ankylosing spondylitis
Ankylosing spondylitis is the prototype for the spondylo­
arthropathies. It is three times more common in men than in
women. Symptoms usually begin in the late teens or twenties.
It generally first presents with morning stiffness and a dull ache
in the low back or buttocks. On physical examination, there is
decreased spinal mobility, decreased chest expansion, and
tenderness of the sacroiliac joints with direct pressure and with
maneuvers that stress the joints.95
Findings outside the spine are also common. Hip or
shoulder arthritis is seen in about 30% of patients, and
asymmetric peripheral joint arthritis is also seen in about 30%
of patients. Bony tenderness and enthesitis at multiple sites,
such as the heels, greater trochanters, iliac crests, and tibial
tuberosities, is common. Systemic disease manifestations
include anterior uveitis, heart disease, and inflammatory bowel
disease.195
The modified New York criteria are widely used for diagnosis.
These are the presence of sacroiliitis on x-ray and one of the
following: history of inflammatory back pain (insidious onset of
back pain before age 40 that lasts longer than 3 months, is
accompanied by morning stiffness, and improves with activity),
decreased ROM of the spine, and limited chest expansion.
Blood work can also be helpful in establishing the diagnosis. The
HLA-B27 gene is present in 90% of patients with ankylosing
spondylitis. Most patients also have an elevated sedimentation
rate. Beyond the changes to the sacroiliac joints of erosions and
sclerosis, as the disease progresses there are typical changes in
the lumbar spine, including reactive sclerosis and erosions. This
5/9/2006 3:20:03 PM

can lead to squaring of the vertebral body, and eventually to
bony bridging between vertebrae.195
The initial treatment includes exercises that promote spinal
extension. There is evidence that exercise promotes mobility,
improves function, and prevents severe deformity in many
cases.195 NSAIDs are helpful to relieve pain and inflammation,
so that the exercises can be done and function maintained.
Indomethacin is particularly effective for this condition. Sulfa­
salazine and methotrexate are sometimes used, especially if
there is peripheral arthritis. Disease-modifying agents such as
the tumor necrosis factor inhibitors are also being used to treat
ankylosing spondylitis, and large studies to determine their
effectiveness are needed.95 Sacroiliac injections under fluoros-
copy can reduce symptoms acutely but do not cause long-term
benefit.195
Other spondyloarthropathies
Reiter syndrome and reactive arthritis can affect the spine.
Asymmetric sacroiliitis and discontinuous spondylitis are seen.
These usually begin after a genitourinary or gastrointestinal
infection. Systemic symptoms are common, and conjunctivitis
is seen in up to 50% of patients. Psoriatic arthritis can affect
the spine, but an oligoarticular pattern of distal joints is much
more common. Enteropathic spondyloarthropathies occur in
about 20% of patients with inflammatory bowel disease and
can be indistinguishable from ankylosing spondylitis. The term
undifferentiated spondyloarthropathies is used if a patient has
some features of, but does not fully meet, the diagnostic criteria
for a well-defined spondyloarthropathy. Treatment of these
conditions from a rehabilitation standpoint is similar to the
treatment of ankylosing spondylitis.95
Differential diagnosis and treatment:
leg pain greater than back pain
The differential diagnosis for those with leg pain greater than
back pain is shorter than that for whom back pain predomi-
nates. Common causes of this are discussed below, as are
common mimickers of radicular pain that are not to be
missed.
Lumbosacral radiculopathy
Radicular symptoms can be the result of overt mechanical com-
pression of a nerve root, or a chemically mediated inflammatory
process. The most common compressing lesion by far is a disk
protrusion. Less than 1% of patients who present with radicular
symptoms have other causes, including infection, malignancy,
or fracture.43 Rare presentations of radiculopathy, i.e. those
with fever, weight loss, night pain, cancer history, or osteoporo-
sis risk factors, certainly warrant special attention to evaluate
for the less common but potentially more catastrophic causes
of radiculopathy.
The most common levels of disk herniation are L4–5 and
L5–S1, with L5 and S1 being the most common nerve roots
involved in radiculopathy. Multiple nerve roots can be affected
Ch041-X2610.indd 917
Chapter 41
Low Back Pain 917
by a single disk herniation, given the organization of the cauda
equina. Central disk herniations can affect nerve rootlets that
are descending in the cauda equina. The affected nerve root
level might not correlate with the level of the disk herniation.
For example, a central L3–4 disk herniation could impact the
L5 or S1 rootlets as they descend through the thecal sac before
exiting out of their expected neural foramen. True cauda equina
syndrome occurs when the lowest sacral rootlets are affected,
resulting in bowel, bladder, and sexual dysfunction. Up to 1%
of all disk herniations present as cauda equina syndrome.184 In
the appropriate clinical setting, a large postvoid residual of urine
is a good predictor of cauda equina syndrome.43 Cauda equina
syndrome is a surgical emergency. Recovery of neurologic
deficits, including bowel and bladder dysfunction, is greatest
if decompressive surgery is performed within 48 h.220
The natural history of lumbosacral radiculopathy resulting
from disk herniation tends to favor spontaneous resolution of
symptoms over time.35 There have been multiple reports that
disk protrusions and extrusions can regress without surgical
treatment.196 Conservative treatment is best used to decrease
pain and improve the patient’s level of functioning during acute
management of radiculopathy. Even with some neurologic
injury, conservative management should be considered, as
various studies have documented the same neurologic recovery
in groups treated surgically and non-surgically.223
The specifics of conservative management of lumbosacral
radiculopathies, however, are still debatable. Given that radicu-
lar pain is thought to have some inflammatory component,
antiinflammatory medications are commonly implemented in
the initial management. NSAIDs are useful medications for the
short-term symptomatic relief of acute low back pain; however,
they have been found to be less effective in patients with
radiculopathy.206 There is also no definite support for oral ster-
oids in the treatment of acute radiculopathy.40 The neuropathic
pain agents (anticonvulsants and tricyclic antidepressants) are
often used for radicular pain, although no studies have proven
their efficacy.40 They are sometimes more useful for their
known side effect of sedation in those patients with an associ-
ated sleep disturbance.
Although exercise therapy has not specifically been demon-
strated to alter the course of acute radiculopathy, there is prob-
ably a role for exercise.202 Relative rest is initially indicated for
the first 1–3 days. After that, increasing activity level is impor-
tant. Whether to do this in a structured, supervised setting
(i.e. in physical therapy) or alone is debatable, as the studies
that evaluate exercise programs are not specific to an anatomic
diagnosis. This is due to the fact that most studies lump together
patients with variable causes of back pain and radiculopathy (far
lateral disk herniation versus central disk herniation versus
stenosis) when analyzing an exercise approach. Saal reported
very favorable outcomes using aggressive non-operative care (an
active exercise program potentially with epidural steroid injec-
tions) in the treatment of lumbar disk herniation with radicu-
lopathy.173 Their protocol is the basis for many exercise programs
used in the treatment of lumbar disk herniations with radicu-
A
lopathy today.
5/9/2006 3:20:03 PM
 918 Section 4 Issues in Specific Diagnoses

Relative rest
NSAIDs
+/– opioids
(1–3 weeks)

Improved Unchanged Neuroprogression

advance activity
NSAIDs MRI scan MRI scan
weak opioids Epidural injection Surgical referral

Improved Not improved Improved Not improved

MRI scan Progress Review films

Epidural injection activity Review exam

Improved Not improved Consider Consider Consider

specific different surgical
Progress Review films physical injection referral
activity Review exam therapy

Consider Consider Consider

specific different surgical
physical injection referral
therapy

Figure 41-25  Algorithmic approach to acute lumbosacral radiculopathy (without cauda equina). (From Chiodo and Haig 2002,40 with permission.)

Lumbar epidural steroid injections have become a common
adjuvant for the treatment of lumbosacral radiculopathy. The
more recent literature supports the use of fluoroscopically
guided transforaminal epidural injections for early pain relief,
and potentially a more rapid recovery and reduced need for
surgical intervention.94,111,167,209 They are best used in combina-
tion with an active rehabilitation program, and are commonly
used to facilitate active therapy by decreasing pain and
inflammation.
Surgical management of lumbosacral radiculopathy is best
reserved for those patients who have significant persistent
radicular symptoms despite 6–8 weeks of maximized conserva-
tive management, neurologic progression, or cauda equina
syndrome. Common decompressive procedures with favorable
outcomes include lumbar hemilaminotomy with diskectomy,
and lumbar hemilaminectomy.190 Patients need to be counseled
regarding appropriate expectations following surgery for lumbar
disk herniation with radiculopathy. Surgery might slightly accel-
erate the resolution of neurologic deficits for the typical radicu-
lopathy; however, the major benefit of surgical intervention is
pain relief.45 Relief of leg pain should be expected; however,
back pain relief is more difficult to predict. Patients should be
counseled that they are likely to have recurrent back difficulties
even after a successful decompressive surgery. Figure 41-25
shows a useful algorithmic approach to the management of
acute lumbosacral radiculopathy.
A
Lumbar spinal stenosis
The symptoms of spinal stenosis result from a complex series
of changes within the lumbar spine.66 Generally, these changes
are related to aging. The narrowing of the spinal canal that
occurs in stenosis results from the degenerative changes
described by Kirkaldly-Willis.100 Not all patients with significant
narrowing, however, have symptoms. There are probably vas-
cular and biochemical factors involved that add to the mechani-
cal compression (resulting from narrowing of the canal), which
ultimately leads to symptomatic spinal stenosis. These have
been described earlier in this chapter. Box 41-4 gives a classifi-
cation schema for spinal stenosis, and Table 41-9 outlines a
radiologic grading scale.
The variable symptoms of spinal stenosis are due to the fact
that a single nerve or multiple nerve roots can be affected at
one or multiple locations within the lumbar spine. Mechanical
compression of the nerves can occur due to central canal nar-
rowing, lateral recess narrowing, and intervertebral foraminal
narrowing. This results in variable symptoms, from a mono­
radiculopathy to polyradiculopathy to the hallmark symptoms
of neurogenic claudication.
Neurologic claudication is the most common presenting
symptom of lumbar stenosis, and results from central canal
narrowing. It is classically described as bilateral leg pain initi-
ated by walking, prolonged standing, and walking downhill
(relative lumbar extension). Typically, it is relieved by sitting or

Ch041-X2610.indd 918 5/9/2006 3:20:04 PM


Table 41-9 Grading lumbar stenosis on magnetic
resonance imaging
Grade Percentage of the anteroposterior
canal dimensions at a normal level
Mild 75–99
Moderate 50–74
Severe <50
Box 41-4  Classification of spinal stenosis
• Congenital
Achondroplasia or dwarfism
Idiopathic or congenital
• Acquired
Degenerative
Iatrogenic or postsurgical
• Traumatic
• Combined
bending forward. If foraminal or lateral recess stenosis is the
primary pathologic issue, then patients can present with more
standard radicular pain in the typical dermatomal distribution.
Most patients default to a forward-flexed posture to widen the
central canal, subsequently decreasing mechanical compression
of the nerve roots. This can lead to significant hip flexion
contractures.
The natural history of lumbar spinal stenosis is fairly favora-
ble overall. Johnsson followed patients with lumbar stenosis
over a 4-year period with conservative treatment.92 Based on
subjective patient reports, 70% remained unchanged, 15%
improved, and 15% worsened. Walking capacity improved in
42% of patients, remained unchanged in 32%, and decreased in
26%. Amundson reported on a 10-year study of patients ran-
domly assigned to surgical or non-surgical treatment.5 Non-
surgical treatment consisted of bracing for 1 month followed
by physical therapy. He demonstrated that neurologic deterio-
ration was rare, that delaying surgery (with conservative man-
agement) had no effect on postoperative outcomes and that, at
4 years, half the conservative treatment group and four-fifths
of the surgical group had favorable outcomes. During the final
6 years of study, clinical deterioration of symptoms was rare.
In general, most patients with symptomatic stenosis remain
unchanged, while some improved and others worsened. It is
impossible to predict which patients will fall into each of these
categories. It is useful information that a diagnosis of lumbar
stenosis does not mean rapid neurologic deterioration, and that
conservative management for those with mild to moderate
symptoms is warranted.
Ch041-X2610.indd 919
Chapter 41
Low Back Pain 919
The primary goals of conservative management are pain
control, and reducing the functional limitations that result from
the lessened activity and pain of stenosis. There are multiple
facets to this management program, including oral medications,
epidural steroids, and a comprehensive functional rehabilitation
program. The oral medications are no different than what have
been described previously for treatment of radiculopathy. Even
more attention needs to be placed on side effects, however, as
most patients with lumbar stenosis are elderly and potentially
have multiple medical problems that already require multiple
medications.
Botwin has demonstrated that there probably is a role for
epidural steroid injections in the non-operative treatment of
symptomatic lumbar stenosis.28 He performed transforaminal
epidural steroid injections in stenosis patients who were deemed
surgical candidates. They also received oral medications and
physical therapy. Even at 1-year follow-up, 64% of his patients
felt subjectively better. Only 17% of patients went on to surgery
within the 1-year follow-up period.
Although there is a paucity of studies examining specific
rehabilitation protocols, there is certainly a role for a therapeu-
tic exercise program in the management of lumbar spinal steno-
sis. The basis of any protocol should be flexion-based lumbar
stabilization exercises. This includes strengthening the abdomi-
nals and pelvic girdle stabilizers, including the gluteals. Improv-
ing hip mobility through stretching, especially of the anterior
muscles (iliopsoas and rectus femoris), is also key. Aerobic
conditioning is the final component of a comprehensive reha-
bilitation program for stenosis. Bracing with an abdominal
corset might be beneficial for overweight patients with a pro-
tuberant abdomen, to lessen the forces creating an exaggerated
lordotic posture. However, there is a lack of clear data support-
ing the role of lumbosacral orthoses in spinal stenosis.
Surgical consideration for lumbar stenosis should be given to
patients with intractable pain recalcitrant to non-operative
management, profound or progressive neurologic deficit, or life-
style impairment.170 Age is not a contraindication to surgery,
although the patient’s general health status must be consid-
ered.10,82 Laminectomies are the most common decompressive
procedures.170 When spinal stenosis is associated with instabil-
ity, degenerative spondylolisthesis, deformity, or recurrent ste-
nosis, fusion is often performed. Instrumentation often improves
the fusion rate but does not influence the clinical outcome.183
If selectively chosen, most patients with neurogenic claudica-
tion do quite well with surgical management. However, if the
chief symptomatic complaint is axial low back pain, the surgical
outcome is generally poorer.96
Non-lumbar spine causes of ‘radicular’
leg symptoms
There are a number of non-spinal disorders that mimic lumbar
radiculopathy, because they generate pain referral patterns
similar to lumbosacral dermatomes. Their etiology is diverse
and includes joint, soft tissue, vascular, and peripheral nerve
sources. A thorough history and physical examination can
A
5/9/2006 3:20:04 PM
 920 Section 4 Issues in Specific Diagnoses

typically help differentiate these disorders from lumbosacral buttock, and lateral thigh.185 It is often initially diagnosed as
radiculopathy; however, other diagnostic studies might be trochanteric bursitis but, given its recalcitrant nature and not
necessary. always responding to well-placed greater trochanter bursa injec-
tions, is probably multifactorial in etiology. There is probably
an association with gluteal muscle (medius and minimus)
Joint disorders
pathology, potentially tendonopathy, tears, or myofascial pain.
The sacroiliac joint is now generally accepted as a potential pain
On physical examination, besides the generalized tenderness in
generator that can refer into the lower limb. Other than true
the region, typically there is significant gluteal muscle inhibition
sacroiliitis (associated with the spondyloarthropathies), the
and deconditioning that can manifest as hip abductor weakness.
exact pathologic structure or source of pain from the sacroiliac
Generally, a comprehensive rehabilitation program focusing
joint is still uncertain. In 2002, Vilensky reported that sub-
initially on pain control and neuromuscular reeducation of the
stance P may be found in the posterior sacroiliac ligament.211
gluteal muscles is important prior to progressing to strength-
However, it is still not known whether it is the synovium, the
building exercises for the gluteals.
articular cartilage, the capsule, the ligamentous structures, the
Iliotibial band syndrome can be confused with an L4 or L5
muscular support of the sacroiliac joint, or a combination that
radiculopathy. The iliotibial band is an extension of the tensor
is the primary source of pain referred to as sacroiliac joint
fascia lata that traverses the lateral aspect of the thigh, attaching
pain.
at Gerdy’s tubercle on the proximal lateral tibia. Iliotibial band
Although there are multiple physical examination maneuvers
syndrome typically presents as lateral knee pain, but it can also
created to stress the sacroiliac joint and reproduce pain, rigor-
present with more proximal (lateral thigh) pain or radiate dis-
ous studies have demonstrated that no one physical examina-
tally into the calf. When the iliotibial band is tight, it can also
tion maneuver (nor combination) correlates well to diagnose
exacerbate trochanteric bursitis and be associated with lateral
sacroiliac joint pain confirmed from diagnostic local anesthetic
hip and buttock pain. Iliotibial band tightness is evaluated with
injections into the joint.49 The gold standard for diagnosing
Ober’s maneuver.114
sacroiliac joint pain is a fluoroscopically guided injection of local
Myofascial pain syndromes are quite common, and are
anesthetic into the sacroiliac joint.
thought to arise from active trigger points within a muscle or
Guided injections have helped to delineate the sclerotomal
its fascia.186 Activation of trigger points in various muscles have
referral pattern of pain emanating from the sacroiliac joint.59,60
typical pain referral patterns that can mimic lumbosacral
Sacroiliac joint pain generally does not radiate above the lumbo­
dermatomes (see Ch. 42).
sacral junction. It can radiate into the groin, thigh, and even
below the knee, with significant overlap of lumbosacral radicu-
lar pain patterns. Vascular disorders
Disorders involving the hip joint generally refer pain into the Vascular claudication from peripheral vascular disease can be
groin and sometimes the anterior thigh. The prototypical dis- difficult to differentiate from neurogenic claudication second-
order is osteoarthritis of the hip. This pain pattern is easily ary to lumbar spinal stenosis, especially because both are
confused with L1–2 to 3 nerve root involvement. Plain films of common in elderly patients. Symptoms from both are exacer-
the hip as well as hip ROM on physical examination are gener- bated by walking; however, flexing forward or sitting is neces-
ally most helpful in differentiating an intraarticular hip source sary to alleviate the symptoms of neurogenic claudication. On
of pain from spinal referred pain. the contrary, just stopping ambulation typically improves the
vascular symptoms. Leaning forward on a grocery cart or walker
while ambulating can also reduce neurogenic claudication but
Soft tissue disorders
does not help with vascular claudication. The bicycle test can
Piriformis syndrome is thought to cause sciatica via the piri-
be used to differentiate between the two, because any lower
formis muscle putting local pressure on the sciatic nerve in the
extremity exercise should exacerbate vascular claudication;
pelvis. Pain generally emanates into the posterior thigh but can
however, stationary cycling (while sitting with lumbar flexion)
refer below the knee in an L5 or S1 dermatomal pattern. The
should not exacerbate neurogenic claudication. Finally, a patient
patient also describes buttock pain and typically has tenderness
with neurogenic claudication typically has more pain with
over the sciatic notch. There are multiple examination maneu-
downhill walking, due to the relative lumbar extension and
vers used to reproduce sciatica resulting from piriformis syn-
resultant narrowing of the spinal canal, whereas uphill walking
drome.18 Pace’s maneuver is described as resisted abduction and
is more strenuous and thus brings on symptoms of vascular
external rotation of the thigh. Freiberg’s maneuver is forceful
disease.
internal rotation of the extended thigh. Beatty described his
maneuver as deep buttock pain produced by the side-lying
patient holding a flexed knee several inches off the table. Peripheral nerve disorders
Fishman described an electrophysiologic approach to diagnose Peripheral polyneuropathy is a common cause of paresthesias
piriformis syndrome using H waves.58 in the distal lower extremities and feet that can mimic symp-
Greater trochanteric pain syndrome is a descriptive term for toms of lumbar stenosis. They are often seen together in elderly
A
a regional pain syndrome focused about the greater trochanter, patients with diabetes. Electrodiagnostic studies are used to

Ch041-X2610.indd 920 5/9/2006 3:20:04 PM


diagnose a superimposed peripheral polyneuropathy in patients
who have MRI findings of lumbar stenosis. Epidural steroid
injections can sometimes be helpful in this situation to help
determine how much of the patient’s leg and foot symptoms
are related to spinal stenosis over peripheral polyneuropathy.
Prevention of back pain
Because back pain is so common, and because it results in
enormous expense to society, the question of whether or not
back pain is an inevitable consequence of life or is preventable
is often asked. The answer is still not completely known, but
certain factors appear to reduce the risk of developing first
episodes of back pain and the risk of a particular episode
becoming chronic.
Psychosocial factors
It is unclear how much of a role psychosocial factors play in the
new onset of low back pain, but probably the strongest preven-
tions against the development of chronic back pain are psycho-
logic and social factors. Strong work and family relationships, a
sense of being connected to a community, good mental health,
proactive beliefs about pain that do not include catastrophizing
and fear-avoidance, the management of any depression and
anxiety that exists, and high job satisfaction all appear to be
protective against the development of chronic pain.217
Physical factors
Studies have found conflicting results of whether physical
fitness is protective in the development of low back pain. In
Linton and van Tulder’s review of prevention of back pain, they
identified six randomized controlled trials. Four of the six trials
found a benefit of exercise in reducing the occurrence of back
pain and work-related absenteeism. One trial was inconclusive,
and one found no difference between advice to exercise and a
health club membership, although it is unclear how much
exercise was being done. Overall, it appears that exercise is
beneficial in reducing the incidence of back pain.109
Smoking and low back pain
Smoking is a risk factor for the development of back pain, most
probably because degenerative changes of the lumbar spine are
increased and the blood flow and nutrition to disks are decreased
in smokers.139
Education
Studies are conflicting as to whether back schools (educational
courses to teach about ergonomics, good lifting techniques, and
other back-related issues) prevent back pain and disability or
make no difference.109
Lumbar supports
Although the results of some non-randomized controlled trials
looked promising for back pain prevention, the majority of
Ch041-X2610.indd 921
Chapter 41
Low Back Pain 921
randomized controlled trials do not show that lumbar supports
prevent back pain.
Prognosis of low back pain
Prognosis is difficult to fully ascertain for several reasons. One
is that low back pain is a symptom caused by a vast spectrum
of pathology with a variety of prognostic outcomes. Another is
that the pain experience is individual, and treatment expecta-
tions vary. There is a huge body of medical literature that
highlights the complex cultural, psychologic, social support,
and economic factors that influence pain and rehabilitation
outcome.110
That being taken into account, the prognosis for low back
pain is being better defined. The much quoted view that 90%
of cases of acute low back pain will recover within 6 weeks does
not include the entire story of low back pain, either in clinical
practice or in reviews of the scientific literature. Most studies
are performed with subjects who seek medical care for their
low back pain, and this might be a select population not gener-
alizable to all those who develop back pain. A recent meta­
analysis of patients who sought medical care for back pain of
less than 3 weeks’ duration was done. They included both those
in treatment arms of studies and in the placebo arms, so that
both the natural course and the clinical course of back pain
could be evaluated. The study found that most patients rapidly
improved within 1 month, and that most continued to have
pain decrease, although more slowly, until about 3 months.
From 3 months to a year, little change in pain was seen. The
risk of a recurrence within 3 months varied between 19 and
34%, and the risk of a recurrence within a year was between
66 and 84%. This was a heterogeneous diagnostic population,
although the vast majority of patients fell under the diagnosis
of mechanical low back pain.
Low back pain in special populations
Low back pain in pregnancy
Low back pain is a common problem in pregnancy. Multiple
studies have estimated the prevalence at 49–76%.54,103,150,151,221
Risk factors for the development of low back pain during preg-
nancy include a history of prior back pain, previous pregnancy-
related back pain, and low back pain during menses.32,221 Low
back pain is also correlated with the pregnant woman’s age.221
The risk of development of back pain during pregnancy decreases
with age. Studies differ on the timing of low back pain during
a pregnancy. Earlier studies demonstrated that back pain was
generally present in the first 5–7 months of pregnancy, and that
pain then decreased subsequently thereafter.54 More recent
studies demonstrate occurrences at any time during the preg-
nancy, generally reaching a peak at 36 weeks.103,151,221 Pain
decreases after this point and is substantially improved by 3
months postpartum.151
The specific etiology of low back pain in pregnancy is unclear.
A
The potential pain generators in pregnant women are probably
5/9/2006 3:20:04 PM
 922 Section 4 Issues in Specific Diagnoses
multiple, and probably similar in etiology to those in the non-
pregnant patient with mechanical low back pain. However,
there is a very different reason that the tissue is stressed and
generating pain in the pregnant patient. Pain drawings have
shown that the pain location is variable. In some, it is localized
to the sacroiliac areas, and in others more to the lumbar
spine.150
Lumbar disk herniation is uncommon as a cause of pain, as
the prevalence is only 1 in 10 000 pregnant women.105 The
prevalence of disk abnormalities on MRI is the same for preg-
nant and non-pregnant women.225
The etiology of low back pain in the pregnant woman is
hypothesized to be increased biomechanical strain or an altered
hormonal influence. The biomechanical alterations are due to
changes in spine posture related to the anterior movement of
the pregnant woman’s center of gravity. However, an argument
against purely biomechanical factors as the primary cause is that
the back pain often starts prior to significant weight gain by the
mother, and the incidence does not parallel the weight gain.33
There probably is a hormonal influence in the etiology of low
back pain in pregnancy. The hypothesis is that the hormonal
changes during pregnancy alter the lumbopelvic ligaments,
influencing the stability of the lumbosacral spine and making it
more vulnerable to loading.103 However, a direct correlation
between circulating levels of the hormone relaxin and pelvic
and back pain is controversial.2,78,104,113
There are only a few high-quality studies evaluating thera-
peutic interventions in pregnancy-related low back pain, and
there is not much evidence on which to base recommendations
for management.191 To decrease pain, individualized physical
therapy, water aerobics, acupuncture, and massage therapy can
be recommended.57,99,146,224 Instruction on a home exercise
program, use of a sacroiliac belt, and back school have not been
shown to significantly diminish pain intensity.50,119,130,145 There
are no good data to offer an opinion on the use of lumbar–
abdominal orthoses that are designed to support the pregnant
woman’s abdomen.
Pediatric low back pain
Back pain in the pediatric population has traditionally been
considered to be relatively rare and, if present, a concern for
serious pathology was generally raised. This belief is now known
to be untrue. In a subset of studies involving greater than 300
children each, the prevalence of back pain was cited between
30 and 51%.15,69 Severe back pain, which is either relapsing or
permanent, was reported in 3–15%.15 There is a noted increase
in back pain prevalence as the child ages. In a Finnish cohort
study, back pain prevalence was reported as 1% in children 7
years old, 6% when 10 years old, and 18% when 14 years old.193
Another reported the prevalence at 12% for 11-year olds and
50% for 15- to 18-year olds, which approaches the adult preva-
lence.34 The same study reported that the pain is often recur-
rent, but that the experience of back pain is frequently forgotten.
Other studies demonstrate that the prevalence of low back pain
has the greatest increase during puberty and the time of the
A
maximum growth spurt.106,212 Risk factors for non-specific low
Ch041-X2610.indd 922
back pain in the pediatric population include increase in age,
female gender, parents with low back pain, hyperlordotic
posture, history of spinal trauma, participation in competitive
sports or a high level of physical activity, and depression.15 The
literature does not support the following as risk factors for
pediatric back pain: being overweight, hamstring tightness, a
low level of physical activity, and poor school performance.15 In
the pediatric population, sitting appears to be the main exacer-
bating factor of low back pain.15 There also appears to be a
positive correlation between low back pain in adolescence and
the presence of pain as an adult.79
There has been more recent attention focused on the role of
backpack use in the development of pediatric low back pain;
however, there is still not a proven correlation. Carrying a
backpack greater than 7.5–15% of the wearer’s body weight
increases the metabolic demands over what is required to move
a person’s body weight alone.112,168 The general recommenda-
tion for a child’s backpack weight is limited to 10% of body
weight.112 This limit is based on concerns of increasing meta-
bolic costs, and not on the risk of back pain development (there
are conflicting reports in the literature regarding backpack
weight and back pain).76,112,200,222 There are many new backpack
designs to improve ergonomic fit; however, there are no studies
demonstrating their effectiveness in reducing back pain.112
Some of the specific causes of low back pain in the pediatric
population are listed in Box 41-5. Spondylolysis and isthmic
spondylolisthesis often present in young athletes with back
pain, and have been reported as the most common underlying
cause of persistent low back pain among children and adoles-
cents.132 Most believe the etiology is from overuse, particularly
during the growth spurt. The presence of isthmic defects in
children in the western world is between 2 and 7%, and as high
as 30% in elite athletes.149
Scheuermann disease typically presents in the adolescent as
painless exaggerated thoracic kyphosis. From a postural stand-
point, the teenager typically presents with excessive thoracic
kyphosis (which is demonstrated to be fixed in attempted
hyperextension), with a compensatory lumbar hyperlordosis.
Radiographic criteria for the diagnosis of Scheuermann disease
include anterior wedging of at least three adjacent vertebrae,
end-plate irregularities, Schmorl’s nodes, and disk space
Box 41-5  Etiology of pediatric low back pain
• Non-specific
• Spondylolysis with or without spondylolisthesis
• Lumbar disk herniation
• Slipped vertebral apophysis
• Scheuermann disease
• Diskitis
• Vertebral osteomyelitis
• Neoplasm
• Rheumatic disease
• Somatization
5/9/2006 3:20:04 PM

narrowing.75 These findings are present equally in the adoles-
cent population without back pain, but there is a higher preva-
lence of concomitant degenerative disk changes in those with
pain.197
The etiology of Scheuermann disease is uncertain. Some
believe that it is due to repetitive loading of the immature spine
that might have some preexisting abnormality of the cartilagi-
nous end plate.88 There does appear to be a familial link.129
Scheuermann disease can have a benign course, although some
untreated patients develop progressive structural kyphosis.
Brace wearing is recommended until skeletal maturity is reached
to help prevent the progressive kyphosis.
Idiopathic scoliosis is not generally painful. If associated with
pain, often there is more serious underlying pathology such as
tumor, infection, or spondylolisthesis. The curve direction in
idiopathic scoliosis is typically right thoracic and left lumbar. If
an atypical curve is encountered, further evaluation beyond
plain films is generally warranted.
Neoplastic disease of the pediatric spine is fortunately rare.
Most pediatric spinal tumors are primary (not metastatic),
benign bone tumors arising from the vertebrae.88 The most
common tumors of the pediatric spine include osteoid osteoma,
osteoblastoma, and aneurysmal bone cysts. The classic pain of
osteoid osteoma is nocturnal pain that responds to aspirin. The
most frequent malignant lesion affecting the pediatric spine is
Ewing’s sarcoma.
Acknowledgments
The authors would like to thank Nilda Gatchalian for her assist-
ance in preparing this manuscript.
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