BLUK017-Tjandra September 12, 2005 20:16

Textbook of Surgery
Edited by Joe J. Tjandra, Gordon J.A. Clunie, Andrew H. Kaye & Julian A. Smith
© 2006 by Blackwell Publishing Ltd

78 Acute back pain

Jeffrey V. Rosenfeld

back of L4–L5 intervertebral disc to exit below the L5

Introduction
Back pain is one of the commonest ailments suffered by
humans, probably because our erect posture places ex-
cess mechanical strain on the spine. In addition, acute
stressors of the spine may be cumulative and acceler-
ate a natural tendency to osteoarthritic degeneration.
Genetic factors, underlying structural anomalies, occu-
pation, pain tolerance, psychological factors and social
circumstances all contribute to the origin and persis-
tence of back pain.
There are many possible pain generators in the back,
including discs, ligaments, facet (zygapophysial) joints,
nerve roots, paraspinal muscles and extraspinal struc-
tures. It is difficult to identify the exact cause of back
pain in many cases, particularly as the pain is often em-
anating from multiple structures at multiple segmental
levels in the spine. This makes the treatment of back
pain problematic, particularly as much of the treatment
available for back pain is not founded on a strong ev-
idence base. Back pain results in a large financial cost
to the community and is therefore an important public
health issue. Prevention of back injury is an important
strategy to reduce the prevalence of back pain.
Applied anatomy
There are seven cervical vertebrae, twelve thoracic ver-
tebrae, five lumbar vertebrae and five sacral vertebrae.
The spinal cord terminates in the adult at the LI–L2
disc level, where it becomes the filum terminale. The
nerve roots of the cauda equina arise from the conus
and pass through the lumbar and sacral canal.
The spinal nerve roots exit through the interverte-
bral foramina, and in the lumbar spine each nerve root
passes under the pedicle of its numbered level; for ex-
ample, the L5 nerve root passes inferiorly across the
pedicle. Therefore, a posterolateral disc prolapse at L4–
L5 will compress the L5 nerve root. A posterolateral
disc prolapse at L5–S1 will compress the S1 nerve root.
A ‘far’ lateral disc prolapse may compress the lumbar
root passing beneath the pedicle above; for example, a
far lateral disc prolapse at L4–L5 may compress the L4
nerve root. There are 8 cervical spinal nerve roots, and
the pattern is similar to the lumbar spine; for example,
C7 passes across the C6–C7 disc and exits the C6–C7
intervertebral foramen. Posterolateral C6–C7 disc pro-
lapse will therefore compress the C7 nerve root.
Pain generators in the back
Pain arising from the bones of the spine, ligaments,
muscles, or intervertebral discs is often called mechan-
ical back pain. There is a lot of crossover in segmen-
tal nerve supply in the lumbar spine between different
structures. The annulus of the intervertebral disc and
the facet joints are supplied with nerve fibres. Pain from
the disc (discogenic pain) or facet joints is felt in the
back centrally (somatic pain) but may radiate to the
buttock and upper thigh (somatic referred pain). So-
matic back pain may also emanate from musculoskele-
tal structures, bone and extra- or paraspinal structures.
Nerve root compression or irritation results in radic-
ular pain, which is sharp lancinating pain radiating
down the lower limb and may pass into the foot or
down the arm into the hand. It may not follow an ex-
act dermatomal pattern. It is often difficult to distin-
guish somatic referred pain from radicular pain. The
overall clinical assessment and correlation with the
radiological findings is important. Local anaesthetic
facet joint blocks which suppresses facet joint pain,
and discograms which evoke discogenic pain, have also
been used to identify the principal pain generators in
patients with chronic back pain (see below).

665
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666 Problem Solving
Box 78.1 Differential diagnosis of back
pain.
r Pancreatic disease, e.g. pancreatitis
r Renal disease, e.g. hydronephrosis (usually lateral loin
pain)
r Abdominal aortic aneurysm
r Pelvic disease
r Rectum, bladder, gynaecological
r Hip disease – there is pain on moving the hip. The pain
may radiate to the buttock and posterior or lateral thigh
down to the knee.
r Sacroiliitis
r Lumbo-sacral plexus pathology
r Peripheral nerve pathology, e.g. schwannoma, entrap-
ment, inflammation
The history
A detailed history will provide a likely cause of the
patient’s back pain and should help to distinguish me-
chanical, radicular and long tract symptoms. If the pa-
tient has limb pain or paraesthesia, a nerve root may be
compressed by whatever pathology is causing the back
pain. The site of limb pain and paraesthesia will help
localize the site of the pathology in the spine. The age
of the patient is an important factor in the analysis of
cause of back pain. Back pain can be caused by disor-
dres of organs that are not part of the musculo-skeletal
system (see Box 78.1).
Examination of the spine
The examination is done in the erect, prone and supine
positions. It is important to differentiate between upper
and lower motor neuron lesions and to identify the level
of spinal pathology.
Spine and joints
Standing
Inspection for midline skin lesions such as a pit, sinus,
hairy patch, lipoma, naevus or angioma over the spine.
These may indicate underlying occult spinal bifida,
spinal dysraphism or tethering of the spinal cord.
Assess general posture and spinal alignment, partic-
ularly for scoliosis or kyphosis. Are both feet planted
symmetrically on the ground? The cervical spine and
the lumbar spine normally have a lordosis (forward
curve).
Range of movement includes forward flexion, lateral
flexion, rotation and extension. Examine the shoulders
and upper limbs if the patient has neck pain.
Supine
Examine the movements of the hips and knees. Exam-
ine the sacroiliac joint by adduction and internal rota-
tion of the flexed hip.
Prone
Palpate the back for tenderness, paraspinal mass,
paraspinal muscle spasm. Percuss the spine for tender-
ness. Complete the examination of the hip joint with
extension.
Motor function
Neurological examination
Even in the absence of limb pain a careful examination
must be made of the limbs, as the neurological signs
that may be detected will often lead you to the precise
site of pathology in or around the spine.
Gait
Observe for limping, rate of movement, length of stride,
and need for walking aid. This will give many clues as
to what is wrong and the severity.
Muscles
Muscle wasting and fasciculation imply denervation of
muscles – examine all of the muscle groups including
the shoulder girdle and gluteal region.
Muscle tone, power and reflexes including the plan-
tars, are measured to determine whether it is an upper
or lower motor neurone problem, or a mixed picture
(Table 78.1).
Sensation
If you suspect a spinal cord lesion then full sensory
testing should be performed. Test pain with pinprick
(spinothalamic tracts), and light touch and proprio-
ception (dorsal columns). Do not forget to test sacral,
BLUK017-Tjandra September 12, 2005 20:16
Table 78.1 Myotomes and deep tendon reflexes
Muscle weakness
C5 Deltoid, supraspinatus, infraspinatus
C6 Biceps, brachioradialis (± wrist extension)
C7 Triceps (± wrist extension)
C8 Finger flexion
T1 Interossei
L2–L3 Iliopsoas
L4 Quadriceps, tibialis anterior
L5 Extensor hallucis, extensor digitorum
S1 Gastrocnemius, toe flexors (± hamstrings)
S2 Glutei, hamstrings
perianal and scrotal/vulval sensation. Establish a sen-
sory level on the trunk for a suspected case of spinal
cord compression. This will help with the localisation
of the pathology.
Special tests
Straight leg raising is normally to 90 degrees with the
patient in the supine position. Lift the whole lower limb
passively whilst it is straight, flexing at the hip joint.
This stretches sciatic nerve roots. Record the angle at
which sciatica stops the movement.
Lesegue’s stretch test is a test of pressure on the sci-
atic nerve.
The ankle is dorsiflexed with the lower limb out-
stretched and flexed at the hip, placing extra stress on
the sciatic nerve, which, if it is already tethered by some
pathology such as a disc prolapse, will cause a sharp
jab of pain.
Femoral stretch test is a test of pressure on the upper
lumbar nerve roots.
The patient is prone and the lower limb is ex-
tended at the hip, placing tension on the upper lumbar
roots.
Rectal examination includes prostate and pelvis, anal
tone, external sphincter contraction (the patient tight-
ens the anus with the gloved finger in the rectum), pe-
rianal and perineal sensation. Assess the abdomen for
bladder fullness.
Anal reflex (S4.5) involves contraction of the subcuta-
neous portion of the external sphincter in response to
scratching the perianal skin.
Sacral sparing may occur within a widespread area
of sensory loss caused by an intramedullary spinal cord
78: Acute back pain 667
Tendon reflex
Biceps
Brachioradialis
Triceps
–
–
–
Patella
–
Achilles
lesion, and is due to the laminar arrangement of the fi-
bres in the spinothalamic tract. The sacral segments are
lateral in the tract. It thus means there is an incomplete
spinal cord problem and may be the only sign of this.
General examination
The examination includes chest, abdomen and lymph
nodes. Rectal and internal pelvic examinations are
done when relevant. In a patient with back or radic-
ular pain always consider intra-abdominal and other
pathologies as a cause for pain.
Assess the adequacy of the arterial circulation in the
lower limbs in the older patient.
Causes of acute back or neck pain
(Box 78.2)
Musculo-ligamentous strain
This is the commonest cause of acute back or neck
pain. Usually there is an acute event such as a twist-
ing, bending or lifting motion. The pain is localised
but may spread to the trapezius, shoulder, occiput, or
interscapular region if from the neck, or the buttock
and upper thigh if from the lumbar region. There is
spinal stiffness, local paraspinal muscle tenderness but
no abnormal neurological signs.
Intervertebral disc prolapse
This is a common problem. The fibrous annulus of
the disc tears, allowing the softer nucleus of the
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668 Problem Solving
Box 78.2 Key points and pitfalls
r Most back pain is benign in nature and cause, and usually
resolves, even without treatment, in 3 to 4 weeks.
r It is important to try and differentiate radicular pain from
musculoskeletal spinal pain and spinal cord compression
r Hip pain may mimic sciatica due to compression of a
spinal nerve root
r Back pain in children should not be ignored as it often
has a serious underlying cause.
r Negative plain radiographs or CT scans do not exclude
the presence of serious spinal pathology.
r Make sure adequate investigation of back pain is under-
taken at an early stage so that serious pathology is not
missed.
r In patients with signs of spinal cord compression, do not
forget to examine perineal sensation or to percuss the
bladder.
disc to herniate or prolapse. If the prolapsed nucleus
separates from the disc it becomes a sequestrated frag-
ment and may not resolve with expectant treatment.
The intervertebral disc usually prolapses posterolater-
ally and may compress the exiting spinal nerve root
which is adjacent to it and cause sciatica or brachial-
gia. In the acute phase the back pain is usually a
minor component. Much less common is the central
disc prolapse, which compresses the spinal cord or
the cauda equina nerve roots depending on the spinal
level.
Disc prolapse is most frequent in the lower cervi-
cal spine (C5–C6, C6–C7) and the lower lumbar spine
(L4–L5, L5–S1). These are also the levels where degen-
erative changes are most common. Disc bulging (pro-
trusion) occurs where the there is no prolapse (or ex-
trusion) of nucleus. This is a common finding on CT or
MR imaging and is not necessarily the cause of back
pain and sciatica.
Thoracic disc prolapse may compress an intercostal
nerve laterally and cause radiating pain in the distribu-
tion of that nerve or may cause spinal cord compression
when central.
Infection
Osteomyelitis may be due to pyogenic infection usually
by haematogenous spread, or due to tuberculosis. This
will cause acute back pain and may cause neurological
deficit due to vertebral deformity, bony instability or
secondary epidural abscess.
Primary epidural abscess may occur without os-
teomyelitis particularly if bacteria are introduced into
the spinal epidural space by a needle puncture or place-
ment of an epidural catheter for analgesia. The prob-
lem has been reported following childbirth, with the
mother developing severe back pain and possibly neu-
rological deficit in the weeks following the placement of
an epidural catheter for analgesia during labour. Disci-
tis caused by a bacterial infection may also cause acute
(and chronic) back pain.
Trauma
Trauma to the spine may cause vertebral fractures
which may be unstable and may cause neurological in-
jury. These injuries cause acute and often severe local
pain and tenderness.
Vertebral collapse
Crushing of the anterior portion of the vertebral body
in the thoracic or lumbar region is common following a
hyperflexion injury to the spine. This causes a wedging
of the affected vertebral bodies and acute pain. Wedg-
ing and vertebral collapse is also common in elderly
patients and may be due to neoplastic infiltration, os-
teoporosis or, less commonly, infection.
Haematoma
An acute subdural or epidural haematoma in the tho-
racic spinal canal may cause acute cord compression
with severe back pain and paraparesis. The cause of
the bleed may be a ruptured vascular malformation or
a spontaneous bleed in a patient on anticoagulants such
as warfarin.
Spinal stroke
Thrombotic occlusion of the anterior spinal artery usu-
ally in a patient with diffuse atherosclerotic vascular
disease causes an acute paraplegia, with severe acute
back pain in the thoracic region. Myelogram does not
show any compressive lesion but MRI may show cord
signal hyperintensity, which indicates oedema or devel-
oping infarction.
BLUK017-Tjandra September 12, 2005 20:16
Investigation of back pain
Plain X-rays
Plain X-rays are often done as an initial screen for pa-
tients with back pain but have a low sensitivity. Plain
cervical X-rays are also used as a routine screen in mul-
tiple trauma patients and other regions of the spine if
clinically indicated.
Computed tomography
Computed tomography (CT) scan is often ordered as
the initial investigation for back pain. It shows the bony
anatomy and the facet joints very clearly but is of vari-
able and often inferior quality at showing the soft tis-
sues, including the discs and intraspinal pathology.
Magnetic resonance
Magnetic resonance (MR) is now the main modality
for spinal imaging and has virtually replaced CT myel-
ography because it is non-invasive and because of the
extensive information provided in different projections
including the sagittal.
Myelography
The introduction of intrathecal contrast produces a
myelogram which outlines the spinal roots and cord
and is a dynamic study which can demonstrate a spinal
block of the subarachnoid space by a mass lesion. Myel-
ography is often followed by CT (CT myelography)
which shows the contrast on the axial (horizontal) CT
images.
Discography
Discography involves the injection of the intervertebral
disc with contrast which may show internal derange-
ment of the disc and may be used as a provocative test
to identify the origin of back pain. It may not be reli-
able.
Dynamic (flexion–extension) views
These are plain radiographs, fluoroscopy, or MR scans
used to demonstrate mechanical instability of spinal
segments.
78: Acute back pain 669
Biopsy and needle aspirate of vertebral or
paraspinal disease
Biopsy and needle aspirate under CT guidance is a use-
ful diagnostic technique which may be used when open
surgery is not indicated and provides specimens for
histopathology and microbiology analysis.
Blood tests
Blood tests, including blood cultures, full blood exami-
nation and inflammatory markers are performed selec-
tively.
Treatment
Nonoperative treatment
Most back pain is benign in nature and cause, and usu-
ally resolves in 3 to 4 weeks even with no treatment. De-
generative disease and disc prolapse are initially man-
aged conservatively and surgery should be considered
a last resort unless there is spinal cord or cauda equina
compression, when urgent surgery may be required (see
below). Conservative treatments may include rest, and
physiotherapy, which may include cervical collar, mas-
sage, traction, interferential heat treatment, and manip-
ulation. Chiropractic treatment and acupuncture offer
alternatives. Drugs include non-steroidal inflammatory
drugs, analgesics, muscle relaxants, and steroids. Acute
sciatica or brachialgia may require opiates to control
the pain. Exercises are not useful in treating acute back
pain, but have a role once it has largely settled so as to
strengthen the paraspinal and abdominal muscles (e.g.
Pilates program) which are often weakened in patients
with degenerative spinal disease and disc prolapse.
Spinal surgery
A patient with disc prolapse and unremitting sciatica or
brachialgia and neurological deficit despite conserva-
tive measures and who has radiology correlating with
the clinical picture should be considered for surgery.
Lumbar disc prolapse can be treated with minimally in-
vasive microdiscectomy via an interlaminar approach.
Cervical disc prolapse is usually treated with an ante-
rior cervical discectomy and interbody fusion.
Acute or subacute spinal cord compression and
cauda equina syndrome are urgent problems which
BLUK017-Tjandra September 12, 2005 20:16
670 Problem Solving
require urgent referral to a neurosurgeon. Emergency
decompressive surgery may be required to preserve
neurological function and reverse neurological deficit.
Whether the decompression of the spinal canal is done
via a posterior approach (laminectomy or costotrans-
versectomy) or via an anterior approach (anterior cer-
vical, thoracotomy or transabdominal) depends upon
the nature and site of the pathology and the experi-
ence of the surgeon. A diseased vertebral body may
require excision and replacement by a prosthesis and
the stability of the spine may need to be restored with
metallic internal fixation using rods, plates, screws and
bone grafts. Following such spinal surgery the pa-
tient may require radiotherapy or chemotherapy for
a neoplasm or prolonged antibiotic therapy for an
infection.
An osteoporotic vertebral collapse can be treated
with an injection of acrylic cement into the affected
vertebral body under radiological guidance to restore
the volume and strength of the bone and relieve
pain.
MCQs
Select the single correct answer to each question.
1 A 30-year-old man presents with 1 week of right sciatica
and has numbness on the dorsum of his right foot and
weak dorsiflexion at the ankle. Which of the following is
true?
a he probably has an L4–L5 disc prolapse, with
compression of the L4 nerve root
b he needs an urgent CT myelogram
c he can be managed initially with rest and analgesics
d he is likely to require surgery
e he should be encouraged to undertake spinal
extension exercises
2 A 35-year-old woman presents with acute lumbar back
pain, bilateral sciatica, difficulty in voiding and on
examination has weakness in the ankles and feet, absent
ankle reflexes and decreased sensation in the soles of
both feet. Which of the following statements is false?
a she has developed an acute cauda equina compression
b she has developed an acute spinal cord compression
c central disc prolapse at L5–S1 is a likely cause
d urgent magnetic resonance imaging is required
e urgent surgery will be required
3 A 30-year-old diabetic presents with a severe mid and
lower thoracic pain, radiation of the pain to the
mid-abdomen, and on examination he is tender in the
thoracic spine at the level of T10, has weak lower limbs
and finds it difficult to walk. Which of the following
statements is false?
a CT scan will be helpful as an initial investigation
b he should have an FBE and ESR
c he may have a dissecting aneursym of the aorta
d a needle biopsy is indicated initially
e an MRI is indicated and urgent surgery should be
considered