Pain, muscle tension or

stiffness localized below the

costal margin and above the
inferior gluteal folds, with or
without leg pain

International Association for

the study of pain (IASP)
Low Back Pain
Gluteal and Loin
• Lumbar spinal pain pain (not considered
• Sacral spinal pain
• Lumbosacral pain
LBP)
 LBP prevalence in Indonesia is 18%.

The prevalence of LBP increases with age and

most often occurs at the age of the middle decade
and the beginning of the fourth decade.
The most common cause of LBP (85%) is non-
specific, due to abnormalities in soft tissue, in the
form of muscle injuries, ligaments, spasms or muscle
fatigue.

Other serious causes include specific, vertebral

fractures, infections and tumors
 Mechanical
(HNP, OA,
spinal stenosis,
spondylolisthesis,
compression
fracture)

• Tumor (metastases, MM,

lymphoma)
Nonmechanical • Infection (osteomyelitis, diskitis)
• Inflammatory arthritis (RA, AS)

Visceral disease
(AAA,
nephrolithiasis,
pancreatitis,
prostatitis, PID)
Complicated (“Red Flag” conditions)

Specific Diagnosis

• Lumbar Radiculopathy
• Lumbar Spinal Stenosis
• Others such as Ankylosing Spondylitis

Uncomplicated (Non-Specific)

• A diagnosis of exclusion
 Infection
Metastatic CA
(Unexplained fever*, Cauda Equina Syndrome
(History of cancer*, Fracture (Steroids*, (Urinary retention or
Recent bacterial incontinence, Saddle
Unexplained weight Osteoporosis, Recent
infection, anesthesia, Decreased rectal
loss, Rest pain, Age trauma, Age >70) tone, Bilateral lower extremity
Immunosuppression, weakness/numbness)
>50)
IVDA)

Severe or progressive
Failure to improve
focal neurologic Pain > 4 weeks
with therapy
deficit
Compression
Metastatic
Fracture
CA (0.7%)
(4%)

Cauda
Equina Infection
Syndrome (0.01%)
(0.04%)
 Osteoporosis

Location

Thoracolumbar Midthoracic
junction spine

Pain may not be localized to the level of

fracture, as thoracolumbar fractures may
present with low back or lumbosacral
pain.
 Past history of cancer is by far the single strongest
indicator of cancer related low back pain.
Metastatic
(Prostate, Lung, Multiple myeloma Lymphoma
Breast)

Increases post test probability from 0.7% to 9%

Not including nonmelanoma skin CA

 Urinary retention
(Retention
develops initially
Large central disc
and leads to
herniation (L4-5)
overflow
incontinence
later.)

Normal post-void
residual Surgical
essentially rules it emergency
out.
L4-5 or L5-S1 levels (90%)

Inflammation > Mechanical

compression

Phospholipase A2, TNF-α

Pain with sitting, bending and

coughing

Pain radiates below the knee in a

narrow band.
Nerve Pain Motor Sensory DTR
Root Referral
L4 Medial leg Ankle Medial ankle Knee
dorsiflexion
L5 Lateral leg, Great toe First web No
dorsal foot dorsiflexion space between reliable
1st and 2nd toe reflex
S1 Posterior Foot plantar Lateral aspect Ankle
calf, flexion of the sole of
lateral or foot
sole of foot
 Uncomplicated low Ask “Where is the
back pain is often pain worst?”
referred to lower leg. “Where do you feel
(somatic referred the pain most
pain) consistently?”
Radicular Pain Somatic Referred Pain

Leg > Back Back > Leg

Shooting, Lancinating, Cutaneous Dull, Pressure-like, Deep

component

Travels along the limb in a narrow Extends into limbs across a wide
band region

+/- neurologic deficit - neurologic deficit

Guidelines recommend the non-pharmacological
and non-invasive management

These include the provision of advice to stay active

and the use of patient education and exercise
therapy

Guidelines regularly recommend the use of

physical exercise for non-specific LBP

Guidelines endorse the cautious use of imaging, of

medication, and of surgery.

A risk stratification tool is recommended in the

National Institute for Health and Care Excellence
(NICE) guidelines,

so that treatments can be co-ordinated to each risk

subgroup
Patients with low back pain can be triaged using a clinical
assessment .

This should include history-taking, physical examination,

and neurological tests to recognize radicular features .

With low back pain, patients should be screened for ‘red

flags’ to exclude serious pathologies, and diagnostic tests
(such as imaging) carried out if suspected .
Psychosocial risk factors (yellow flags
using prognostic screening tools) should
be assessed to predict poorer outcomes .

There can be mutual decisions made

with the patient as to whether simpler
and less-intensive management is called
for.

If there is no improvement after 4 weeks,

and a serious pathology or radiculopathy
is suspected, then specialist consultation
is recommended
guidelines (as stated above) promote the avoidance of
bed rest, and the continuation with activities as usual

The aim of physical treatments is to improve

function, and to prevent disability from getting worse

Exercise therapy has become a first-line treatment

and should be routinely used
 A recent Cochrane Low-quality evidence
systematic review of showed back schools to
RCTs evaluating the be no better than
effectiveness of back exercise in the
schools was undertaken intermediate-term