Review of Literature

PRESENTING BY:
MONIKA S. KULKARNI
1st YEAR MPT
DEPARTMENT OF ORTHOPAEDIC MANUAL THERAPY
Differential Diagnosis in Low Back Ache
 CONTENTS
 Definition
 Causes
 Risk factors and Conditions
 Prolapsed Intervertebral disc
 Spondylolisthesis
 Lumbar Spondylosis
 Spinal stenosis
 Ankylosing Spondylitis
 Facet joint Arthropathy
 Scoliosis
 Pott’s disease
 Paget’s disease
ANATOMY OF LUMBAR VERTEBRAE
Classification of Low Back Ache
 Definition
Low backache is a pain felt in the lower area of the spine. The pain in the lumbar
spine can have multiple anatomical location.
 Pain from hip/pelvis as well as from thoracic spine can project to the area of lumbar
vertebrae and is perceived as low back ache (LBA).
Causes:
 LBA can be caused by structural pathology such as herniated or protruded disc,
arthritis of lumbar joint.
 It can be also caused by pinched nerve within or around the structure of spinal canal
or spinal foramen.
 It could also be functional, muscular or ligamentous pain such as:
 Poor posture , muscular/ligamentous pain
 Poor motor control of lumbar spine
 SI joint restriction or hypermobility
 RISK FACTORS:
 The most frequently reported are heavy physical work, frequent bending,
twisting, lifting heavy objects, pulling/pushing, repetitive work, static posture
and vibrations.
 Psychological work include stress, anxiety, depression etc.
 Prolapsed Intervertebral disc (PIVD)
 A slipped disc (PIVD) is a herniation of the nucleus pulposus posteriorly or
posterolaterally through the annulus fibrosis.
 This lesion occurs most often at the lumbosacral or lumbar 4/5 levels and in
young adult life.
Stages of Prolapsed disc :
 Nucleus degeneration
 Nucleus displacement
 Stage of fibrosis
 FEATURES SPINAL STENOSIS ANNULAR TEARS FACET JOINT
ARTHROPATHY

Pain Heaviness(no pain) Back pain greater than Localized tenderness

develops after walk leg pain present unilaterally
over joint
Pain on flexion No No No

Pain on extension Yes Yes Yes

Age group affected Above 50 years 20-40 years Above 30 years

Levels commonly L3- L5 L4-L5 L4-L5 and L5-S1

affected

Special test SLRT is negative SLRT B/L positive SLRT affected side
positive
Diagnosis:
 Straight leg raise test
 Lasegue’s test
 Myelography
 MRI and CT scan
 Nerve conduction study: This test measures the electrical impulse and functioning in
muscle and nerves.
 Electromyography : This is used to find denervation, localized to the distribution of a
particular nerve root.
 Lumbar Discography : It is an imaging test to identify
damage to a particular spinal disc in the lower back
causing pain or discomfort.
 SPONDYLOLISTHESIS

This condition is defined as the forward displacement of a vertebra over the one
below it. It commonly occurs between L3 – S1, and between L4-L5.
 It is divided into five types:
1. Isthmic : This is the commonest type overall. The lesion is in the pars
interarticularis.
2.Dysplastic : In this, the least common, there is a congenital abnormality in the
development of the vertebrae, so that one vertebra slips over the other.
3. Degenerative : This is seen fairly commonly in elderly people
 The posterior facet joint becomes unstable because of OA and subluxate
 Vertebral displacement is occasionally backward
4.Pathological: This type is results from generalised/localised bone diseases
weakening the articulation between vertebrae
5. Traumatic: This is a very rare type where one vertebrae slips over other following
injury
Signs and symptoms:
 LBA is the chief symptom
 This begins gradually and intermittently but becomes severe and worsened in
movements
 In traumatic, the nerve root at the level of the shift become progressively
stretched giving rise to bilateral sciatica.
 The early sign is first confirmed to limited lumbar movement with local
tenderness at affected level on deep palpation.
 Lumbar lordosis
 Special test : Stork test
SLRT
Differential Clinical features Clinical Investigations
examination

Lumbar Pain in the back, SLRT EMG

radiculopathy buttock region, calf. Femoral nerve Nerve conduction
Pain is radiating, stretch test study is done
numbness and Motor and sensory Mass seen on the
paresthesia examination MRI or CT scan
Lumbar bursitis Pain in upper to Decreased in lumbar Ultrasound or MRI
mid-back laterally movements are used if bursitis
that may radiate to SLRT is positive cant easily be
groin but no leg. diagnosed with
physical
examination
Fluid aspiration
from inflamed bursa
Lumbar Pain in the lumbar Decreased in lumbar X-rays
fibromyositis region, lack of movements MRI
energy, fatigue, SLRT is negative
headache
Title and Author Lumbar spine stability for subjects with and without low back pain
during one-leg standing test

The aim of this study was to evaluate the lumbar stability index, which
AIM includes relative holding time (RHT) and relative standstill time (RST),
in subjects with and without LBP.

Methodology All participants were asked to maintain the stork test position
(standing on one leg with the contra lateral hip flexed 90 degrees) for
25 seconds. The outcome measures included RHT and RST for the
axes of the core spine and lumbar spine.
The RHT was longer for the lumbar spine axis in subjects without LBP
than those with LBP, especially without visual feedback.
Conclusion The control group included slightly younger volunteers compared with
the LBP group, the stability index of the core spine significantly
decreased in RHT and RST. The interaction between visual feedback
and trunk rotation indicated that core spine stability is critical in
coordinating balance control.
 Lumbar Spondylosis
This is a degenerative disorder of the lumbar spine characterized clinically
by an insidious onset of pain and stiffness.
 Causes : Bad posture and chronic back strain is the commonest cause.
 There is a loss of disc height and dehydration of the nucleus pulposus with
osteophyte formation at the attachment of annulus fibrosus.
 In the posterior joints there is a loss if articular cartilage and local
osteophyte formation which can compress the local nerve root canal
causing pain.
 Clinical features : The symptoms begins as low backache, initially worst
during activity.
 There may be feeling of ‘catch’ while getting up from a sitting position, which
improves as one walks few steps. Pain may radiate down the limb up to the
calf ( sciatica).
 Special test : SLRT
Neurodynamic ( SLRT 1)
 X-ray of lumbo-sacral spine
Title Painful lumbar spondylolysis among pediatric sports players: a pilot
Author MRI study.

Aim The purpose of this study is to clarify the cause of LBP associated with
pars defects in athletes. To evaluate the inflammation around the pars
defects, short time inversion recovery (STIR) MRI was performed along
with the sagittal section.

Methodology Six pediatric athletes (5 boys and 1 girl) below 18 years old with painful
bilateral lumbar spondylolysis were evaluated. Fluid collection, which is
an indicator of inflammatory events, was evaluated in 12 pars defects as
well as in 12 cranial and caudal adjoining facet joints.

Conclusion The present study showed that inflammation was always present at the
pars defects and in some cases at the adjoining facet joints. This
mechanism could cause LBP associated with terminal-stage
spondylolysis in athletes.
 Spinal stenosis
It can be defined as narrowing of the spinal canal. The actual mechanical pressure
exhibited on the contained neural structure will determine the degree of narrowing.
 It is classified into developmental or acquired lesions or a combination of both, it
may be symmetrical or asymmetrical, central or lateral and may be due to soft
tissue changes such as intervertebral, fibrous scar, tumor or bony changes.
 There is a osteophyte formation on the margins of the vertebral bodies and
remodeling changes in the facet joints and vertebral body osteophyte formation
 Patients with spinal stenosis may present with a back pain, radiculopathy and
neurogenic claudication.
 Special test : SLRT
Kemps test
Modified Schober test
FEATURES NEUROGENIC VASCULAR LUMBAR
CLAUDICATION CLAUDICATION SPONDYLOSIS
PAIN

Type Vague cramping tightness, cramping dull aching low back

aching, sharping (usually in calf)
burning in lower
extremities
Location Lower back, buttock Calf Lower back

Radiation Proximal to distal Localized to lower Localized to back

extremities

Improvement With sitting, flexion with sitting With decreased

and squatting activity and rest

Special test : SLRT Negative Negative Negative

Bicycle test Positive with lumbar Positive Negative

hyperextension
Title Differentiation of vascular claudication due to bilateral common iliac
Author artery stenosis versus neurogenic claudication with spinal stenosis

Aim The aim of the study is to differentiation of vascular claudication due to

bilateral common iliac artery stenosis versus neurogenic claudication
with spinal stenosis

Methodology : A 68-year-old female presented with low back, right hip, and groin pain
while walking short distances. She had previously undergone lumbar and
cardiac surgery with negative repeated lumbar studies, the CT angiogram
(CTA) revealed a dense calcified plaque in the right common iliac artery
resulting in 90% stenosis at its origin and
Conclusion It may be difficult for spine surgeons to differentiate between lumbar
neurogenic claudication and peripheral vascular claudication. Whereas
MR studies best document lumbar stenosis, abdominal/pelvic CTAs
readily demonstrate aortoiliac disease.
 Ankylosing Spondylitis
It is a chronic disease characterized by a progressive inflammatory stiffening
of the joints, especially the sacro-iliac joint ( SI joint)
 The exact etiology is not known. A strong association has been found
between a genetic marker- HLA –B27 and this disease.
 SI joint are usually the first to get involved, followed by the spine from the
lumbar region upwards.
 Initially synovitis occurs, followed by cartilage destruction and bony
erosion. Ossification also occurs in the anterior longitudinal ligament of
the spine
 After bony erosion occurs, the pain may subside leaving the spine
permanently stiff ( burnt out disease)
Clinical features:
 The early findings are limited movements in the lumbar region and diminished chest
expansion
 The stiffness may be noticed only after a period of rest, and improves with
movement.
 Pain tends to be worst at night or early morning, awakening the patient from sleep.
 There may be loss of lumbar lordosis. Lumbar spine flexion may be limited.
 Special test : Gaenslen’s test
SLRT, Modified Schober test
 Bath Ankylosing Spondylitis Disease Activity Index:
The BASDAI consists of a 0 - 10 scale measuring discomfort, pain, and fatigue (0 being
no problem and 10 being the worst problem) in response to six questions asked of the
patient pertaining to the five major symptoms of AS: Fatigue, Spinal pain, Arthralgia
(joint pain) or swelling, inflammation, morning stiffness duration, morning stiffness
severity.
Radiological examination:
 Disease Clinical Investigations

Stiffness Occurs at any age or gender Signs of TB spine on X-rays

TB spine Localized tenderness, cold
abscess

Back pain Non-specific, localized X-Rays are normal

Lumbo-sacral strain tenderness present
Disc prolapse tenderness is present

Osteoarthritis Localized tenderness is Osteophytes are present on

present X-ray
Title Imaging features of spinal fractures in ankylosing spondylitis
Author and the diagnostic value of different imaging methods

The aim of the study is to characterize the imaging appearance of

Aim spinal fractures in ankylosing spondylitis (AS) and identify
situations in which the use of magnetic resonance imaging (MRI) is
necessary.
A total of 70 cases of spinal fractures associated with AS were
Methodology retrospectively enrolled. The location, type, ligament injury,
neurological injury, and epidural hematoma and spinal fractures
were assessed. Only one patient had a vertebral compression
fracture, and 69 patients had 77 transverse fractures involving three
columns. The anterior longitudinal ligament (ALL) was the most
frequently torn ligament. 

A whole-spine CT examination with three-dimensional

Conclusion reconstruction for detecting a suspected fracture in AS patients. In
cases with neurological injury, MRI examinations are always
mandatory. 
 Facet joint Arthropathy
It is a disorder mostly caused by the structural degeneration of one or more
vertebrae that can eventually generate pain.
 The main cause is imbalances that can occur in stress levels, harmone
levels and nutritional levels. These imbalances can affect the posture
which can leads to neck and back pain.
 It can also caused by a combination of aging, pressure overload of facet
joint and injury, that includes arthritis of lumbar facet joints and disease
of spine.
Clinical features:
 Patient usually complaints pain in the lower back that increases with
twisting or arching the body.
 The pain sometimes moves to the buttock or the back of the thighs, the
pain is usually a deep dull ache.
 Other symptoms includes stiffness or difficulty standing up straight or
getting out of a chair.
 Numbness and muscle weakness will affect different parts of the body,
depending on which nerves are being affected.
 Special test : Kemps test
Distraction test
Compression test
Gillet’s test
 Facet joint Clinical features Intervertebral

Phase 1 ( Dysfunction)
Synovitis Restricted movements Circumferential and radial
Minimal cartilage Unilateral radicular annular tear
degeneration symptoms

Phase 2 ( Unstable)
Facet joint subluxation Increased in restrictions of Entire annular tear
Subperiosteal osteophyte movement Complete internal disc disruption
Unilateral radicular
symptoms
Phase 3 ( Stabilization) Restricted movements
Periarticular Bilateral radicular Ossification
Osteophyte symptoms
 Scoliosis
It is the sideway/lateral curvature of the spine.
 Classification : Structural ( Permanent)
Non-structural ( Transient)
 Structural scoliosis : It is a scoliosis with a permanent deformity.
Sub types : Idiopathic, Congenital, Paralytic scoliosis
 Non-structural scoliosis : This is a mobile or transient scoliosis.
Subtypes : Postural , Compensatory and Sciatic scoliosis.
Clinical features:
 In most cases, visible deformity is the only symptoms.
 Pain is the main feature in adults with long standing deformity.
 One shoulder blade that appears more prominent than the other
 Uneven shoulder and waist
 Radiological features : Cobb’s angle
Reisser’s sign
 Pott’s Disease ( TB Spine)
The spine is the commonest site of bone and joint tuberculosis, the
dorso-lumbar region being the one affected most frequently.
It is a combination of osteomyelitis and arthritis which involves
multiple vertebrae.
The main cause of this disease is vertebral collapse and when this
occurs anteriorly, anterior wedging results, leading to kyphotic
deformity of spine.
Types of vertebral tuberculosis: Paradiscal
Central
Anterior
Posterior
Clinical features:
 Back pain is the commonest presenting symptom.
 It may be a ‘radicular’ pain i.e. radiating along a nerve root.
 Stiffness is the very early symptom in the TB spine.
 The patient may present the first time with a swelling (cold abscess)
 The patient with TB of the spine walks with short steps in order to avoid
jerking the spine.
 Special test : Crossed SLRT
Bowstring sign
Reverse sciatic tension test
Schober’s test
Differential Clinical features Investigations

Back pain H/O trauma present X-ray – disc height normal

Traumatic No fever or cold abscess Wedging of vertebra present
Myeloma H/O trauma Normal X-ray

Prolapsed disc Radiating pain -------------

SLRT – positive, morning
stiffness
Ank.Spondylitis Chronic back pain, SLRT is Bamboo appearance on X-
positive ray
Spinal tumor Chronic back pain Pedicle erosion is present

Traumatic H/O Trauma, weakness is X-ray – fracture-

sudden onset dislocation
Secondaries back pain present X-ray – erosion of vertebrae
 Paget’s Diseases
It is a disease of bone marked by repeated episodes of increased bone
resorption followed by excessive attempts at bone formation, resulting in
weakened and deformed bones of increased mass
 The main disturbance is an exaggeration of osteoclastic bone resorption.
 Early in the disease process, osteolysis( loss of bone) is accompanied by
some level of repair. The repair is usually occurs in local areas near the
region of excessive resorption.
 In this phase, the bone becomes increasingly sclerotic and brittle.
 It can affect lumbar spine, skull, pelvis, femur and tibia. Fracture as a
result of this condition are common especially in weight bearing long
bones.
Clinical features:
 The patient complaints of pain directly or as result of nerve root irritation
or compression.
 Pressure of spinal cord is unusual.
 Limb pain may be due to the lesion or from nerve root compression.
 Pagetoid bone lacks the strength of normal bone. As a result it deforms and
fractures easily.
 Paget’s disease may develop primary bone malignancies in the Pagetoid
bone, including osteogenic carcinomas and have poor prognosis.
Diagnosis:
 X-ray
 Blood investigation ( measurement of serum alkaline phosphate)
 Bone scan
 Tumors

Both the benign tumor and malignant tumor occurs in the spine and spinal canal.
It is usually classified as extradural and intradural.
Benign tumor:
 Osteoid osteoma is the commonest begin tumor of the spine.
 It causes severe backpain especially at night.
 The tumor is usually the size of a pea and round in the pedicle or lamina.
 Hemangioma also occurs in vertebral body which is present in backpain or
radiating pain.
Malignant tumor:
 Multiple myeloma is common of spine .
 Metastatic deposits are extremely common in the spine because of its rich
venous connection.
 Severe backpain is seen.
Clinical Features:
 As the disease progresses, spinal cancer symptoms may grow to include
weakness, inability to move legs and, eventually, paralysis.
Some common signs of spinal tumors may include:
 Pain( back and/or neck pain, arm and/or leg pain).
 Muscle weakness or numbness in the arms or legs.
 Difficulty walking
 General loss of sensation.
 Difficulty with urination(incontinence).
 Change in bowels habits(retention).
 Paralysis to varying degrees.
 Spinal deformities.
 Pain or difficulty with standing.
Investigation:
 Magnetic resonance Imaging(MRI) : This is the most reliable method
for diagnosing spine tumors. MRI can identify spinal cord compression.
 Positron emission tomography(PET) : PET can screen for spinal
metastases and help distinguish between malignant and benign bone
lesions. Before this scan begins, a small amount of radioactive sugar is
injected into a vein. Because cancer cells absorb sugar more rapidly than
normal cells, they show up on the scan.
 Myelography : A radiologist takes an X-ray of the affected area after
injecting a dye into your spinal fluid cavity. The image shows tumor’s
outline and can help direct radiation beams during radiation therapy.
Because MRI is more effective for diagnosing spine tumors.
 Bone scan : It is a nuclear medicine procedure that creates a picture of the
metabolism of the bones
 Liquid molecular biopsy : These are non-invasive blood test that detects
circulating tumor cells and fragments of tumor DNA that are shed into the
blood.
Differential Diagnosis
OSTEOBLASTOMA OSTEOID OSTEOMA
1. INCIDENCE One fifth as common as osteoid 10% of benign bone tumor
osteoma

2. COMMONEST Vertebral column, often posterior Proximal femur

LOCATION element

3. CLINICAL Pain inconsistent Pain persistent, nocturnal

PRESENTATION

4. RADIOGRAPHY Size > 2cm Size< 2cm, perifocal tissue

No or minimal perifocal tissue reaction is marked.
reaction

5. HISTOLOGY <Osteoid trabeculae with >osteoid trabeculae with

discontinuous and irregular bone
formation
>abundant fibrous stromal
reaction.
>Many multinucleated
osteoblastic giant cells
continuous and regular bone
formation.
>Scanty stromal reaction
> Multinucleated osteoblastic giant
cells are rare.
 Reference
 Text book on Low Back Syndromes - Craig E. Morris, 5th edition
 Text book on Low Back Pain - Kenneth Mills, 4th edition
 Essential Orthopaedics (Including Clinical Methods)- Maheshwari &
Mhaskar, 3rd edition
 The Clinical Anatomy And Management Of Back Pain Series - Giles K P
Singer, 4th edition
 Cailliet R, Eccles A. Soft tissue pain and disability. Philidelphia: FA Davis;
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 Magee DJ, Zachazewski JE, Quillen WS, Manske RC. Pathology and
intervention in musculoskeletal rehabilitation. Elsevier Health Sciences;
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 S. Brent Brotzman; clinical orthopedic rehabilitation; 2nd edition.
 Song Q, Liu X, Chen DJ, Lai Q, Tang B, Zhang B, Dai M, Wan Z. Evaluation of
MRI and CT parameters to analyze the correlation between disc and facet joint
degeneration in the lumbar three-joint complex. Medicine. 2019 Oct;98(40).
 Ren C, Zhu Q, Yuan H. Imaging features of spinal fractures in ankylosing
spondylitis and the diagnostic value of different imaging methods. Quantitative
Imaging in Medicine and Surgery. 2021 Jun;11(6):2499.
 Shields LB, Iyer VG, Self SB, Zhang YP, Shields CB. Differentiation of vascular
claudication due to bilateral common iliac artery stenosis versus neurogenic
claudication with spinal stenosis. Surgical Neurology International. 2021 May
17;12(231):1.
 Sung PS, Yoon B, Lee DC. Lumbar spine stability for subjects with and without
low back pain during one-leg standing test. Spine. 2010 Jul 15;35(16):E753-60.
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