The lower back includes the lower lumbar spine, the lumbosacral or sacroiliac region.
I. Five types of lower back pain.
Localized pain – caused by local activity, spinal involvement (causes include tears and pulling) sensitizes some nerve endings to pain. Pulling and back pain – note that such generally comes from the pelvis and this is not of spinal activity origin. Pain of spinal origin – confined to the back or involving the lower extremities, pain in upper lumbar spine disorders involving the upper back, groin and anterior thighs, lower lumbar spine disorders involving the buttocks or posterior thighs.
Spinal nerve root pain – originates from specific nerve areas in the spine or legs and can be caused by coughing, sneezing, lifting heavy objects or overexertion. Muscle spasm pain – multi-source, accompanied by spinal muscle tension.
II. Key points of physical examination
Check whether it originates from internal organs, including abdominal cavity, pelvis and rectum. Examine for the presence of scoliosis or muscle spasm. Pain on palpation of the lower back mostly originates from spinal lesions.
It should be noted that hip pain can be easily confused with spinal pain. Internal/external rotation of the thigh hip (habituation and and hip flexion) can produce pain, straight leg raise sign – passive bending of the leg to bring the knee towards the
The patient is standing or supine and the L5/S1 nerve root and sciatic nerve are stretched from the posterior to the buttock during manipulation. If pain recurs with manipulation, the straight leg raise sign is positive. Crossed straight leg elevation sign – positive when one thigh is elevated and pain is present in the contralateral thigh or buttock, with nerve root damage on the painful side. Reverse straight leg raising sign – when the patient is supine or standing and
The thigh is passively extended toward the trunk while extending the knee joint. Manual manipulation is performed to distract the L2 to L4 nerve roots and femoral nerve passing from the front to the buttock. Neurological examination – to detect any atrophy of the lesion, weakness, loss of reflexes, and loss of sensation distributed in the skin.
Third, auxiliary examination
Routine laboratory tests and lumbar spine X-rays – are of little use in diagnosing acute lower back pain, but can identify risk factors for the presence of serious underlying disease. MRI or CT myelography can be chosen for the anatomical structural changes that reveal spinal diseases.
IV. Etiology
1.Lumbar intervertebral disc disease
This is a common cause of lower back pain, usually at the level of L4-L5 or L5-S1, with loss of skin sensation, diminished or absent deep tendon reflexes, and low muscle tone, and this is more helpful in localizing the diagnosis than the mode of pain. Usually unilateral, bilateral large central type disc herniation compressing multiple nerve roots can cause cauda equina syndrome.
2. Spinal stenosis
Its causes back pain or lumbar pain that is caused when standing or walking and relieved by sitting or standing. Unlike claudication caused by vascular disease, the symptoms can appear when standing; unlike paravertebral disease, the
symptoms can be relieved during sitting and standing. Neurological lesions are uncommon, and severe neurological symptoms (paralysis, urinary and fecal incontinence) are rare.
3. Trauma
Usually complaints of milder lower back overexertion or sprain, self-limiting damage with lower back pain. Clinical history, physical examination and spinal x-ray can make the diagnosis.
4.Anterior displacement of the spine
The anterior spine slips forward and the lower part is placed back. l4-L5 is higher than the level of L5-S1, causing lower back pain or nerve root pain (cauda equina syndrome)
5.Osteoarthritis
Back pain can be induced by spinal activity, and its onset increases with age. Radiological manifestations are not related to the severity of pain, and joint surface syndrome shows radicular symptoms, with nerve roots compressed by an overly enlarged unilateral small joint surface.
6.Tumor spine metastasis
The most common polyneurological symptom in patients with systemic tumors is back pain. Metastatic cancer, multiple myeloma and lymphoma often involve the spine. Lower back pain can be considered as a symptom of cancer, characterized by: it often cannot be relieved at rest.
MRI or CT examination after myelography can formally metastasize the vertebral body and narrow the intervertebral disc space.
7.Spinal osteomyelitis
It cannot be relieved by rest, the lesion spine pain is obvious to touch, and the blood sedimentation rises. Mainly due to lung, urinary tract or skin infection, accounting for 40%. Staphylococcus is the most common. There is often destruction of the vertebral body and intervertebral disc space.
Back pain and fever may occur in case of spinal abscess, physical examination may be normal or with radiological manifestations, manifestations of cauda equina syndrome may be seen, and MRI examination may determine the extent of the abscess.
8.Lumbar arachnoiditis
It appears after local injury to the subarachnoid space causing an inflammatory response. Nerve root plexus fibrosis MRI examination can be found.
9.Immune dysfunction
Spondylitis, rheumatoid arthritis, Reiter syndrome, psoriatic arthritis, chronic enterocolitis. Ankylosing spondylitis usually given that less than 40 pairs of men, back pain at night, rest without relief, exercise can improve.
10, osteoporosis
Hyperparathyroidism causes loss of bone parenchyma, chronic steroid use, immobilization or other medical conditions. Back pain increases with activity.
11.Internal diseases
Intrapelvic disease may involve pain in the sacral region, lower abdominal disease may involve lumbar pain, and upper abdominal disease radiates to the lower chest/ or upper lumbar region. There are no local manifestations and normal vertebral motion is painless. More than 20% of patients with concomitant abdominal aortic dissection present with isolated lower back pain.
Etiology of lower back pain due to visceral disease
gastric (posterior wall) lesions – cholecystitis, gallstones pancreatic lesions – tumors, cysts, pancreatitis retroperitoneal lesions – hemorrhage, tumors, pyelonephritis vascular lesions — abdominal aortic aneurysm, renal artery or vein thrombosis Crohn’s disease — colitis, diverticulitis, tumor uterosacral ligament lesions — endometritis, cancer uterine displacement dysmenorrhea tumor Invasion of nerves.