Low Back Pain

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Important Clinical Distinctions Spinal Stenosis and Disc pain

Spinal stenosis usually presents with pain radiating beyond the back to the buttocks, thighs or lower legs. The pain is worsened with extension of the lumbar spine (eg, standing or walking) and improves with flexion of the spine (eg, sitting or stooping forward). This is in contrast to pain originating from a disc which is typically worsened by lumbar flexion

Myofascial pain

The features of myofascial low back pain include diffuse low back pain of gradual onset which worsens after resting or sitting. The pain is aggravated by cold and relieved by warmth and movement. There is often associated stiffness and limited range of motion, with a sensation of tightness in the back. Bilateral leg pain and paresthesia may occur, but limping and listing are unusual. Tenderness is present within the affected muscle and soft tissues, and often the sacroiliac joints. Fibromyalgia may also present as back pain with these features.


Severe, constant back pain, persisting at night, suggests the presence of neoplasm, infection, or lateral recess nerve root compression.

Thoracolumbar fractures present with back pain and segmental radiation in the distribution of the contiguous nerve roots. Sitting often aggravates the pain and muscle spasm may disturb sleep. Dorsal kyphosis, "dowager hump", and loss of height
may be noted. Compression fracture may be the first symptom of osteoporosis.

Sciatica

Sciatica, which refers to pain radiating in a dermatomal distribution is highly suggestive of a herniated disc. The classic features are aching pain in the buttock and paresthesias radiating into the posterior thigh and calf or into the posterior lateral thigh and lateral foreleg.

In most nerve root syndromes, a precise description of radiating pain will help localize to a nerve root level. Over 95 percent of herniated discs affect the L4-5 or L5-S1 interspace. The sensitivity of sciatica (the proportion of patients with a herniated disc who have sciatica) was 0.95 in one report, indicating that its absence makes lumbar disc herniation unlikely. The specificity of sciatica (the percentage of patients without a herniated disc who do not have sciatica) is also high at approximately 0.88. However the diagnosis should not be based solely on the presence or absence of sciatica. Irritation of non-neural structures in the lumbar spine, such as the facet joints and numerous ligaments and other supporting structures, can produce radiating pain in the lower extremities which can cause diagnostic confusion in some patients. Furthermore, radicular pain ("sciatica") can be caused by such diverse entities as neoplasms, spinal stenosis, entrapment neuropathy, myofascial pain syndromes, trochanteric bursitis, vascular malformations, endometriosis, diabetic radiculoneuropathy, herpes zoster (shingles), idiopathic lumbosacral plexitis, and entrapment of the sciatic nerve by the pyriformis muscle.

Table 3: Differences between the pain of a herniated disc and spinal stenosis

Characteristic Spinal stenosis Disc-pain

Aggravating factor Lumbar extension Lumbar flexion (standing, sitting)

Relieving factor Lumbar flexion (sitting Lumbar extension (lying or stooping over) down)

Table- 4

Nerve Root Pain worst in Radiation Sensory Motor Reflexes of pain loss weakness

S1 Leg>>Back Buttock, Fifth toe flexors, Absent ankle

posterior lateral foot gastrocne-

thigh , mius

PL calf and PL calf and rarely jerk

heel PL thigh hamstrings

L5 Back >>Leg PL thigh, great toe externsor no reflex

groin, medial foot hallucis loss

lateral

Calf and DM AL calf longus,

foot, first (less often) Tibialis anterior

Two toes and peronii-

foot drop

L4 or L3 Back >> Leg AM thigh AM thigh Quadriceps Absent knee and knee and knee and jerk

iliopsoas

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Lyndeanw 

Im a 53 y/o healthy, weight appropriate female. I was diagnosed with degenerative lumbar spinal disease, including stenosis at the age of 38. I have a history of several low back injuries, including dislocation of my coccyx, due to falls from horseback riding
I've also worked as an EMT/Paramedic for over 32 years in several different ED units. Long hours on my feet in physically demanding situations.
I developed right hip pain with occasional leg weakness a few years ago, but managed to perform daily tasks without severe discomfort.
I've started to have increased (R) hip/glut pain in the past three months, radiating laterally through my thigh, calf and ankle. This frequently causes thigh and calf spasms that have been debilitating In all of my daily activities. I've seen my PCP, and an Orthopaedic surgeon, with negative findings on exam and MRI.
Any idea what the possible problem could be? Then, how to manage the pain and be able to work, sleep, clean my home and enjoy life again?
Thank you
Lyndean W

md111 

i am unable to bend my knee without severe pain. Very difficult and painful. My lower back always has a stifness and throbing pressure.
I also have servere shooting pain across my back periodically.

thersea 

I have been diagnosed with spinal stenosis & spondolylesis. I have pain radiating from my butt down leg top of foot. Sometimes bottom of foot & also in the groin area. 1 side or the other every day. The pain is horrible. Sometimes both sides. Can't sit can't stand hardly sleep. Help? Have had 2 cortizone shots in a 6mo. period.1st helped. 2nd to a small degree. Unable to take pain meds.

colatulgupta 

Very good material. I wonder if some photographs and radio graphs could be added. Dr Atul Gupta

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