Low+Back+Pain

Epidemiology
-Affects 60-90% of the population at one time during a lifetime -Sciatica occurs in 1-3% of those with LBP -Risk factors: occupations that require repetitive lifting in the bent forward and twisted position exposure to occupational vibrations cigarette smoking 1% "totally disabled" because of back pain

History
90% of patients with low back pain 5% of patients with low back pain 85% of costs due to loss of work and compensation 50% have clear structural diagnosis made for cause of their back pain
 * Acute Pain:** onset < 6 weeks
 * Only 10-20% can be given precise patho-anatomical diagnosis**
 * Chronic Pain:** onset > 3 months

Relevant Anatomy
Lumbar Vertebrae Lumbar Discs Lumbar Facet Joints Lumbar Spinal Nerves

[[image:lumbar_region_muscles.png width="344" height="290" align="right"]]
Lumbar Spinal Musculature Sacroiliac Joint Quadratus Lumborum Muscle

Differential Diagnosis
The Leading Cause Of Low Back Pain (97%) Types: Lumbar strain (70%) Degenerative processes of disks and facets (10%) Herniated disk (4%) Spinal stenosis (3%) Osteoporotic compression fracture (4%) Spondylolisthesis (2%) Traumatic Fracture (<1%) Congenital Disease (<1%) (2% of All Low Back Pain) Types: Disease of pelvic organs: prostatitis, endometriosis, chronic PID Renal Disease: nephrolithiasis, pyelonephritis, perinephric abscess Aortic aneurysm GI disease: pancreatitis, cholecystitis, penetrating ulcer (1% of All Low Back Pain) Types: Neoplasia: multiple myeloma, mets, lymphoma, leukemia, spinal cord tumors, retroperitoneal tumors, primary vertebral tumors (0.7%) Infection: osteomyelitis, septic diskitis, paraspinous abscess, shingles (0.01%) Inflammatory arthritis: Ankylosing spondylitis, psoriatic spondylitis, Reiter’s syndrome, IBD(0.3%) Herniated Nucleus Pulposis (HNP) L4-S1 in 95% of cases of radiculopathy L2-4 in 2-5% 75% of those with cauda equina syndrome have saddle anesthesia L5 radiculopathy: pain/dysesthesia in posterior thigh and anterolateral leg; foot drop with weakness on dorsiflexion S1 radiculopathy: pain/dysesthesia in posterior thigh and leg, posterior lateral foot; weak plantar flexion; decreased Achilles reflex Acute, severe onset of focal pain Elderly, prednisone therapy and SLE predispose Pain will resolve spontaneously in 3-6 months Ankylosing Spondylitis Reiter's Syndrome Arthritis of Inflammatory Bowel Disease Psoriatic Arthritis Degenerative (seen in elderly; most common) Congenital Pseudoclaudication/Neurogenic claudication Mycobacterium Tuberculosis (Pott's Disease) Paravertebral Abscess Intervertebral discitis or osteomyelitis Herpes Zoster Pyelonephritis Endocarditis Multiple myeloma Lymphoma Pancreatic Prostate Breast Renal Cell Thyroid Lung Colon
 * Mech****anical Low Back or Leg Pain**
 * Visceral Disease**
 * Nonmechanical Spinal Conditions**
 * Radiculopathy:**
 * Compression Fracture:**
 * Inflammatory Back Disease:** morning stiffness, symptoms better with activity, worse with rest, young person (< 40)
 * Spinal Stenosis:** better with flexion of back, bilateral neurologic deficits, wide-base gait
 * Infection**
 * Primary cancer:**
 * Metastatic cancer:**

Weight loss, fever History of cancer, exposure to TB, IV drug abuse Age > 50 Adenopathy Neurological symptoms uni/bilateral urinary retention saddle anesthesia Writhing in pain (visceral/vascular) Unrelenting pain at rest (infection/ malignancy)
 * Red Flags**

Physical Exam
Posture shoulders and pelvis level normal lordotic/kyphotic curve present Skin abnormalities Gait Flexion (> 60 degrees*) Schober's test floor-to-finger measurement Extension (> 25 degrees*) Lateral Bending (> 25 degrees*) Rotation Motor Sensory DTRs Pathologic reflexes Cord levels (Motor, sensation and reflexes)
 * Inspection**
 * Palpation**
 * Range of motion**
 * values for which no disability would be assigned
 * Neurologic examination**

Radiographs
Indications in acute low back pain: -Age > 50 -History of serious trauma -History of cancer -Pain at rest -Unexplained weight loss -Drug/alcohol abuse -Previous treatment with steroids -Temperature > 38° C or 100.4° F -Suspicion for inflammatory cause -Neuromotor deficit -Systemic symptoms

Biomedical Treatment
-Bed rest: patients functional in 6.6 days compared to 11.8 days for those kept ambulatory; more beneficial in radiculopathy 2 days of bed rest are as effective as 7 days and results in 45% less time away from work -Analgesics -Muscle relaxants: controversial -Aerobic exercise -Weight loss -Stop smoking -Back exercises -Williams/flexion exercises: better tolerated -Extension exercises: may be more efficacious -Physical Therapy -Ultrasound -Diathermy -TENS -Exercise instruction -Traction -Bracing: controversial; not clearly efficacious; may weaken back/abdominal musculature -Facet injection: probably not effective -Epidural Steroid Injection for radiculopathy controversial -66% with sx < 6 months show improvement -33% with sx > 12 months show improvement -Narcotics in chronic LBP are best avoided -Antidepressants in low doses may be beneficial -USA rates > twice other developed countries -Important neurologic deficits (i.e., foot drop) best treated surgically -Long-term functional outcome unaffected if surgery delayed up to 12 weeks Indications: -Progressive or severe neurologic deficit -Persistent neuromotor deficit despite 4-6 weeks conservative therapy -Persistent radiculopathy, sensory deficit or reflex loss after 4-6 weeks conservative therapy with +SLR, consistent clinical findings and favorable psychosocial circumstances (no depression, substance abuse or somatization disorder)
 * Acute:**
 * Chronic**
 * Surgery**

Biomedical Outcome
Resolution of pain (without sciatica) in 6 weeks with nonspecific treatment in 75-90% 60% will have a recurrence within one year 50% with sciatica recover in 6 weeks
 * Acute:**

TCM Disease Classification
//Yao Tong// = “lumbar or low back pain” -According to TCM, the low back is the domain of the Kidneys. -Despite the localized manifestation, low back pain can be complicated and pain characteristics can vary depending on the pathogen involved. -Low back pain can radiate to other areas, including the upper back, the hips, and the legs and feet.

TCM Etiology and Pathogenesis
Low back pain can be divided into three etiological categories: -Invasion by exogenous pathogens: among these, Dampness is considered a key contributor to low back pain due to its characteristic heaviness, turbidity, and tendency to settle downwards. Cold-Dampness and Damp-Heat are two forms Dampness takes in low back pain; these pathogens are carried into the body by Wind, and obstruct the circulation of Qi and Blood in the low back.

-Trauma, sprain/strain, overuse: these factors obstruct the flow of Qi and Blood in the low back causing pain.

-Constitutional vacuity, aging, chronic illness, or excessive sexual activity: these factors lead to Kidney vacuity with failure to nourish the low back, sinews, and bones.

Identification of Repletion and Vacuity
-Repletion/Excess patterns generally have a more acute onset and are associated with obstruction by exogenous pathogenic factors or trauma, overuse, or sprain/strain. -Vacuity/Deficiency patterns generally have a gradual onset and are associated with Kidney deficiency. -Mixed excess/deficiency patterns are possible.

TCM Differential Diagnosis
Multiple causes of low back pain are possible, some of them quite serious. These have been covered in the biomedical section. One condition to keep in mind is Lin Syndrome (Painful Urination Syndrome), which can present with severe low back pain accompanied by urgent, frequent, and difficult/painful urination. In such a case, the underlying cause – in this case Painful Urination Syndrome – must be treated in order to resolve low back pain. Painful Obstruction Syndrome primarily affects the muscles and joints of the extremities, or it manifests as low back pain WITH additional pain in the joints and extremities.

TCM General Treatment Principles
Early-stage of exogenous invasion: expel pathogenic factors, open the channels and collaterals, relieve pain. Chronic low back pain: supplement the Kidney, relieve pain. Mixed excess and deficiency: treat Root and Branch simultaneously with both supplementation and invigoration.

Low Back Pain Manifesting As Cold-Damp
mild to severe cold pain with heaviness in the low back with decreased range of motion; pain is better with light exercise and heat, worse with rest and exposure to cold and dampness; one cold predominates, pain is more severe and muscles are stiffer and were contracted; when damp predominates, swelling and numbness are possible Herbal Treatment: Gan Jiang Ling Zhu Tang
 * Tongue:** white, greasy coat
 * Pulse:** deep, tight or deep, slow
 * Treatment Principles:**Dispel Cold, eliminate Dampness, warm and open the channels and collaterals, relieve pain

Low Back Pain Manifesting As Damp-Heat
mild to severe low back pain with sensation of heat in the area; possible sensation of heaviness; pain aggravated in damp, hot weather + Mu Gua (Chaenomeles fruit) 9g Luo Shi Teng (Star Jasmine stem) 12g
 * Secondary Symptoms:** bitter taste in the mouth, dark, scanty urine
 * Tongue:** red (possibly) with yellow, greasy coat
 * Pulse:** soft or slippery and rapid
 * Treatment Principles:** Clear Heat, eliminate Dampness, open the channels and collaterals, relieve pain
 * Herbal Treatment:** Si Miao Wan

Low Back Pain Manifesting As Qi Stagnation and Blood Stasis
severe, fixed, stabbing pain that may be better with light movement; pain aggravated by rest, pressure, and at night; decreased range of motion; noticeable muscle spasm; possible history of recent injury Herbal Treatment: Sheng Tong Zhu Yu Tang
 * Tongue:** dark, purplish; may have stasis macules
 * Pulse:** choppy
 * Treatment Principles:** Quicken the Blood, transform stasis, move Qi, relieve pain

Low Back Pain Manifesting As Kidney Yang Vacuity
gradual onset and long history of dull, aching pain in the low back that is aggravated by exertion and relieved by rest and pressure; possible cold sensation in low back Herbal Treatment: You Gui Wan (Right-Restoring Pill)
 * Additional Symptoms:** cold extremities, pale complexion, nocturia, low libido, sore/weak knees, possible lower body edema
 * Tongue:** pale with thin, white coat
 * Pulse:** deep, thin, weak
 * Treatment Principles:** Warm and supplement Kidney Yang, relieve pain

Low Back Pain Manifesting As Kidney Yin Vacuity
gradual onset and long history of dull, aching pain in the low back that is aggravated by exertion and relieved by rest and pressure Herbal Treatment: Zuo Gui Wan (Restore the Left Pill)
 * Additional Symptoms:** insomnia, malar flush, 5 center Heat, dry throat, sore/weak knees
 * Tongue:** red with scanty coat
 * Pulse:** thin, rapid
 * Treatment Principles:** Nourish Kidney Yin, relieve pain

Acupuncture for Low Back Pain
Main points: BL23, GV3, Hua Tuo Jia Ji, BL 25, BL26, BL28, BL30, BL32, BL54, GV4, Shiqizhuixia, Yaoyan Secondary points: other BL points, GB25, GB30 Distal points: BL40, BL60, BL57, BL58, SI3, BL62, KI3, Yaotongxue, GB34 Acupuncture for Low Back Pain
 * Local points:**

Cold-Dampness: BL40, GV3, SP9 + moxa Damp-Heat: BL40, SP9, BL28, LI11 Qi & Blood stagnation: BL40, SP10, SP6, BL17, BL32; acute sprain: GV26 Kidney vacuity: KI3, BL23, GV3, GV4, CV4, CV6, BL52 + moxa
 * According to pattern:**

Cupping Electroacupuncture
 * Ear Acupuncture:** Lumbar Vertebrae, Sacral Vertebrae, Kidney, Shen Men

Dietary Recommendations
Balaced diet, calcium, vitamins C and D (liver, eggs,milk, cheese, yogurt, fruit), proteins (meat, cheese, eggs), vitamin B contained in fish, chicken and peanuts. Maintain ideal weight, consume milk products, take a devil's claw (anti-inflammatory) supplement and B1

=Addendum: Sciatica= [Martin Kidwell, MSOM, L.Ac.Fall, 2009] Sciatica refers to pain, weakness, numbness, or tingling in the leg. It is caused by injury to or compression of the sciatic nerve. It may be sudden in onset and can persist for days or weeks. Sciatica is a symptom of another medical problem, not a medical condition on its own.

[[image:sciatica_vertebra.png width="200" height="175" align="right"]]Sciatica: Etiology
Common causes of sciatica include: -Piriformis syndrome (a pain disorder involving the narrow piriformis muscle in the buttocks) -Herniated disk -Degenerative disk disease -Spinal stenosis -Pelvic injury or fracture -Tumors -Vascular problems due to abnormalities of blood vessels in and around the spinal canal. -Other causes such as trauma, infection, and inflammation can affect nervous tissue.

//Dermatomes of Lower Extremities// People who get sciatica are usually between the ages of 30 and 50 years. Approximately 80% to 90% of people with sciatica recover over time without any surgical intervention. Sciatica: Symptoms Sciatica pain can vary widely. It may feel like a mild tingling, dull ache, or a burning sensation. In some cases, the pain is severe enough to make a person unable to move. The pain most often occurs on one side. Some people have sharp pain in one part of the leg or hip and numbness in other parts. The sensations may also be felt on the back of the calf or on the sole of the foot. The affected leg may feel weak.

Sciatica Symptoms
The pain often starts slowly. Sciatica pain may get worse: -After standing or sitting -At night -When sneezing, coughing, or laughing -When bending backwards or walking more than a few yards, especially if caused by spinal stenosis Call your doctor right away if you have: -Unexplained fever with back pain -Back pain after a severe blow or fall -Redness or swelling on the back or spine -Pain traveling down your legs below the knee -Weakness or numbness in your buttocks, thigh, leg, or pelvis -Burning with urination or blood in your urine -Pain that is worse when you lie down, or awakens you at night -Severe pain and you cannot get comfortable -Loss of control of urine or stool (incontinence)
 * Sciatica: Red Flags**

Also call if: -You have been losing weight unintentionally -You use steroids or intravenous drugs -You have had back pain before but this episode is different and feels worse -This episode of back pain has lasted longer than 4 weeks If any of these symptoms are present, your patient needs to be checked for any sign of infection (such as meningitis, abscess, or urinary tract infection), ruptured disk, spinal stenosis, hernia, cancer, kidney stone, twisted testicle, or other serious problem.

Orthopedic Tests for Sciatica:
With the patient lying down on his/her back on an examination table/or exam floor, the examiner lifts the patient's leg while the knee is straight. When performing the SLR, remember that: Sciatic pain in the leg produced from 0 to 30 degrees indicates piriformis or sacroiliac cause. Sciatica produced between 30 and 60 degrees indicates nerve root compression. Sciatic pain produced with leg motion beyond 60 degrees points to lumbosacral joint conditions. Lift the Head: Once the leg is raised to the point at which symptoms are reproduced, instruct the patient to lift his or her head, bringing the chin to the chest. If this movement is limited or increases the pain in the lower back or leg, it suggests inflammation of the nerve root.
 * Straight Leg Raise (SLR)**
 * Bragard's Sign:** If the SLR is positive, lower the leg on the affected side to just below the point of pain and quickly dorsiflex the foot. If the pain is duplicated or increased, this suggests sciatic neuritis.
 * Well Leg Raise:** The SLR is performed on the unaffected leg. If pain is referred back to the symptomatic side, this indicates nerve root compromise by an extruded disc.

Acupuncture for Sciatica
BL Channel: BL40, BL60, BL57, BL58, GB Channel: GB34, GB35, GB39 Extraordinary Vessels: SI3, BL62
 * Local points:** BL23, BL24, Hua Tuo Jia Ji (L-3 to L-5 primarily), BL32, BL54, GB30, Huan Zhong, Ashi
 * Distal points:**

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Differential Diagnosis
Sprain, strain (poor posture, mechanical factors), fibromyalgia, herniated intervertebral disc, osteoarthritis, trauma, infection, tumor, congenital defects, spondylolisthesis, spinal stenosis, visceral disease

History
OPQRST loalization, diffuse, radicular, referred Mechanics -Movement: muscular & neuro -Visceral: Constant, < night -Nerve Root Compression - disc protrusion, intraspinal tumor --valsalva (straining, coughing, sneezing) --Decrease SLR --Decrease DTR --Sensory changes

Physical Exam
Inspection: lordosis, pelvic tilt Flexion/extension/lateral bending Palpation: height of iliac crests, PSIS Tightness of paravertebral muscles Tenderness over lumbar spine, lumbrosacral joint, SI joints, sciatic nerve (halfway between greater trochanter & ischial tuberosity) ROM of hips Leg length Orthopedic tests: SLR (lasegue's) w/ Braggard's, Gaenslen's, Patrick's Neuro examination: DTR's; muscle strength - tibialis anterior, extensot digitorum longus; sensory deficits -pinprick

Imaging
-X-rays -MRI

Treatment
-Rest -NSAIDS, muscle relaxants -Heat, diathermy after acute phase -Lumbrosacral belt -Exercises -Naturo: massage, manipulation, vitamin C