Non-specific low back pain
The term non-specific low back pain is frequently encountered in the literature. Instead
expressions such as mechanical low back pain, simple low back pain, lumbar strain are also used
. All these concepts are confusing and vague. It is not clear whether it is used because the source of pain
cannot be found or because there is no pathology.
However, in the European guidelines, low back pain that cannot be diagnosed specifically such as infection, tumor, osteoporosis, fracture, structural deformity, inflammatory diseases, radicular syndrome or cauda equina syndrome and lasts longer than 12 weeks. Pain is defined as non-
specific low back pain. Its prevalence is 23%. 85% of patients presenting with low back pain cannot receive a specific diagnosis.
In non-specific low back pain, anamnesis and physical examination findings are variable.
There are no specific diagnostic tests. Tests and imaging are used to rule out other diagnoses
Lumbar spondylosis (calcification)
Intervertebral disc, corpus, intervertebral foramen, facet joints, lamina and
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The clinical picture that occurs with degenerative changes in the ligaments is called lumbar
spondylosis.
Most sources describe the pathophysiology and clinic of this disease based on the degenerative cascade of Kirkaldy-
Willis. The intervertebral disc in the front and the two apophyseal joints in the back, located in a spinal movement segment, are called the three-joint complex.
A change in one of these joints affects the other two. A trauma or degenerative disease that deteriorates the facet joint, eventually destroying the disc; Lesions that disrupt the disc also sooner or later disrupt the facets. Pathological
changes occurring in the three joint complexes in a segment lead to similar changes at the upper and lower levels. Thus, multi
level spondylosis develops. Clinical findings of lumbar spondylosis vary depending on the location of the pressure caused by the changes in the three joint
complex. Facet joint pain when the facet joints are affected, lumbar discopathy when the intervertebral disc is affected, and spinal stenosis when the bone and soft tissue surrounding the spinal canal are affected. profit table
Facet syndrome
The most common causes of facet syndrome are functional diseases (functional blockage
or reversible facet joint limitation due to meniscus entrapment) and degenerative
>changes.
Rarely, spondyloarthropathy, infection, tuberculosis, and synovial cyst may occur. Although facet
joints are among the common causes of chronic low back pain (15-45%), they are often overlooked. Because it creates a non-specific clinical picture. This syndrome can also cause leg pain. The mobility of the lumbar spine is reduced. Since lumbar extension
and rotation increase the load on the facet joint, especially
hyperextension and rotations are painful. There is tenderness
by pressing on the facet joint. Diagnostic maneuvers for facet joint pain are fluoroscopic facet joint injections or medial branch blocks performed with local anesthetics only. But this technique is not a widely used diagnostic tool.
Spinal stenosis (stenosis)
Spinal stenosis is often due to lumbar spondylosis. The patient may have regional symptoms such as low back pain and stiffness, or radicular symptoms described as neurogenic claudication (claudication). Single or multiple nerve roots may be affected due to narrowing in the central canal, lateral recess and
intervertebral foramina
. Neurological claudication is the most common symptom of lumbar stenosis and is caused by central canal narrowing.
It is classically defined as bilateral leg pain that begins during walking, standing for long periods of time and walking downhill.
Patients are in typical flexion posture to relax the central canal
. Extension is painful and limited. The most
valuable diagnostic method is MRI, then CT.
Spondylolysis
In spondylolysis, there is a unilateral or bilateral defect in the pars interarticularis.
Incidence is 6-8% in the general population. Upright posture and ambulation play an important role in the development of this situation. Because no cases have been reported in non-ambulatory people. Spondylolysis develops after children begin to walk. It is rare under the age of 5
, usually seen after the age of 10 r. Repetitive microtraumas can cause stress fractures in people with a congenital anatomical
predisposition.
It often affects the l5 vertebra, and its incidence decreases
as the spine moves up. It is usually seen bilaterally. Unilateral cases were reported in 15%. When it is bilateral, anterior or posterior spondylolisthesis may be seen. It is usually
asymptomatic. It is one of the common causes of low back pain in children and adolescents over the age of ten. Patients typically have low back pain that worsens with extension and is relieved with rest
or activity limitation. On physical examination, local
tenderness, pain with lumbar extension and tension in the hamstrings may be observed. Neurological
examination is usually normal. Radiological examination
should be performed in a suspected pars defect. Anterioposterior, lateral, 45 degree right and left oblique films and collimated
lateral films should be taken. And with these radiographs, a pars defect is detected with a 95% probability. Oblique
images reveal the 'Scottish Dog' appearance of the lumbar vertebrae and the pars
defect is seen as a collar around the dog's neck. Computed tomography is the technique that best displays the pars
defect.
Spondylolisthesis (lumbar slippage)
Spondylolisthesis is the forward slippage of a vertebra on the one below it
is called. Sliding usually occurs forward.
If it occurs towards the back, it is called retrolisthesis. Spondylolisthesis is divided into six types. The isthmic
type is the most common. It occurs due to spondylolysis or stress fracture of the pars interarticularis
. It is most commonly seen in L5. Classifying it as low grade or high grade is important for the treatment plan. The slip below 50% is defined as low grade, and the slip above 50% is defined as high grade. Most low grade patients
are asymptomatic. Symptomatic patients have low back pain. Sometimes there may also be radicular pain
. There is palpable stepping at the slip site. Flexion is often clear
and painless, but extension and rotations are painful and limited. Lateral radiography is the imaging method frequently used and the degree of shift is calculated. Slip between 1-5
degree is criticized. It is evaluated whether it is stable in flexion/extension lateral radiographs
. Tomography and MRI are other radiological imaging methods used in diagnosis.
Spondyloarthropathies
Spondyloarthropathies (SpA) share many clinical features and genetic predisposition
It is a group of diseases. These include ankylosing spondylitis, reactive arthritis,
psoriatic arthritis, spas with inflammatory bowel disease (ulcerative colitis,
Chron's disease), undifferentiated spas and juvenile-onset spas.
Spondyloarthopathies are characterized by inflammatory low back pain and sacroiliitis, peripheral arthropathy,
lack of rheumatoid factor, subcutaneous nodule, enthesis, extra-articular or extra-
spinal involvement. . It is associated with the HLA-B27 allele. Ankylosing spondylitis
It is the most common and typical form of spondyloarthropathies. Its prevalence is 0.2-1.2%.
Low pain caused by spondyloarthropathy is different from the characteristics of pain caused by lumbar discopathy
. Pain in the hips and waist is especially evident in the second half of the night. Unlike mechanically induced low back pain, morning stiffness is prominent. Pain decreases with exercise. On physical examination, spinal mobility is restricted and sacroiliac compression tests may be positive. In addition, patients
other musculoskeletal involvements such as arthritis and enthesitis, which can be observed in spondyloarthropathies, and
symptoms and examination findings regarding the involvement of non-musculoskeletal systems may also be present
.
Spinal fractures
Most spinal fractures are secondary to trauma. The frequency of non-traumatic vertebral fractures increases with increasing life expectancy. Because
The risk of osteoporosis and metastasis is higher in the elderly population.
Compression fractures due to osteoporosis are an important cause of low back pain.
Fractures may also be asymptomatic. Sometimes it can start as a severe pain. In case of suspicion of fracture, palpation of all vertebrae and neurological examination should be performed. Radiography,
tomography, MRI are the imaging methods used.
Spinal infections
Spinal infections are rare pathologies, but in recent years Its incidence
is also increasing. The reason for this may be the increase in average life expectancy and the resulting increase in factors that increase susceptibility to infection and increased diagnostic accuracy.
If the infection affects the disc, the term spondylodiscitis is used, and if it affects the end plate and vertebral body, the term osteomyelitis or spondylitis is used. Because the specificity of symptoms and findings is low, diagnosis is delayed by 2-6 months. Non-specific low back pain is usually the first symptom, but 15% of patients may not have pain. The pain begins insidiously
It gets worse, especially at night. Fever is not common. Neurological findings may be present in 1/3 of the patients. Sediment analysis is sensitive but has low specificity. Crp is also high. Wbcin
sensitivity is low. The specificity of radiography is low. Irregularity in the vertebral end plates and narrowing of the intervertebral disc space are observed.
Soft tissue swellings
Priformis Syndrome: It occurs due to prolonged contraction of the Priformis muscle.
Due to its proximity to the sciatic nerve, it occurs in the hips, hip joint and lower extremities
There may be pain. Piriformis syndrome is responsible for 5-6% of patients with sciatic pain.
Palpation of the piriformis muscle and sensitivity of the trigger point are seen in 59-
92% of patients. Freiberg maneuver forces the patient's thigh into forced internal rotation in the supine position.
The presence of pain means that the test is positive.
It is positive in 56.2% of the patients. In the Pace maneuver, while the patient is sitting, the thigh is abducted and externally rotated against resistance
and the presence of pain and weakness means that the test
is positive.
Greater trochanteric pain syndrome
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It is a term used for pain in the greater trochanter, hip and lateral aspect of the thigh. Any disease in the peri-trochanteric area around the hip may cause
. Trochanteric bursitis, gluteus medius and minimus muscle and tendon tears are some of the causes of major trochanteric pain syndrome. On examination, there is widespread
sensitivity in that area. MRI, bone scintigraphy and plain radiography are used for diagnosis.
Iliotibial band syndrome
The most common symptom is lateral knee pain.
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