Frequently Asked Questions
About Diagnosis and Treatment of Low Back Pain (LBP)

1. What is the differential diagnosis of lower back pain (LBP)?
2. What are the different causes of mechanical (structural) LBP?
3. What are the nonstructural causes of spinal conditions?
4. What types of tumors grow in the spine?
5. What kinds of infection occur in the spine?
6. What type of arthritis occurs in the spine?
7. Which physicians at Advocate Lutheran General Hospital treat these types of spine conditions?
8. What types of abdominal and pelvic diseases cause LBP?
9. How many Americans have lower back pain?
10. How do you treat Acute LBP?
11. How do you localize and treat chronic LBP?
12. How do you treat patients with chronic LBP after conservative therapy fails?
13. What are the events that lead to pain due to disc degeneration?
14. Sensory neuropeptide stains have demonstrated pain nerves in which areas of the spine?
15. Stains for voltage-gated sodium channels have demonstrated pain nerves in which areas of the spine?
16. What is the rational for fusing the spine to eliminate pain?
17. Who is a candidate for percutaneous lumbar spinal fusion?
18. What are the complications?
19. How effective is surgery?
20. How do patients recover from surgery?

1. What is the differential diagnosis of lower back pain (LBP)?
Mechanical low back or leg pain: 97%
Nonmechanical spinal conditions: 1%
Visceral disease: 2%

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2. What are the different causes of mechanical (structural) LBP?
Lumbar strain or sprain: 70%
Degenerative disease of disc or facet: 10%
Herniated disc: 4%
Spinal stenosis: 3%
Osteoporotic compression fracture: 4%
Spondylolisthesis: 2%
Traumatic fracture: <1%
Congenital kyphosis or scoliosis: <1%

3. What are the nonstructural causes of spinal conditions?
Neoplasia (tumors): 0.7%
Infection: 0.01%
Inflammatory arthritis: 0.3%
Scheuermann's osteochondritis: rare
Paget's disease: rare

4. What types of tumors grow in the spine?
Multiple myeloma
Metastatic carcinoma
Lymphoma & leukemia
Spinal cord tumors
Retroperitoneal tumors
Primary vertebral tumors

5. What kinds of infection occur in the spine?
Osteomyelitis
Septic discitis
Paraspinous abscess
Epidural abscess
Shingles

6. What type of arthritis occurs in the spine?
Ankylosing spondylitis
Psoriatic spondylitis
Reiter's syndrome
Inflammatory bowel disease

7. Which physicians at Advocate Lutheran General Hospital treat these types of spine conditions?
Dr. Jerry Bauer
Dr. Dennis Spencer
Dr. Avi Bernstein
Dr. Steve Mardjetko
Dr. Sam Jaglin
Dr. Andrea Kramer
Dr. Thomas Gleason
Dr. Martin D. Herman

8. What types of abdominal and pelvic diseases cause LBP?
Disease of pelvic organs
Prostatitis
Endometriosis
Chronic pelvic inflammatory disease
Renal disease
Nephrolithiasis
Pyelonephritis
Perinephric abscess
Aortic aneurysm
Gastrointestinal disease
Pancreatitis
Cholecystitis
Penetrating ulcer

9. How many Americans have lower back pain?
2/3 of Americans have LBP: 200 million
10% of LBP is degenerative: 20 million
Recurrence is common: 40% within 6 months

Chronic LBP is a chronic problem with intermittent exacerbations, analogous to asthma, rather than an acute disease that can be cured.

10. How do you treat Acute LBP?
FIRST TWO WEEKS:
R/o cauda equina syndrome, hemodynamic instability, significant trauma, cancer, fever/infection, substance abuse, abdominal or pelvic pain, urinary retention, unexplained weight loss, unrelenting night pain, leg weakness, abdominal aortic aneurysm.
If none: conservative therapy

Conservative therapy—first two weeks:
Limited bed rest—less than two days
Aspirin/ibuprofen
Muscle relaxants may be helpful
Heat/cold
Early ambulation and exercise (progressive)
No lifting/bending
70% improved in two weeks (reassurance)

2 - 6 weeks:
Reassessment in office
Consider medication change
Order x-rays if: change in symptoms, patient is over age 50, chronic steroid use, chronic LBP
6 months without prior treatment
Physical therapy if: unable to work, chronic LBP for more than 6 months
90% improve in six weeks (reassurance)

6 weeks:
Re-examine abdomen and pelvis
Sedimentation rate and CBC
Magnetic Resonance Image

6 weeks - 6 months
Pain clinic therapies may include:
Physical therapy for more than 2 months
Consider chiropractic
Acupuncture - not of proven value
Medications can include neurontin, amytriptilline, NSAIDs
Epidural steroid injections
Back school

11. How do you localize and treat chronic LBP?

1. Facet injections may provide relief and localize pain and facet rhizotomy may effectively treat pain in ~40% of patients (Tzaan & Tasker, Can J Neurol Sci 27(2)125-130, 2000)
2. SI joint injections may effectively treat pain in ~40% of patients (Ferrante, etal, Regional Anaes & Pain Med., 26(2):137-42, 2001)
3. Discograms may help localize pain and IDET may treat pain (controversial)

12. How do you treat patients with chronic LBP after conservative therapy fails?
Consider spinal fusion surgery (several types) - depends on whether pain is due to disc disease, joint disease, number of levels involved, etc.:

• Open post lumbar fusion with iliac crest bone graft
• Open posterior spine fusion of pedicle screws (PSF)
• posterior lumbar interbody fusion (PLIF)
• anterior lumbar interbody fusion (ALIF)
• PSF and PLIF
• PSF and ALIF
• Minimally invasive techniques

13. What are the events that lead to pain due to disc degeneration?
Cascade of events:
Pain fibers have been identified in the discs and joints and ligaments of the spine using neuropeptide stains and sodium channel markers (see next paragraph). Discs degenerate due to environmental and genetic factors leading to poor disc rehydration and nutrient diffusion. This leads to breakdown of chondroitin sulfate and type II collagen, which then leads to acidosis release of inflammatory mediators and irritation of nerve fibers (Guiot & Fessler, Neurosurg)

14. Sensory neuropeptide stains have demonstrated pain nerves in which areas of the spine?
SP and CGRP sensory markers found in synovial membrane of facet joints (Giles, etal, Lancet 2:692, 1987)
SP and CGRP sensory markers found in ligamentum flavum (Ahmed, etal, Spine: 18, 2121-2126, 1993)
SP and CGRP sensory markers found in annulus fibrosis (Konttinen, etal, Spine 15: 383-386, 1990)
SP sensory marker detected in posterior longitudinal ligament (Korkala, etal, Spine 10: 156-7, 1985)

15. Stains for voltage-gated sodium channels have demonstrated pain nerves in which areas of the spine?
Particular slow inactivating channels are expressed in nociceptive sensory neurons. Antibodies to these tetrodotoxin-resistant channels have been developedSNS/PN3 and NaN/SNS2 accumulate in injured peripheral nerve terminals and may mediate chronic mechanical hypersensitivity after nerve injury and inflammation SNS/PN3 and NaN/SNS2 are found in joint capsule ligaments and lig flavum, but much less in annulus fibrosis Bucknill, etal, Spine 27:2:135-140, 2002.

16. What is the rational for fusing the spine to eliminate pain?
Lumbar instability and abnormal motion in the joints and discs have been suggested as significant contributors to nerve irritation—eliminating the motion by fusing the spine eliminates the pain.

17. Who is a candidate for percutaneous lumbar spinal fusion?
Patients with low-grade spondylolisthesis and degenerative disc disease. Patients who have failed non-surgical therapy. Patients who fulfill other specific diagnostic criteria.

18. What are the complications?
To date, we have not had infections, nerve injuries, or fusion failures with this procedure.

19. How effective is surgery?
Pain resolved: 66% of patients
Pain somewhat improved: 26% of patients
No pain improvement: 9% of patients

20. How do patients recover from surgery?
Patients:
Are in the hospital for three to four days.
Are walking in one to two days.
Take pain medication for a few weeks.
Can usually return to a sedentary job in 3-7 weeks.
Can usually swim and ride a stationary bicycle in 4-6 weeks.
Often begin physical therapy for back strengthening in 8-10 weeks.
Usually wear a brace for three months.
Can usually return to sports activities in approximately six months

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