Lumbago (Low Backache)

Definition

Classification

1. Acute lumbago: duration less than 6 weeks
2. Subacute lumbago: 6 to 12 weeks
3. Chronic lumbago: persisting for more than 12 weeks

• Mechanical or non-specific low back pain
• Radicular pain due to nerve-root compression
• Specific spinal pathology, such as infection, fracture, malignancy, or inflammatory disease
• Referred pain from abdominal, pelvic, renal, or vascular disease

Etiology

A. Mechanical causes

• Lumbar muscle or ligament strain, often after lifting weight, twisting, prolonged bending, or bad posture
• Myofascial pain with paraspinal muscle spasm
• Degenerative disc disease
• Lumbar spondylosis
• Facet joint arthropathy
• Sacroiliac joint dysfunction
• Intervertebral disc prolapse
• Spondylolysis and spondylolisthesis
• Lumbar spinal stenosis

B. Inflammatory causes

• Ankylosing spondylitis and other axial spondyloarthropathies
• Rheumatoid or psoriatic arthritis
• Sacroiliitis

C. Infective causes

• Vertebral osteomyelitis
• Discitis
• Spinal tuberculosis, also called Pott disease
• Epidural abscess

D. Neoplastic causes

• Vertebral metastasis
• Multiple myeloma
• Primary spinal tumours

E. Traumatic and metabolic causes

• Vertebral compression fracture, especially in osteoporosis
• Trauma
• Paget disease of bone

F. Referred pain

• Renal colic or pyelonephritis
• Pancreatitis
• Peptic ulcer disease
• Pelvic inflammatory disease or endometriosis
• Abdominal aortic aneurysm
• Prostatic disease

Predisposing Factors

• Heavy manual work and improper lifting
• Obesity
• Sedentary lifestyle and weak trunk muscles
• Poor posture
• Repeated vibration, for example long driving
• Smoking
• Psychological stress, anxiety, and sleep disturbance
• Pregnancy
• Increasing age and degenerative spinal disease

Clinical Features

Symptoms

• Pain in lower lumbar region, which may be sudden or gradual in onset
• Pain worsened by movement, bending, lifting, coughing, or prolonged standing
• Stiffness and restricted movements of the back
• Paraspinal muscle spasm
• Pain may radiate to buttock or thigh

Features suggesting nerve-root involvement

• Shooting pain down the leg
• Tingling or numbness
• Weakness of foot or ankle
• Positive straight-leg raising test

Red-Flag Symptoms and Signs

Examination

General examination

• Observe gait, posture, spinal curvature, and ability to stand or walk.
• Look for fever, weight loss, skin lesions, deformity, or signs of systemic illness.

Local spinal examination

• Inspect for scoliosis, kyphosis, swelling, or muscle wasting.
• Palpate for localized tenderness, paraspinal spasm, and sacroiliac tenderness.
• Assess range of movement: flexion, extension, lateral bending, and rotation.

Neurological examination

• Straight-leg raising test and crossed straight-leg raising test
• Motor power in lower limbs
• Sensory examination in dermatomal distribution
• Deep tendon reflexes:
  • Knee jerk: L3-L4
  • Ankle jerk: S1
• Check plantar response.
• Assess perianal sensation and anal tone if cauda equina syndrome is suspected.

Investigations

Basic investigations

• CBC, ESR, CRP: if infection, inflammatory disease, or malignancy is suspected
• Urine examination: if renal disease is suspected
• Serum calcium, alkaline phosphatase, protein electrophoresis: when metabolic bone disease or myeloma is suspected

Imaging

1. X-ray lumbosacral spine
   • Fracture
   • Spondylolisthesis
   • Degenerative changes
   • Vertebral collapse
2. MRI lumbosacral spine
   • Best for disc prolapse, nerve compression, infection, tumour, cauda equina syndrome, and spinal stenosis.
3. CT scan
   • Useful for detailed bony anatomy or when MRI cannot be done.

Management

1. General measures

• Reassure the patient that most acute non-specific low back pain improves.
• Encourage continuation of ordinary activity as tolerated.
• Avoid prolonged bed rest.
• Advise proper posture and avoidance of heavy lifting during the acute phase.
• Apply local heat or cold for symptomatic relief.

2. Physiotherapy and rehabilitation

• Gradual mobilization
• Lumbar stretching exercises
• Core strengthening and trunk-stabilization exercises
• Aerobic exercise, such as walking or swimming
• Correction of posture and ergonomic advice
• Weight reduction where appropriate

3. Drug treatment

• NSAIDs may be used at the lowest effective dose for the shortest possible period, after considering gastrointestinal, renal, hepatic, and cardiovascular risks.
• A short course of a muscle relaxant may be considered in selected patients with marked spasm.
• Weak opioids may be considered only for short-term acute pain if NSAIDs are unsuitable or ineffective.
• Avoid long-term opioid therapy.
• Paracetamol alone is not recommended for routine management of low back pain according to NICE.

4. Interventional and surgical treatment

• Epidural steroid injection for acute severe radicular pain or sciatica in appropriate cases
• Radiofrequency denervation in selected chronic facet-mediated pain after diagnostic confirmation
• Surgical decompression or discectomy for persistent disc prolapse with disabling radiculopathy, progressive neurological deficit, or cauda equina syndrome
• Stabilization surgery for selected instability or spondylolisthesis cases

Prevention

• Maintain ideal body weight.
• Regular walking, exercise, and core-strengthening programme.
• Use correct lifting technique: bend knees, keep the load close to the body, and avoid twisting.
• Avoid prolonged sitting and take regular breaks.
• Maintain ergonomic chair, desk, and work-station setup.
• Stop smoking.
• Treat anxiety, sleep problems, and occupational stress where relevant.

Prognosis

Recent evidence note