Symptomatology: The Lumbar and Sacral Areas
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This is Chapter 12 from RC’s best-selling book:
“Symptomatology and Differential Diagnosis”
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Chapter 12: THE LUMBAR AND SACRAL AREAS
Low Back Pain
Low back pain has been the second most frequent health complaint in the United States for many years, second only to headaches. More lost working hours are attributed to this affliction than any other factor, and the vast majority of these complaints find their cause in biomechanical failures. These failures are often complex, accumulative, and subtly hidden by the body’s marvelous adaptive mechanisms –a diagnostic challenge when pain is solely referred.
BASIC INVESTIGATIVE APPROACH
Because of its prevalence, backache requires a meticulous consideration of all possibilities, a comprehensive case history, and a systematic examination associated with necessary laboratory data and x-ray findings. In addition, emotional factors must be considered. In eliciting the case history, the manner of onset, location and nature of pain and spasm, aggravating and relieving factors, and a thorough systems review are almost mandatory if professional justice to the patient is to be achieved.
The Lumbar Nociceptive Receptor System. The lumbar ligaments and fascia are richly innervated by nociceptive receptors. When the lumbar spine is in a relaxed neutral position, its nociceptive receptor system is relatively inactive. However, any mechanical force that will stress or deform receptors, with or without overt damage, or any irritating chemical of sufficient concentration will depolarize unmyelinated fibers and enhance afferent activity. Thus, the pain experienced after either intrinsic or extrinsic trauma can be the result of mechanical factors, chemical factors, or both.
Mechanical Pain. Normal mechanical force applied to normal tissue does not produce pain. However, abnormal mechanical deformation occurs whenever:
(1) abnormal stress is applied to normal tissues (eg, postural pain),
(2) abnormal stress is applied to abnormal tissues, or
(3) normal stress is applied to abnormal tissues (eg, soft-tissue shortening).
Pain from mechanical causes is sharp, acute, and occurs immediately. If mechanical pain does not occur until several minutes or hours after an activity, it is most likely that the position assumed following the activity is the cause of the pain rather than the activity itself.
Mechanical pain may be intermittent, appearing and disappearing, or vary in intensity according to aggravating and beneficial circumstances. It is usually intermittent because of increased and decreased mechanical deformation forces.
In cases of pain of mechanical origin, the examiner should always be able to reproduce the patient’s symptoms by test movements. Constant pain from constant mechanical deformation (eg, irreducible disc protrusion) is always possible but not common. The rule to remember is that pain of mechanical origin is always affected by movement, for better or worse.
Chemical Pain. Chemical irritants accumulate in damaged tissue soon after injury. As soon as the nociceptive receptor activity is enhanced, pain will be experienced. Chemical irritation can be the result of any inflammatory, infectious, or traumatic process of sufficient degree. It can also be the result of any abnormal metabolic by-product, especially that of ischemia, of sufficient concentration to irritate free nerve endings in involved tissues.
In contrast to pain of mechanical origin, pain from chemical causes is constant, dull, and aggravated by normal movements as long as the chemical irritants are present in sufficient concentration. It may not occur until several minutes or hours after an injurious event has taken place. Chemical pain subsides during the natural healing process as scar tissue forms. Rarely does chemical pain from trauma extend past 20 days after the precipitating accident.
Because more research has been done on the IVD than any other structure, there is a tendency to attribute almost any type of backache to some type of disc disorder. This leads to tunnel vision because many disorders, both spinal and extraspinal, may simulate disc disease. See Table 12.8. The most common causes of nondisc functional pain are postural fatigue, spinal strains (acute and chronic), and IVF syndromes. Certain pelvic disorders may also be involved such as chronic abdominal collapse, sacroiliac sprain, and coccygeal stress.
The major predisposing factors to low back pain appear to be a poor sitting posture, a loss of motion within the normal range of lumbar extension, and/or excessive hyperflexion activities. The primary precipitating factors usually involved are a sudden stress at an unguarded moment or lifting with inadequate mechanical advantage.
Common Problems in Children. Intrinsic backache is not frequent in the preadolescent. When it occurs, it is painfully acute and has its highest incidence in the thoracic or thoracolumbar spine. The typical clinical picture exhibits severe antalgic spasm, thoracolumbar hyperkyphosis, muscular tenderness, no bony tenderness, positive Lasegue’s sign, tight hamstrings, and negative roentgenographs. These signs suggest instability that is rarely confirmed by physical examination alone. Initial differentiation must be made from forgotten trauma and early Scheuermann’s disease. Relief usually comes spontaneously after rest, but idiopathic episodes may occur and then disappear with further maturation.
Common Problems in Adulthood. A loss of tissue elasticity and other signs of repeated trauma or degeneration are common during middle age. Quite frequently, psychologic stress superimposed on a biomechanical fault precipitates episodes of backache. The overt symptoms are increased by activity and relieved by rest. These must first be differentiated from the claudication-type backache and butock pain associated with aortic block, aneurysm, and spinal stenosis. After severe trauma, Helfet/Gruebel Lee describe the vertebral degenerative process as follows: compression injury fractures the end plates which leads to disc and posterior joint changes. In following years, new bone forms markedly on the posterior articular processes and this leads to spinal stenosis at the level of injury. Fixation at this level produces added stress above and below leading to extension of the degenerative arthritis and spinal stenosis.
Common Problems in Senior Citizens. In treating the fragile elderly, the cardinal concerns in both diagnosis and therapy are arteriosclerosis, demineralization, and diminished collagen. These disorders are said to seriously affect 25% of females and 18% of males over 70 years of age. Symptoms first arise in those joints under the greatest chronic stress such as at the hip joint and the T11–L1 area. The loss of systemic collagen will be most noticeable on the dorsal aspect of the hands, where the skin will appear atrophic, thin, marbled and capillary fragility will usually be apparent. Unless the metabolic defect can be corrected, progressive thoracic kyphosis, pulmonary symptoms, disc degeneration and failure, vertebral collapse, and wedge fractures can be expected.
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