There are five types of low back pain. The history is of paramount importance to uncover risk factors for serious underlying disease that requires specific evaluation by physical examination or laboratory tests. Back pain quality varies considerably, but there are features that help to distinguish anatomic sources and etiologies of back pain.
- Local pain is caused by processes that compress or irritate sensory nerve endings. They are usually due to fractures, tears, or stretching of pain-sensitive structures.The site of the pain is near the affected part of the spine. Local pain that does not vary with changes in position suggests spine tumor or infection.
- Pain referred to the spine may arise from abdominal or pelvic viscera. The pain is usually described as abdominal or pelvic as well as spinal and is often unaffected by position of the spine.This type of pain may be described occasionally as back pain only.
- Pain of spine origin may be referred to the buttocks and legs. Diseases affecting the upper lumbar spine may refer pain to the lumbar region, groin, or anterior thighs. Diseases affecting the lower lumbar spine may result in pain referred to the buttocks, posterior thighs, or rarely the calves or feet. Provocative injections into pain-sensitive structures of the spine (diskography) may produce leg pain that does not follow a dermatomal distribution. The exact pathogenesis of this "sclerotomal" pain is unclear.
- Classic radicular back pain is usually sharp and radiates from the spine to the leg within the territory of a nerve root ( "Lumbar Disk Disease").Coughing, sneezing, or voluntary contraction of abdominal muscles (lifting heavy objects or straining at stool) often elicits radiating pain. The patient notices increased pain in postures that stretch the nerves and nerve roots.Sitting stretches the sciatic nerve (L5 and S1 roots) because the nerve passes posterior to the hip. The femoral nerve (L2, L3, and L4 roots) passes anterior to the hip and is not stretched by sitting.The description of the pain alone usually fails to distinguish clearly between pain of bony spine origin and radiculopathy.
- The pain associated with muscle spasm, although of obscure origin, is commonly associated with many spine disorders. The spasms are accompanied by abnormal posture, taut paraspinal muscles, and dull pain.
Back pain at rest or unassociated with posture should raise the index of suspicion for underlying spine tumor, fracture, infection, or referred pain from visceral structures.Leg pain initiated by ambulation or standing and relieved by the sitting or supine position is suggestive of spinal stenosis. Knowledge of the circumstances associated with back pain onset are important when weighing possible serious underlying causes for the pain. Some patients involved in accidents or work injuries may exaggerate their pain for the purpose of compensation or for psychological reasons
General examination of the back
A general physical examination that includes the abdomen and rectum is advisable. Back pain referred from visceral organs may be reproduced during palpation of the abdomen (pancreatitis, abdominal aortic aneurysm) or percussion over the costovertebral angles (pyelonephritis, adrenal disease, L1-L2 transverse process fracture).
Inspection of the normal spine reveals a normal thoracic kyphosis, lumbar lordosis, and cervical lordosis. Exaggeration of these normal alignments may result in hyperkyphosis (lameback) or hyperlordosis (swayback) of the lumbar spine. Spasm of lumbar paraspinal muscles results in flattening of the usual lumbar lordosis. Inspection may reveal lateral curvature of the spine (scoliosis) or an asymmetry in the appearance of the paraspinal muscles, suggesting muscle spasm. Taut paraspinal muscles limit the motion of the lumbar spine in coronal and sagittal planes. Local back pain is often reproduced by palpation or percussion over the spinous process of the affected vertebrae.
Forward bending is frequently limited by paraspinal muscle spasm which accompanies disease of pain-sensitive spine structures. Flexion of the hips is normal in patients with lumbar spine disease (spondylosis), but flexion of the lumbar spine is limited and sometimes painful. Lateral bending to the side opposite the injured spinal element may stretch the damaged tissues, worsen pain, and result in limited motion. Hyperextension of the spine (with the patient prone or standing) is limited when nerve root compression or bony spine disease is present.
Pain from hip disease may mimic the pain of lumbar spine disease. The first movement to be limited is internal rotation of the hip. Manual internal and external rotation at the hip with the knee and hip in flexion may reproduce the pain, as may percussion of the patient's heel with the palm of the examiner's hand.
Passive flexion of the thigh on the abdomen while the knee is extended produces stretching of the L5 and S1 nerve roots and the sciatic nerve. The sciatic nerve passes posterior to the hip. Passive dorsiflexion of the foot during the maneuver adds to the stretch. Flexion to at least 80° is normally possible without causing pain, but tight hamstrings may limit motion. This straight leg-raising (SLR) sign is positive if the maneuver reproduces the patient's pain. The SLR sign may be elicited in the sitting position to determine if the finding is reproducible. The patient may describe pain in the low back, buttocks, posterior thigh, or lower leg. The crossed SLR sign is positive when performance of the maneuver on one leg reproduces the patient's pain symptoms in the opposite leg or buttocks. The nerve or nerve root lesion is always on the side of the pain. The reverse SLR sign is elicited by placing the patient in the prone position and passively extending the thigh. This maneuver stretches the L2-L4 nerve roots and the femoral nerve, which pass anterior to the hip. The reverse SLR test is positive if the maneuver reproduces the patient's pain.
The neurological examination includes a search for weakness, atrophy, asymmetric or age-inappropriate absence of reflexes, diminished sensation in the legs, and signs of spinal cord injury
Most of the cases respond well with homeopathy.
In acute sprains the best remedy that has produced wonderful results is the RHUS TOXICODENDRON. The dosage and potency is also more important . Higher potencies does show miraculous results.
Other remedies include BRYONIA;ARNICA; RUTA. Calcarea is a good remedy for chronic sprain.The inter vertebral disc prolapsed cases also responds well with homeopathy. With medicines and some good stretch exercises the complaints can be almost cured. The best remedies are PHOS;LACH;LYCOPODIUM;NUX VOM; COLOCYNTH;AESCULUS etc.
Ref: Harrison's Principle of Internal Medicine.