mechanical back pain_
Although usually suspected following history taking, clinical examination and the study of appropriate radiographs, the diagnosis is made largely by a process of elimination: it is back pain which is not due to a prolapsed intervertebral disc or any other clearly defined pathology. The patient is usually in the 20^15-year age group, and complains of dull backache aggravated by activity. There is often a history of morning stiffness which is gradually relieved as the patient moves about. Physical signs are often slight, and extensive radiation of pain and positive neurological signs are not a feature.
Acute cases may be precipitated by a traumatic incident, such as the flawed lifting of a heavy weight, a fall, or a head-on impact pattern road traffic accident. There may be intense protective muscle spasm. As far as treatment is concerned, analgesics should be prescribed for a short period and prolonged bed rest should be avoided. An early return to work should be encouraged, even in the presence of some degree of residual pain. Physiotherapy should be started after a week if symptoms are still marked.
In the majority of cases symptoms resolve completely over a 4-6-week period. In a number of cases, however, symptoms become prolonged, with the impatient sufferer often trying any of the large number of alternative medicine treatments now so widely available.
In chronic cases there is often a long history of intermittent low back pain over a number of years. The cause is often obscure, although degenerative changes in the spine are not uncommonly present. Resistance to treatment is a frequent problem, and many are ultimately referred to pain clinics. Sometimes a change of employment to work of a lighter character may have to be contemplated.
In patients with this complaint of pain in the coccygeal area there is often a history of a fall in the seated position on to a hard surface; consequently, in a number of cases radiographs may reveal a fracture of the end piece of the sacrum, or show the coccyx to be subluxed into the anteverted position. Symptoms of pain on sitting and defecation are often protracted for 6-12 months, but tend to resolve spontaneously. It was formerly thought that if symptoms proved persistent either a disc lesion in the lumbar spine (with distal referral) or a functional problem was likely to be the problem, but this is now discounted.
In stubborn cases conservative treatment should invariably be first employed: 60% of cases respond to local injections of steroids, and 85% to the injection of a long-acting local anaesthetic followed by manipulation. If there is complete failure to respond to a substantial period of conservative treatment (this occurs in about 20% of cases), excision of the coccyx is reported as being successful in 80% of cases.
commoner causes of back complaints in the various age groups__________
Scoliosis Spondylolisthesis Pyogenic or tuberculous infections Calve's disease Scheuermann's disease Scoliosis (idiopathic and postural) Mechanical back pain Adolescent intervertebral disc syndrome Pyogenic or tuberculous infections Young adults Mechanical back pain
Prolapsed intervertebral disc Spondylolisthesis Spinal fracture Ankylosing spondylitis Coccydynia
Middle-aged Mechanical back pain, including primary osteoarthritis Prolapsed intervertebral disc Scheuermann's disease and old fracture Spondylolisthesis Rheumatoid arthritis Spinal stenosis Paget's disease Coccydynia Spinal metastases Pyogenic osteitis of the spine Elderly Osteoarthritis, primary and secondary
True senile kyphosis Osteoporosis, with or without fracture Osteomalacia, with or without fracture Spinal metastases
8.1. Inspection from the side (1): Ask the patient to stand. Look at the spine from the side. Although normal posture is difficult to define, try to make an assessment of the thoracic curvature, noting whether the curve is quite regular and if it appears to be increased.
8.2. Inspection (2): It is valuable to know whether the thoracic spine is mobile, especially if there is a kyphosis. Ask the patient to bend forward, carefully examining the How of movement in the spine, and whether the curvature increases. As the range of flexion in the thoracic spine is small it may also help to check rotation, which is the main movement occurring in the thoracic spine (see later).
8.3. Inspection (3): Now ask the patient to stand upright and brace back the shoulders to produce extension. An increased curvature (kyphosis) which is regular and mobile is found in postural kyphosis.
8.4. Inspection (4): If a regular but fixed kyphosis is found, the commonest causes are senile kyphosis (sometimes with osteoporosis, osteomalacia or pathological fracture), Scheuermann's disease and ankylosing spondylitis.
8.5. Inspection (5): If there is an angular kyphosis, with a gibbus or prominent vertebral spine, the commonest causes are fracture (traumatic or pathological), tuberculosis of the spine, or a congenital vertebral abnormality.
8.6. Inspection (6): Note the lumbar curvature. Flattening or reversal of the normal lumbar lordosis is a common finding in prolapsed intervertebral disc, osteoarthritis of the spine, infections of the vertebral bodies and ankylosing spondylitis. Flexion of the spine, hips and knees (simian stance) is suggestive of spinal stenosis.
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