Professional Documents
Culture Documents
185
186 CHAPTER 13
steroid therapy may help to give transient pain mobilizing despite adequate relief with bed rest.
relief, the limited benefit is probably outweighed In this group of patients physiotherapy and a
by the possible complications of corticosteroid limited trial of a spinal brace might be tried, but
treatment. they usually have only limited success.
Chemonucleolysis has, in the past, been advo-
cated as a treatment for lumbar disc prolapse. It Neurological deficit. A significant weakness or in-
involves the intradiscal injection of a proteolytic creasing amount of weakness is an indication for
enzyme, such as chymopapain, which dissolves early investigation and surgery.
disc material. Chymopapain was first isolated in
1941 and has been used intermittently since 1963 Central disc prolapse. Patients with bilateral sciati-
in clinical studies. There is a small risk of serious ca or other features indicating a central disc
anaphylactic reaction following intradiscal injec- prolapse, such as sphincter disturbance and di-
tion. Although chymopapain dissolves the nor- minished perineal sensation, should be investi-
mal nucleus pulposus it has a high failure rate in gated promptly. An acute central disc prolapse
the treatment of prolapsed disc, as it fails to affect may lead to acute, severe, irreversible cauda
the extruded disc material, and further nerve equina compression and should be investigated
compression may occur following chemonucle- and treated as an emergency.
olysis from the disc dissolving and collapsing, re-
sulting in narrowing of the intervertebral neural Tumour. Surgery is indicated if the clinical fea-
foramen. The procedure is not recommended for tures suggest that a tumour could be the cause of
use at this time. sciatica.
(a) (b)
Fig. 13.3 Lumbar myelogram using water-soluble contrast medium showing (a) posterolateral L4/5 disc
prolapse and (b) complete block due to a large central L5/S1 disc protrusion.
190 CHAPTER 13
radiological evaluation to exclude fracture or clinician to the possibility of a more sinister basis
disc herniation (if severe trauma) for the back pain.
conservative management with initial bed rest Intra-abdominal pathology should also be con-
followed by gentle mobilization and simple anal- sidered in patients presenting with back pain,
gesic medication. especially:
Most of the pain and stiffness should settle pancreatic disease pancreatitis or tumours
after a few days, although mild discomfort may aortic aneurysm
linger for some weeks. renal disease calculus, infection or tumour.
The more difficult problem is chronic or recur- Lumbar spondylosis, a degenerative disease
rent back pain, where the patient gives a history involving the vertebral column, is the most
of less severe or even trivial trauma. In some common demonstrable cause of low back pain.
cases no pathological cause will be found. The The arthritic process may involve any of the
most common aetiology is degenerative disease spinal joints and be associated with degenera-
which includes: tive disc disease. Low back pain, without fea-
lumbar spondylosis tures of sciatica, is only rarely caused by disc
spondylolisthesis prolapse, and then only if the prolapse is large
degenerative disc disease. and central.
Other uncommon but important causes of low
back pain which, in the early stages, may present
Spondylolisthesis
without pain radiating into the legs or radicular
signs, include: Spondylolisthesis is a subluxation of one verte-
spinal tumours (Chapter 15) bral body on another, usually involving the L4 or
thoracic disc prolapse (Chapter 15) L5 levels, and may be due to congenital defects
spinal abscess (Chapter 15) involving the neural arch or to degenerative
arteriovenous malformation (Chapter 15). changes. Spondylolysis describes a defect in the
These serious but unusual causes may present pars interarticularis, often the precondition for
with acute or chronic back pain but nearly always spondylolisthesis (Fig. 13.10).
have other features, e.g. symptoms or signs of Various classifications have been used to
nerve root involvement, which would alert the categorize spondylolisthesis; most subdivide the
(a)
Congenital
Dysplastic Congenital deficiency of superior facet of sacrum or inferior facet of 5th lumbar vertebra
Isthmic Lesion in pars interarticularis
Lytic fatigue fracture
Elongated but intact pars
Acute fracture
Degenerative In adults, usually at L4/5; a cause of lumbar canal stenosis
Traumatic