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2) Ankylosing spondylosis: 
In ankylosing spondylitis chronic inflammation progressing slowly to bony ankylosis of the joints of the spinal column and occasionally of the major limb joints. 

Cause: Unknown. There is strong hereditary link to the HLA-B 27 gene (90 %) 
Pathology:
The disease always begins in the sacroiliac joints, and then extends upwards to involve the lumbar, thoracic and often cervical spine. The articular cartilage, synovium and ligaments show chronic inflammatory changes and eventually become ossified. 
Clinical features:
Patient is usually young man. The symptoms are pain in the lower back and increasing stiffness. Later the pain migrates upwards  
On examination there is marked limitation of all movements in the affected area of the spine—‘ poker back’.
Morning stiffness or increasing stiffness after a period of inactivity is one of the important finding seen in ankylosing spondylitis.
When the thoracic region is involved chest expansion is markedly reduced – often less than 2.5 cm (normal 7.5 cm) from ankylosing of the costo- vertebral joints. 
Investigation: 
X – ray findings are destruction and obliteration of sacro-iliac joints and formation of “bamboo spine”. The intervertebral joints in the lumbar, thoracic and cervical region undergo bony ankylosis with prominent anterior bridging of the vertebral bodies. The entire spine become imobilised often in a flexed position and usually the pain then subsides.  
ESR increased while the disease is active. 
Test for HLA-B 27 antigen + ve.
Diagnosis:
Marked limitation of spinal movements, reduced chest expansion, the typical radiological features and the raised E.S.R. are diagnostic. 
Complication:
Usually ceases to progress after 10 to 15 years, leaving permanent stiffness. Fixed flexion deformity of the spine, recurrent respiratory tract infection and iridocyclitis are other complications. 

Homoeopathic medicine:  
Aesculus Kalmia 
Conium mac   Nat mur
Rhus tox 
Agaricus Causticum
Kali carb 

3) Rheumatoid arthritis (R.A) 
  R.A. often affects the cervical spine particularly atlanto-axial articulation. Pain, stiffness and limitation of movements are then in the neck and back of head. [Unlike ankylosing spondylitis, R.A is rarely confined to the spine because of the major affection of other joints.] 
In advanced stages of the disease, one or several of the vertebras may be displaced anteriorly or synovitis of the atlanto-axial joint may damage the transverse ligament of the atlas resulting in forward displacement of the atlas on axis i.e. atlanto-axial subluxation. Here serious and life threatening compression of spinal cord may occur gradually or suddenly.

 MECHANICAL DERANGEMENTS 

1) Prolapsed lumbar disc  
prolapsed lumbar disc is the major cause of severe, chronic or recurrent low back and leg pain. Herniation of part of a lumbar inter vertebral disc is a common cause of combined back pain and sciatica.
Causes: Often precipitated by injury. Spontaneous age degeneration of the disc is another important precipitating factor.
Disc between L5 and S1 most commonly affected. Then L4 and L5 rarely L3 and L4. [IVDP rare in thoracic region. Next frequent in cervical region and most common in lumbar region. In cervical region – frequent between 8th and 7th and 5th and 6th cervical vertebra]   

Pathology:
The part of the gelatinous nucleus pulposus protrudes through the annulus fibrosus at its weakest position, which is posteriolateral or sometimes torn annulus itself protrudes backwards. If it is small, protrusion bulges the pain sensitive posterior longitudinal ligament and causing pain in back. If it is large, the protrusion herniates through the posterior ligament and may impige up on issuing nerve to cause sciatic pain. Herniation of intervertebral disc usually affects the roots below the level of the disc. i.e. L4 – L5 disc affects the L5 root
L5 –S1 disc affects the S1 root
(Natural healing is by shrinkage of fibrosis of the extruded disc materials; not by its reposition with in the disc.) 
Clinical features:
Backache, abnormal posture and limitation of movements. Nerve root involvement is indicated by radiating radicular pain, which is usually felt as unilateral sensory disturbances [paraesthesia, hyperesthesia or hypalgesia and impairment of ankle jerk or rarely of quadriceps reflex L3, L4.) 

Symptoms and signs of disc protrusion: 
1. L5 –S1 (affects the S1 root)
a) Radicular pain, paraesthesia and or sensory loss in lateral leg, foot, sole and 4th and 5th toes.
b) Weakness or atrophy of gastronemius and extensor digitorum brevis.
c) Ankle jerk diminished
d) SLR positive. 
2. L4 –L5 (affects the L5 root)
a) Radicular pain, paraesthesia and or sensory loss in dorsum of foot and great toe.
b) Weakness or atrophy of peroneals and extensor hallucis longus.
c) Reflex no change.
d) SLR positive. 
4. L3 –L4 (affects L4 root)
a) Radicular pain, paraesthesia and or sensory loss in medial leg and arch of foot.
b) Weakness or atrophy of quadriceps.
c) Knee jerk diminished.
d) SLR may be positive. 
Generally pain aggravated by coughing or sneezing etc. Bladder and bowel symptoms indicate lesion in conus medullaris of spinal cord or in cauda equina. But large central disc protrusion may also impair these functions. 
On examination:
1. Forward flexion and extension greatly restricted.
2. Lateral flexion is usually free and painless.
3. SLR is restricted on the affected side.
4. Muscle wasting and weakness in the distribution of the affected nerve and the corresponding tendon jerk is impaired or absent. 

2) Acute lumbago 
Lumbago is a symptom rather than a disease. In a typical attack of acute lumbago the patient suddenly seized with agonizing pain in the lumbar region of the spine, usually while stooping, lifting, turning or coughing. With rest the pain gradually subsides but in some cases acute pain is succeeded by sciatica-due to irritation of lumbar or sacral nerve. 
Pathogenesis is not clear. There may be more than one cause. In many cases the underlined lesion is
1. IVDP or
2. Sudden nipping of synovial membrane in one of the facet joint or
3. Momentary subluxation with consequent ligamentous strain especially at intervertebral joint. 
Treatment:
v Provide rest for the spine- either by recumbancy or by plaster jacket.
v Because of the frightening severity of the pain confidence reassurance may be needed. 
Homoeopathic medicine:
Aesculus Agaricus Bryonia Hypericum ,Baryta carb Colocynth Tellurium,Arnica Kali carb, Mag phos Ruta ,arentula Zincum met

3) Spondylolysis 
Here there is defect in the neural arch of the fifth lumbar vertebra (rarely 4th). There is loss of bony continuity between the superior and inferior articular process – the deficiency being bridged by fibrous tissues.
Clinically spondylolysis (defect without displacement) is often symptomless. But it is some times a cause of deep low back pain. 

4) Spondylolisthesis 
Spondylolisthesis is the term applied to spontaneous displacement of a lumbar vertebral body up on the segment next below it. Displacement is usually forward but may be back wards – retro spondylolisthesis.  
Causes:
1. Congenital malformation of articular processes.
2. Spondylolysis.
3. OA of the posterior facet joints. 
Pathology:
In normal spine, forward displacement of a vertebral body is prevented by engagement of its articular process with those of the segment next below it. In spondylolisthesis there is failure of this check mechanism and the attachment of the intervertbral disc alone are not strong enough to hold the vertebral bodies in alignment.
Congenital:
 Congenital spondylolisthesis is least common. This defect occurs most often at lumbo-sacral joint. The posterior intervertebral joints are unstable because the articular processes are congenitally malformed or even rudimentary, thus they form no bar to forward displacement of the spinal column. The whole lumbar vertebra displaced up on the first sacral segment and the cauda equina may be trapped between the body of sacrum and the lamina of the displaced 5th lumbar vertebra and hence there is a severe neurological disturbance. 
Due to spondylolysis:
Due to a defect in the neural arch of the vertebra allows separation of its two halves. The body and superior articular processes have slipped forward leaving spinous and inferior articular processes in normal relationship with sacrum. 
Due to O.A of facet joints:
Facet joint become unstable due to OA with degeneration and thinning of the articular cartilage. It may occur at any level in the lumbar spine- most commonly – between 4th and 5th lumbar vertebra. This type vertebral displacement is occasionally backward rather than forward. 

Clinical features:
Clinical features depends on
1. Nature of the causative lesion and
2. Degree of displacement. 
Patient is usually an adolescent or young adult in spondylolisthesis due to congenital malformation of articular processes and spondylolysis.
Patient is usually beyond middle age in spondylolisthesis is due to OA of the posterior facet joints.
Patients have chronic backache with or without sciatica. The pain is worse on standing.  
On examination:
There is a visible or palpable step above the sacral crest, due to forward displacement of the spinal column.
In severe displacement – lumbar vertebral bodies may be palpable through the abdominal wall.
SLR positive.
X-ray shows the displacement.  
Homoeopathic medicines: 
Arnica Bryonia Calc carb Rhus tox  
Colocynth Ruta,Calc flour Causticum Hypericum Lycopodium
Nux vom Phosphorus Strontium carb Sulphur .Zincum met

5) Spinal stenosis 
The dimension of the lumbar spinal canal varies in different individual. In some person, there is a congenital narrowing of the canal, though it provides adequate room for the cauda equina in the absence of other pathology. The canal become further narrowed from secondary causes (like osteophytes formation about the facet joints or bulging of an intervertebral disc.) the normal functioning of the nerves of the cauda equina will be impaired by lack of room and constriction of their blood supply.
Clinical features:
Heavy aching sensation in back, in one or both lower limb after walking. 3/4 of patients have this aching sensation while sitting or by lying with the hips and knees drawn up in a sitting poster.

TUMORS OF THE SPINE 

Tumors of spinal column –two types
1. Benign –Chondroma, Haemangioma etc.
2. Malignant
a) Primary– sarcoma, multiple myeloma etc
b) Metastatic tumors from breast, lung, prostate etc. 
Tumors cause compression of cauda equina or spinal cord  
Clinical features:
Clinical features may vary according to their site and character. 
Effects of tumor:
1. Local destruction of the skeliton
2. Compression of the spinal cord
3. Interference with peripheral nerve. 
Diagnosis: X-ray
CT and MRI
(Other tumors of the trunk like tumors of the pelvic girdle [chondroma] may also cause pain in low back) 
Homoeopathic medicines:
Lachesis
Tarentula  

CHRONIC STRAIN 

a) Chronic lower lumbar ligamentous strain or postural back pain:
Postural back pain is characterized by persistent backache without demonstrable pathology (most common condition seen in orthopedic practice) 
Cause:
It is assumed that the spinal muscle fails in their function of protecting the deep ligaments in maintaining poster. 
Predisposing causes:
1. Child birth
2. Overweight
3. General flabbiness of muscle and
4. Debilitating illness.
(Common in occupants of a car struck from behind by another vehicle)  
Clinical features:
More common in women. She often dates the onset of pain from childbirth. Sometimes from an operation or from a debilitating illness.
 The pain is characteristically in the lumbar or lumbosacral region. Worse on activities like stooping.
On examination:
Restriction of spinal movements.
X ray normal
Diagnosis depends up on the exclusion of demonstrable pathologic lesion by careful clinical X –ray examination. 
b) Coccydynia 
Painful condition in the region of coccyx. Persistent pain continues for many weeks or months after a local injury with out any demonstrable pathology. 
Cause:
Injury – usually a fall on tail. 
Pathology:
There is strain of the sacrococcygeal joint or contusion over the periosteum over the lower sacrum or coccyx or crack fracture of the coccyx or sacrum. 
Clinical features:
Pain in sacro-coccygeal area when sitting. There is also pain on defecation. Free from pain when standing or lying.
On examination:
Tenderness over sacro-coccygeal region. 

MISCELLANEOUS 
Senile osteoporosis: 
Clinical features:  Aching pain. Kyphosis. Liability to compression fracture of vertebral bodies and marked rarefaction of the bones of the spinal column.

DISORDERS OF THE SACRO-ILIAC JOINTS 
1. T.B. Of sacroiliac joints.
2. Ankylosing spondylitis of S.I.joints.
3. Other forms of S.I. joints arthritis like pyogenic arthritis, R.A.,O.A etc.
4. Sacro-iliac ligamentous strain: patient is usually adult. The symptoms are often noticed first after a major injury of the pelvis or after childbirth. Pain localized to sacroiliac joints. Pain aggravated by twisting the trunk. 
On examination:
Good range of spinal movements with pain only at the extremes. Forcible stress applied to the pelvis or by extending one hip while the other is held fully flexed, reproduces the pain. No neurological sign. No X-ray abnormalities. 

OTHER LOCAL AFFECTION OF THE BONE 
1. Scheurmann’s kyphosis or adolescent kyphosis:  Not common.  
2. Calve’s vertebral compression or vertebra plana: Uncommon.
 
Lesion of nerve root or radicular pain 
Causes of lesion are –distortion, stretching, irritation and compression of spinal root etc. Spinal stenosis is another cause of nerve root lesion.
 Various manoeuver, which increase the irritation of the root, may greatly intensify the pain. Pain is usually lancinating in character. Cough, sneeze and strain are characteristic evocative maneuver. 
Radicular pain has certain differences from referred pain from deeper structure. These differences are
1. Radicular pain has greater intensity.
2. Distal radiation
3. Circumscription to the territory of root
4. There are certain factors which excite pain 
 
Referred pain 
Two types
1. Pain that projected from spine into the region lying with
in the area of the lumbar and upper sacral dermatomes. Pain due to disease of upper part of the lumbar spine is usually referred to the anterior aspect of the thighs and legs. Pain due to disease of the lower part of the lumbar and sacral segment is referred to the gluteal region, posterior thighs, and calves and sometimes to feet. 
2. Pain that projected from pelvic and abdominal viscera
Pelvic diseases—refer pain to sacral region
Lower abdominal diseases—to the lumbar region [L3-L5]
Upper abdominal diseases- to lower thoracic and upper lumbar region
 [T10- L2]  
In case of pain that projected from pelvic and abdominal viscera, there is no local sign or stiffness of back. This pain unaffected by movement of the spine and does not improved with recumbency and may be modified by the activity of the involved viscera. [Exception- aortic aneurysm – slowly enlarged aortic aneurysm may erode the antero- lateral spine and produce discomfort that changes with movement or recumbancy]  
Lower thoracic and upper lumbar pain: 
 Peptic ulcer, tumor of the posterior wall of the stomach and of the duodenum (particularly if there is retroperitonial extension) the pain may be felt in the region of spine T10 -- L2.
Pain due to peptic ulcer – appears about 2 hours after a meal.
Diseases of the pancreas (peptic ulceration with extension to the pancreas, cholecystitis with pancreatitis, cyst or tumor) are apto cause pain in the back. Head of pancreas- pain more on right of spine. Tail of pancreas – pain more on left of spine.  
Lumbar pain: 
Inflammatory disease of the colon (ulcerative colitis, diverticulitis) or tumor of the colon --- mid lumbar pain. Very severe pain may have a belt like distribution around the body. 
Transverse or first part of descending colon—left sided 2nd or 3rd lumbar vertebral pain. 
Sigmoid colon – lower lumbar. 
Sacral pain (urologic and gynaecologic) 
In pelvic disease, chronic pelvic inflammatory disease, endometriosis, or carcinoma ovary or uterus in woman may cause sacral pain. Menstrual pain itself may be felt in the sacral region.
Most important source of chronic back pain from the pelvic organ is thought to be the utero-sacral ligament. Endometriosis or ca uterus may invade this structures; malposition of the uterus may cause traction on it. Pain is localized centrally in the sacrum below the lumbo- sacral joint.
In endometriosis the pain begins during premenstrual phase and often continues until it merges with menstrual pain.
Malposition (retroversion or prolapse) sacral pain especially after standing for several hours.
 X – ray therapy of pelvic tumors may produce sacral pain from necrosis of tissues and injury to nerve roots.
Chronic prostatitis or ca prostate – sacral pain with other symptoms like increased frequency of urination, prostatic discharge etc. Ca prostrate metastasis to lower spine. Then the pain lumbar or sacral region. 
Renal disease—pain is ipsilateral, being felt in the flank or lumbar region.
Aortic descending aneurysm – thoracic or lumbar pain.
Backache arising after childbirth may sometimes be due to sacro- iliac or lumbo-sacral strain or even prolapsed intervertebral disc.
Any backache higher than the first sacral vertebra is unlikely to be of gynaecological origin.
Backache before and during menstrual periods may be due to hormonal (due to relaxant effects of progesterone on smooth muscle and ligaments in general) or it may due to orthopedic lesion, excluded by x-ray of the spine and sacroiliac joints.
Towards the end of the day patient may complain of vague mid sacral discomfort by rest and recumbancy due to utero- sacral strain.  
Obscure types of low backache: 
There are a group of patients in whom no anatomical or pathological lesion can be found. These patients are
1. Those with postural back pain or
2. Those with psychiatric illness 
Postural backache –due to poor posture, prolonged sitting or standing
Psychiatric illness – Hysteria, malingering, chronic anxiety or depression. 

HOMOEOPATHIC MEDICINE FOR BACKACHE 
3 mark medicines in Kent’ repertory 
Aesculus Alumina Arnica
Baryta carb , Belladonna Bryonia
Calc carb, Calc phos Carb sulph
Eup per Eup pur Graphitis
Ipecac Kali carb Lac canin
Lycopodium Mur acid Nat mur
Nat sulph Nux vom Nux mosh
Pareira Phosphorus Psorinum
Pulsatilla , Rhus tox Sepia
Silicea Sulphur  
2 mark medicines 
Aethusa Agaricus Alumen
Amm mur Apis mel Arg met
Arg nit Atrop Aur
Berberis vulg Camph Cann ind
Capsicum Carb ani Carb veg
Caulophyllum Causticum Chamomila
Chelidonium Chin sulph Cocc
Cimicifuga Colchium Colocynth
Conium mac Crot hor Cub
Ferr Gels Helonius
Hepar Hyper Ignatia
Kali bich Kali nit Kali sulph
Kalmia Lachesis Ledum pal
Medorr Mer sol         Mer cor
Mezerium Naja Nat carb
Nitric acid Petrleum Pic acid
Plb Ran bulb Rhododendron
Sec cor Staphy ,  Sulph acid
Var Zinc  
1-mark medicines  
Aloes Ambra Amm carb
Anacardium Anti crudum Anti tart
Ars iod Asaf ,Asar
Aur mur Brom Calc sulph
Canth Carb acid Chin
Cic Coc cacti Cor rub
Cupr Cycl     Dulc
Elaps Ferr p Hamamelis
Hell Hyos Iod
Kali ars Kali p Kreos
Laur Lil tig        Lith c
Lyssn Mag c Nat ars
Opium Oxalic acid Pall
Phos acid Phyto Plat
Podo Sab     Sang
Saras Spig Stann
Stram Tarentula Ther
Thuja Valer Ver alb  

LAB INVESTIGATION 
1. Blood ESR.
2. Serum Ca, phosphorus, Alkaline phosphate, Acid phosphate, prostate specific antigen (metastatic ca from prostate)
3. Test for rheumatoid factor
4. X –ray
5. Bone scan in fracture, neoplastic and inflmatory lesion
6. MRI

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