Low back pain is the leading cause of disability worldwide and has affected a staggering 619 million people globally (GBD 2021 Low Back Pain Collaborators, 2023). Regardless of age or fitness level, individuals from all walks of life, including active young people and community-dwelling older adults, find themselves grappling with low back pain at some point, at least once in their lives. If you’ve ever felt that twinge when bending backward or standing for extended periods, you’re not alone. Low back pain can result from various factors and conditions. Have you experienced discomfort when bending backward or standing for extended periods? Do you struggle with rising due to back pain? Are you also dealing with symptoms like pain, numbness, and possibly weakness in the legs that coincide with the back pain?

This article explores three prevalent conditions that contribute to low back pain during lumbar extension.

Anatomy

illustrations of the spine

Illustrations of the Spine
[Source: Goodman Campbel, 2023; Mandell et al., 2017]

Before delving into the conditions, it’s crucial to grasp the anatomy of the spine.

Segments
The spine is composed of five segments: the cervical (neck), thoracic (upper back), lumbar (lower back), sacrum, and coccyx (tailbone) in descending order.

Joints
The spine is a series of vertically adjacent bones, known as vertebrae, connected primarily by two types of joints: intervertebral joints and facet joints. Intervertebral joints consist of vertebral bodies and the intervertebral disc connecting them, while facet joints are formed by the joining of the superior articular process and the inferior articular process of adjacent vertebrae.

Spinal Canal
A significant feature of these vertebrae is a hole called the vertebral foramen. When combined, these foramina create the spinal canal, through which the spinal cord runs. It’s essential not to confuse this with the neural foramen, also known as the intervertebral foramen, located between adjacent vertebrae, allowing the passage of nerve roots.

Neural Components
Visualise the neural components akin to a tree: the spinal cord serves as the trunk, while the nerve roots resemble the main branches, and individual nerves act as smaller branches. Positioned centrally within the spine, the spinal cord serves as a conduit, transmitting impulses from the brain to the spine. Meanwhile, nerve roots branch out into individual nerves, conveying impulses from the spine to specific areas of the body.

Differential Diagnoses of Low Back Pain During Lumbar Extension

Spinal Stenosis
Spinal stenosis, often referred to as the narrowing of the spinal cord, affects approximately 11% of the general population, with a higher prevalence among those aged 60 and above (Jensen et al., 2020; Kalichman et al., 2009). This condition typically results from degenerative and arthritic changes, leading to a reduction in the size of the spinal canal (Lee et al., 2020). When the spinal canal narrows during backward bending, compression of the spinal cord may occur, giving rise to various symptoms.

Lumbar Facet Arthropathy
Facet arthropathy, a dysfunction in the facet joints, is a common issue in the lumbar spine, accounting for 15-45% of chronic low back pain (Perolat et al., 2018). This condition is more prevalent in women and older individuals (Goode et al., 2012; Eubanks et al., 2007). Typically, facet arthropathy results from damage to the facet joints due to repetitive movements or degenerative changes (Cohen & Raja, 2007). Therefore, when bending backward, the facet joints undergo additional strain, potentially leading to symptoms.

Spondylolisthesis
Spondylolisthesis refers to the forward displacement of one vertebra relative to another, a condition that can affect both children and adults. In cases of adolescent/isthmic spondylolisthesis, boys are more prone than girls and often experience symptoms during puberty (Kalichman et al., 2009b; Li et al., 2022). However, most children with this condition are usually asymptomatic and lead a normal life without any disability (Gagnet et al., 2018).

For adults dealing with degenerative spondylolisthesis, women are more susceptible than men, and the incidence rises with age (Kalichman et al., 2009b; Li et al., 2022). Athletes can also develop spondylolisthesis due to the spinal stress experienced during sports (Wimberly & Lauerman, 2002). When bending backward, the spine, and even the spinal cord, is stressed, potentially causing symptoms.

Table of Comparison: Typical Presentation

Spinal Stenosis Lumbar Facet Arthropathy Spondylolisthesis
Location of symptoms
  • Low back pain
  • Legs (as a whole)
  • Low back pain
  • Buttocks
  • Groin
  • Thighs
  • Low back pain
  • Legs (as a whole)
Types of symptoms
  • Pain
  • Numbness
  • Weakness
  • Pain
  • Numbness
  • Weakness
  • Pain
  • Numbness
  • Weakness
Aggravating & Easing factors
  • Standing/walking brings about symptoms
  • Symptoms are relieved by sitting, bending forward
  • Bending backward/sideways or rotating brings about symptoms
  • Symptoms are relieved by bending forwards
  • Standing/walking brings about symptoms
  • Symptoms are relieved by sitting, bending forward
Population & history of the condition
  • Gradual onset
  • >50 years old
  • Gradual onset
  • Chronic
  • >50 years old
  • Children: Pubertal periods (8-14 years old)
  • Adults: >50 years old
  • Symptoms often do not progress and may improve with age
Red flags
(if you experience any of these symptoms seek medical attention immediately)
  • Sudden weakness in the legs
  • Incontinence
  • Numbness in the groin area
  • Sudden weakness in the legs
  • Incontinence
  • Numbness in the groin area
  • Sudden weakness in the legs
  • Incontinence
  • Numbness in the groin area

Management

In non-traumatic and mild cases, the initial recommendation is typically conservative treatment. This often involves physiotherapy, incorporating manual therapy and targeted exercises to alleviate symptoms and enhance muscular strength, mobility, and spinal control. Medication may also be prescribed as part of the conservative approach. Physical modalities can be considered to provide symptomatic relief or support the healing process. If conservative measures prove ineffective, more invasive procedures may be explored. Nevertheless, it’s crucial to consult with a medical professional if you suspect you may be dealing with any of these conditions.

Written by Benjamin Tan (3rd Year Physiotherapy Student), Supervised by Timothy Lau (Senior Physiotherapist)

References:

Cohen, S. P., & Raja, S. N. (2007). Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology, 106(3), 591–614. https://doi.org/10.1097/00000542-200703000-00024

Eubanks, J. D., Lee, M. J., Cassinelli, E., & Ahn, N. U. (2007). Prevalence of lumbar facet arthrosis and its relationship to age, sex, and race: An anatomic study of cadaveric specimens. Spine (Philadelphia, Pa. 1976), 32(19), 2058–2062. https://doi.org/10.1097/BRS.0b013e318145a3a9

Gagnet, P., Kern, K., Andrews, K., Elgafy, H., & Ebraheim, N. (2018). Spondylolysis and spondylolisthesis: A review of the literature. Journal of orthopaedics, 15(2), 404–407. https://doi.org/10.1016/j.jor.2018.03.008

GBD 2021 Low Back Pain Collaborators (2023). Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. The Lancet. Rheumatology, 5(6), e316–e329. https://doi.org/10.1016/S2665-9913(23)00098-X

Goode, A. P., Marshall, S. W., Renner, J. B., Carey, T. S., Kraus, V. B., Irwin, D. E., Stürmer, T., & Jordan, J. M. (2012). Lumbar spine radiographic features and demographic, clinical, and radiographic knee, hip, and hand osteoarthritis. Arthritis care & research, 64(10), 1536–1544. https://doi.org/10.1002/acr.21720

Jensen, R. K., Jensen, T. S., Koes, B., & Hartvigsen, J. (2020). Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. European Spine Journal, 29(9), 2143–2163. https://doi.org/10.1007/s00586-020-06339-1

Kalichman, L., Cole, R., Kim, D. H., Li, L., Suri, P., Guermazi, A., & Hunter, D. J. (2009a). Spinal stenosis prevalence and association with symptoms: the Framingham Study. The spine journal : official journal of the North American Spine Society, 9(7), 545–550. https://doi.org/10.1016/j.spinee.2009.03.005

Kalichman, L., Kim, D. H., Li, L., Guermazi, A., Berkin, V., & Hunter, D. J. (2009b). Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine, 34(2), 199–205. https://doi.org/10.1097/BRS.0b013e31818edcfd

Lee, B. H., Moon, S. H., Suk, K. S., Kim, H. S., Yang, J. H., & Lee, H. M. (2020). Lumbar Spinal Stenosis: Pathophysiology and Treatment Principle: A Narrative Review. Asian spine journal, 14(5), 682–693. https://doi.org/10.31616/asj.2020.0472

Li, N., Scofield, J., Mangham, P., Cooper, J., Sherman, W., & Kaye, A. (2022). Spondylolisthesis. Orthopedic reviews, 14(4), 36917. https://doi.org/10.52965/001c.36917

Mandell, J. C., Czuczman, G. J., Gaviola, G. C., Ghazikhanian, V., & Cho, C. H. (2017). The Lumbar Neural Foramen and Transforaminal Epidural Steroid Injections: An Anatomic Review With Key Safety Considerations in Planning the Percutaneous Approach. AJR. American journal of roentgenology, 209(1), W26–W35. https://doi.org/10.2214/AJR.16.17471

Perolat, R., Kastler, A., Nicot, B., Pellat, J. M., Tahon, F., Attye, A., Heck, O., Boubagra, K., Grand, S., & Krainik, A. (2018). Facet joint syndrome: from diagnosis to interventional management. Insights into imaging, 9(5), 773–789. https://doi.org/10.1007/s13244-018-0638-x

Spine anatomy, Goodman Campbell Brain and Spine, accessed on 5 Jan 2023 <https://www.goodmancampbell.com/conditions/spine/spine-anatomy/>

Wimberly, R. L., & Lauerman, W. C. (2002). Spondylolisthesis in the athlete. Clinics in sports medicine, 21(1), 133–viii. https://doi.org/10.1016/s0278-5919(03)00062-0