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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 32  |  Issue : 3  |  Page : 184-186

Quadratus lumborum: One of the many significant causes of low back pain


1 Department of Pain Management, Barge Pain Clinic, Satara, Maharashtra, India
2 Department of Orthopaedics, Mangal Murti Nursing Home, Satara, Maharashtra, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Asha Satish Barge
Barge Pain Clinic, 18, Deshmukh Colony, Sadar Bazar, Satara - 415 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_53_18

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  Abstract 

Quadratus lumborum is one of the common sources of pain and that can be missed or ignored easily. Quadratus lumborum pain syndrome is a myofascial pain syndrome. The pain is due to spasm and stiffness of the muscle. Many a times, weak back muscles are compensated by quadratus lumborum leading to painful spasm. It is diffi cult to differentiate between quadratus lumborum and iliopsoas pain syndrome. Diagnostic quadratus lumborum injection helps differentiate between these two. In this report, we reported a case of quadratus lumborum pain syndrome as a primary diagnosis and iliopsoas pain syndrome as a secondary diagnosis. The diagnosis was confi rmed by fl uoroscopically guided quadratus lumborum injection.

Keywords: Diagnostic injection, iliopsoas, quadratus lumborum


How to cite this article:
Barge AS, Barge SM. Quadratus lumborum: One of the many significant causes of low back pain. Indian J Pain 2018;32:184-6

How to cite this URL:
Barge AS, Barge SM. Quadratus lumborum: One of the many significant causes of low back pain. Indian J Pain [serial online] 2018 [cited 2019 Jun 19];32:184-6. Available from: http://www.indianjpain.org/text.asp?2018/32/3/184/249107


  Introduction Top


Low Back pain is the most common condition which a pain physician come across in the pain clinics and is the second most common variety of chronic pain after headaches. The critical issue in treating a patient with Low Back pain remains in the precision diagnosis so that effective treatment can be instituted. Many a times, Physical examination, history and imaging studies are insufficient in identifying the source of pain that is specific pain generator and diagnosis is always difficult. In these situations Diagnostic Interventions play most valuable role with which we may diagnose the nociceptive source of Low Back pain in nearly 90% cases.


  Case Report Top


A 57-year-old elderly female, weighing 84 kg, very obese, short, homemaker, was admitted in an orthopedic hospital for acute and severe low back pain. The pain intensity was 9 out of 10 on the Numerical Rating Scale. The patient started with severe low back pain in the right median, paramedian, and flank area, radiating to right hip. The pain was aggravated on rolling in the bed side to side, and also on sitting, standing, and walking few steps. The pain was relieved on lying down in supine position. There was no history of trauma, infection, and fever. There was no history of any other comorbidities or medical illness. There was no red flag sign. The treatment was already started by the orthopedic surgeon, pregabalin 75 mg once daily, a combination of tramadol hydrochloride and acetaminophen tablet twice daily, and injection tramadol as needed. X-ray lumbosacral spine was done, which showed loss of lumbar lordosis with scoliosis. Magnetic resonance imaging (MRI) was also done which showed no significant abnormalities. There was no pain relief even though the treatment by the Orthopedic surgeon was continued for three days. Hence, on day 4, the patient was referred to our pain clinic.

The patient was very uncomfortable, crying, in severe pain and agony. On inspection, the posture was abnormal with an abnormal gait. The spine and hip joints showed asymmetry. The pelvis was tilted on the opposite side. Kyphoscoliosis was seen with concavity on the affected side. Flexion, extension, and side bending of the spine were not free. Straight-leg-raising (SLR) test was negative on both the sides. The pain increased on rolling side to side in the bed. The patient was not even able to stand for 30 s or walk 4–5 steps. The pain was reduced on lying supine with no side-to-side movements. Hip flexion against resistance was not painful, which excluded the iliopsoas as pain generator. Hip extension was also not painful which excluded the gluteus maximus as a pain generator. Hip abduction against resistance caused very minimal pain which excluded the gluteus medius and minimus and tensor fasciae latae. Hip adduction was also not painful that excluded adductor muscles. Palpation of the muscles 5–6 cm lateral to the axial plane at the L1 vertebra elicited pain to the iliac crest. Trigger point (TrP) examination was done in prone position, with a palpable muscle area between the 12th rib and the iliac crest. Another TrP was found at the L4 level about 1–2 cm above the posterior iliac crest, and the pain was referred to the greater trochanter. The distraction test was performed to exclude sacroiliac joint as the cause for pain. The flexion, abduction, external rotation test was negative that ruled out hip joint pathology. Facet loading was not possible because of severe pain. Diagnosis was based on the detailed clinical history and examination.

Routine blood investigations and fasting blood sugar were done, which showed normal values. We performed diagnostic cum therapeutic quadratus lumborum injection under fluoroscopy, which gave almost complete pain relief to the patient, and also our diagnosis was confirmed.


  Discussion Top


Although skeletal muscle occupies nearly half of our body, there is an incredible lack of competent research articles on the chief myogenic sources of pain and myofascial TrPs.[1] The prevalence of myofascial TrPs among patients complaining of pain anywhere in the body ranges from 30% to 93% and lumbogluteal pain about 21%.[2] The muscle remains an overlooked source of musculoskeletal pain and dysfunction.[1]

The purpose of this case report was to differentiate between various reasons that cause low back pain in a patient and overcome the diagnostic dilemma. Low back pain can be divided into three categories: axial pain, global pain, and paramedian pain. In our patient, the pain was predominantly paramedian and in the flank area which was not radiating to lower extremity. The most common cause for this is myofascial pain syndrome. Since there was very less axial pain and no radiculopathy or associated loss of sensory and/motor function, electromyography/nerve conduction velocity studies were not performed, and MRI studies though performed were of less importance. The pain spread was more of horizontal, which indicated quadratus lumborum than iliopsoas in which the pain spreads vertically. There was no pain on active or passive SLR test.

In quadratus lumborum pain syndrome, the pain is usually deep and aching, but may be lancinating during movement. The pain may extend to the outer upper aspect of the groin. Sometimes, the pain may be referred to the greater trochanter and outer aspect of the upper thigh. The greater trochanter can be tender to pressure, so that the patient cannot tolerate lying on that side and the pain may prevent weight bearing by the lower limb on the involved side.[3]

Adequate examination to cover the most common causes as a pain generator requires skills. Turning in the bed, getting up from the bed or chair, standing, and walking all are very painful. The pain is set off whenever the trigger area is stimulated by pressure, needling, extreme heat or cold, or motion that stretches the structure containing the trigger area. Palpation of myofascial TrPs will produce or increase a referred, radiating pain pattern recognizable by the patient.[4],[5],[6],[7] More commonly, a patient will flinch away from the palpation in a reaction known as the “jump sign.”[4],[6],[7],[8] There will also be jump sign and local twitch response.[4],[7],[9],[10] The resistance to stretching leads to apparent shortening of the affected muscle with limitation of motion and weakness.[11]

Careful examination of gait, posture, and alignment is important. Abnormal gait is common due to stiff back as a result of paraspinal muscle spasm. The pelvis is tilted downward on the side opposite to the affected muscle. The lumbar spine usually exhibits a functional lumbar scoliosis that is convex away from the side of the involved quadratus lumborum. The normal lumbar lordosis gets flattened due to the vertebral rotation that accompanies scoliosis despite the fact that quadratus lumborum is an extensor of the spine. This can be seen on X-ray lumbosacral spine. Flexion and extension of the spine are restricted. Side bending is restricted toward the pain-free side. Flank tenderness to deep palpation may be marked. Examination with the patient supine can give impression of a shorter limb on the affected side.[3] Careful examination of lumbosacral spine, hip, pelvis, and sacroiliac joint is also important to diagnose the primary pain generator. Diagnosis is by means of exclusion of the more common causes first.

Fluoroscopically guided diagnostic quadratus lumborum injection of local anesthetic with triamcinolone at 4 cm lateral to midline at the L4 level and 2 cm above the posterior superior iliac spine gave excellent pain relief. Thus, it is proved to be simple and effective diagnostic as well as therapeutic tool in our case.

The patient came for regular monthly follow-up up to 9–10 months. There was no pain during this time. However, the patient was coming for advice regarding diet, weight loss, and different exercises for back muscle strengthening.


  Conclusion Top


Patients presenting with acute or chronic low back pain can have various causes. Very often, the common causes such as quadratus lumborum pain syndrome are overlooked. Imaging studies can also mislead us. However, simpler and easier local anesthetic injection in quadratus lumborum was of great help to find out either the quadratus lumborum or iliopsoas as a pain generator and treat the patient appropriately. Thus, simple diagnostic injection tests can overweigh the expensive and sophisticated investigations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Simon DG. Editorial Orphan Organ. J Musculoskeletal Pain 2007;15:7-9.  Back to cited text no. 1
    
2.
Simon DG. Clinical and Etiological update of Myofascial Pain from Trigger points, J Musculoskeletal Pain 1996;4:93-122.  Back to cited text no. 2
    
3.
Travell JG, Simon DG. Myofascial pain and dysfunction. In: Butler JP, editor. Travell & Simons Myofascial Pain and Dysfunction: The Trigger Point Manual. 1st ed., Vol. 2. Ch. 4. Philadelphia: Williams & Wilkins; 1999.  Back to cited text no. 3
    
4.
Simons DG, Travell JG. Myofascial origins of low back pain 1. Principles of diagnosis and treatment. Postgrad Med 1983;73:66, 68-70, 73.  Back to cited text no. 4
    
5.
Travell JG, Simon DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 2. Baltimore: Williams & Wilkins; 1992.  Back to cited text no. 5
    
6.
Wheeler AH. Myofascial pain disorders: Theory to therapy. Drugs 2004;64:45-62.  Back to cited text no. 6
    
7.
Raj PP, Paradise LA. Myofascial pain syndrome and its treatment in low back pain. Semin Pain Med 2004;2:167-74.  Back to cited text no. 7
    
8.
Simons DG. Electrogenic nature of palpable bands and “jump sign” associated with myofascial trigger points. In: Bonica JJ, Albe-Fessard DG, editors. Advances in Pain Research and Therapy. Vol. 1. New York: Raven Press; 1986. p. 913-8.  Back to cited text no. 8
    
9.
Borg-Stein J, Simons DG. Focused review: Myofascial pain. Arch Phys Med Rehabil 2002;83:S40-7, S48-9.  Back to cited text no. 9
    
10.
Cummings TM, White AR. Needling therapies in the management of myofascial Trigger point pain: A systematic review. Arch Phys Med Rehabil 2001;82:986-92.  Back to cited text no. 10
    
11.
Travell J, Rinzler SH. The myofascial genesis of pain. Postgrad Med 1952;11:425-34.  Back to cited text no. 11
    




 

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