This review of the answers to the questionnaire shows that there are many opinions on low backache, but on the whole there is a fairly definite agreement, not only as to the main causes of backache, but also in general as to treatment. The chief point of difference would appear to be on the question of sacro-iliac sprain. The majority believe that there is such a condition. Those who do not believe in a sprain or strain, are very firm in their beliefs. Nothing has appeared in this study to prove or disprove the contention.

It does seem, however, to be possible to outline a fairly consistent course of treatment based on the cause and diagnosis.

The causes of low backache are broadly arthritis, trauma, and posture.

Arthritis may include osteo-arthritis, and the toxic conditions, due to intestinal absorption, or foci of infection including the teeth, tonsils, sinuses, gall-bladder, and other points.

The traumatic conditions include those forms of backache which are the result of direct trauma.

Postural backache is due to static errors resulting in muscular, ligamentous and possibly long strain, due to improper alignment.

The so called anomalies of the fifth lumbar and first sacral can reasonably be put in the postural group. They probably do not begin to cause symptoms until their alignment has been disturbed as a result of some postural defect or trauma.

These three types, although apparently clearly differentiated, are in reality closely associated, and one form may induce one or both of the others, so that in chronic backache all three may have played an important part.

A careful diagnosis must be made in all cases, based on a careful history, past and present, and a careful physical examination, including a gastro-intestinal, and a search for all possible foci of infection.

The acute traumatic conditions are diagnosed by the history and physical findings, by muscle spasm, localization of pain and points of tenderness, and by the x-ray when there has been some bone injury.

Differentiation between sacro-iliac and lumbosacral lesions causes the greatest difficulty.

In sacro-iliac strain there is pain over the sacro-iliac joint and in the sacrosciatic notch. Straight leg raising, especially before the spine begins to move, causes pain in the joint, as is also the case with the cross leg test. In lumbosacral the pain is higher and nearer the mid-line. In lumbosacral conditions straight leg raising is apt to cause pain on both sides. In sacro-iliac, pain is referred down the back of the leg; in lumbosacral, down the front of the thigh. In sacro-iliac, compression of the crests of the ilium may cause pain.

In lumbosacral conditions that region is rigid, and forward bending is at the hips. In sacro-iliac the forward bending takes place in the lumbar spine. In the sitting position forward bending is free in sacro-iliac conditions; in lumbosacral lesions no difference is noted.

The importance of a definite diagnosis between sacro-iliac and lumbosacral lesions is evident if some operative procedure is to be undertaken.

Postural conditions are usually easy of diagnosis, but in this connection the feet must always be considered.

Arthritis can be diagnosed on the history, the physical findings, and the x-ray. In the early arthritic cases and in those cases due to toxic irritation, the x-ray may be negative.

Treatment: In the acute traumatic conditions the treatment is of rest, followed by physiotherapy. Rest may be obtained in the milder cases by adhesive plaster strapping. In the severe cases recumbency is necessary, if in bed, the bed should be hard. In the more severe types a plaster jacket or shell may be necessary, with or without traction. The fixation should be as complete as possible. Rest should be continued for a considerable period.

Physiotherapy should be used as early as possible.

In some cases of acute sacro-iliac strain, manipulation may be used.

In chronic backache, all postural defects must be corrected, and when arthritis or toxic irritation is present, all foci of infection must be removed, elimination promoted, and the diet regulated.

Sacro-iliac supports and spinal braces and corsets may be used, together with postural exercises and muscle training and physiotherapy.

In old chronic and persistent cases, some ankylosing operation may give relief, provided the diagnosis has been carefully made. The removal of large transverse processes does not seem satisfactory, and probably as good results can be obtained by postural training and mechanical support.