LOW BACK PAIN

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LOW BACK PAIN

• By
• ROBERT H. BELDING MD
• Orthopedic Surgeon
• Columbia, SC, USA

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Epidemiology Natural history

• 2nd most common cause for office visit
• 60-80 of population will have lower back pain at
  some time in their lives
• Each year, 15-20 of people will have back pain
• Most common cause of disability for persons lt 45
  years
• Costs to society 20-50 billion/year
• 80 to 90 Resolve in one month
• 20 to 30 Become chronic
• 5 to 10 Become disabling

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Epidemiology of Back Pain ?? 60-90 lifetime
prevalence. ?? 80-90 have recurrent
episode. What is the Natural History? ?? 80-90
resolves in 1 month. ?? 20-30 remains
chronic ?? 5-10 disabling
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• One would have thought by now that the problem
  of diagnosis and treatment would have been
  solved, but the issue remains mysterious and
  clouded with uncertainty.
• Rosomoff HL, Rosomoff RS. Low back pain
  Evaluation and management in the primary care
  setting. Med Clin North Am 199983643-62.

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ANATOMY
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Typical Lumbar Vertebra
ANATOMY
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ANATOMY
Lumbar Intervertebral Disc Annulus Fibrosis ??
Dense connective tissue, interwoven matrix ??
Outer 1/3 innervated from sinuvertebral nerve
and gray rami communicans. ?? Concentric
layers attaching to end plates Nucleus
Pulposus ?? 80-90 water, mucuopolysaccharide,
collagen.
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DISCOGRAM
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Lumbar Ligaments ?? ALL ?? PLL ?? Ligamentum
flavum ?? Facet capsules ?? Interspinous
ligaments ?? Supraspinous ligaments
ANATOMY
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ANATOMY
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Muscle Layers Deep ?? Multifidus, Quadratus
lumborum ?? Iliocostalis, longissimus, (Erector
s.) Superficial ?? Thoracolumbar fascia ??
Lattisimus dorsi
ANATOMY
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ANATOMY
DEEP LUMBAR MUSCLES
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ANATOMY
SUPERFICIAL LUMBAR MUSCLES
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ANATOMY
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ANATOMY
SPINAL NERVES, ARTERIES AND VEINS
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• Pain Generators
• Annulus Fibrosis (outer 1/3 only?)
• Periosteum
• Neural Membranes ( Dura, Arachnoid, Pia)
• Ligaments
• Zygoapophyseal-joint capsules
• Muscles.

ANATOMY
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Causes of Low Back Pain

• Lumbar strain or sprain 70
• Degenerative changes 10
• Herniated disk 4
• Osteoporosis compression fractures 4
• Spinal stenosis 3
• Spondylolisthesis 2

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Causes of Low Back Pain

• Spondylolysis, other spinal instability 2
• Fracture - lt1
• Congenital disease - lt1
• Cancer (primary, metastatic) 0.7
• Inflammatory arthritis (RA, lupus, etc.) 0.3
• Infections 0.01

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TREATMENT GOALS

1. Be able to recognize the difference between
   routine lower back pain and dangerous forms of
   lower back pain.
2. Provide information, advice, and a plan of action.

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DIAGNOSIS

1. HISTORY
2. PHYSICAL EXAM
3. PLAIN X-RAYS
4. DIFFERENTIAL DIAGNOSIS
5. SPECIAL STUDIES

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OUR FIRST OBLIGATION

• Be able to recognize the difference between
  routine lower back pain and dangerous forms of
  lower back pain.

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HISTORY
HISTORY
HOW DID IT BEGIN WHAT AGGRIVATES IT WHEN IS IT
WORSE WHERE IS THE PAIN LOCATED DOES IT RADIATE
TO THE LEG ARE THERE ASSOCIATED NEUROLOGICAL
SIGNS WHAT TREATMENT HAVE YOU HAD WHAT OTHER
CONDITIONS HAVE YOU HAD IS THERE A FAMILY HISTORY
OF BACK PAIN HAVE YOU MISSED WORK IS IT WORK
RELATED IS CLAUDICATION PRESENT
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Red Flags
HISTORY
HISTORY

• Major Trauma
• Osteoporosis
• Fever
• Back pain at rest or at night
• Bowel or bladder dysfunction

• History of cancer
• Unexplained weight loss
• Intravenous drug use
• Prolonged use of corticosteroids
• Older age

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PHYSICAL EXAMINATION
PHYSICAL EXAMINATION

• RANGE OF MOTION
• TENDERNESS
• MUSCLE SPASM
• STRAIGHT LEG RAISING TEST
• SI JOINT STRESS TEST
• TRENDELENBURG SIGN
• LEG LENGTH
• SPINE DEFORMITIES
• ERYTHEMA OR HEAT
• BIRTH MARKS

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BACK EXAMINATION
PHYSICAL EXAMINATION
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PHYSICAL EXAMINATION

• Neurologic Examination
• Strength tests
• L1, L2- Hip flexion (Psoas, rectus femoris)
• L2,3,4 Knee extension (Quads)
• L2,3,4 -- Hip adductors (adductors and gracilis)
• L5 ankle/ toe dorsiflexion (ant. Tibialis, EHL)
• L5 Hip abductors (gluteus medius, TFL)
• S1- ankle plantarflexion (gastroc/ soleus)
• S1 Hip extensors (Gluteus max., Hamstrings)

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PHYSICAL EXAMINATION

• Neurological Examination
• Reflexes
• L2,3,4- Quads
• L5- Medial hamstring
• S1- Achilles
• Sensation
• L-4 Medial Thigh
• L-5 Lateral Leg
• S-1 Lateral Foot
• L-5 First Web Space

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Waddell's signs
PHYSICAL EXAMINATION

• Waddell's signs are a group of physical signs,
  first described by Waddell et al in 1980, that
  may indicate non-organic or psychological
  component to chronic low back pain. Historically
  they have been used to detect "malingering"
  patients with back pain.

One or two Waddell's signs can often be found
even when there is not a strong non-organic
component to pain. Three or more are positively
correlated with high scores for depression,
hysteria and hypochondriasis on the Minnesota
Multiphasic Personality Inventory.
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Waddell's signs
PHYSICAL EXAMINATION

• Superficial tenderness skin discomfort on light
  palpation.
• Nonanatomic tenderness tenderness crossing
  multiple anatomic boundaries.
• Axial loading eliciting pain when pressing down
  on the top of the patients head.
• Pain on simulated rotation - rotating the
  shoulders and pelvis together should not be
  painful as it does not stretch the structures of
  the back.
• Distracted straight leg raise - if a patient
  complains of pain on straight leg raise, but not
  if the examiner extends the knee with the patient
  seated (e.g. when checking the Babinski reflex).
• Regional sensory change - Stocking sensory loss,
  or sensory loss in an entire extremity or side of
  the body.
• Regional weakness - Weakness that is jerky, with
  intermittent resistance (such as cogwheeling, or
  catching). Organic weakness can be overpowered
  smoothly.
• Overreaction - Exaggerated painful response to a
  stimulus, that is not reproduced when the same
  stimulus is given later.

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• Guidelines for Imaging
• Acute pain with NO RED FLAGS!
• Chronic episodes of pain with previous evaluation
• NO X-RAY NEEDED
• Failed symptomatic treatment for 4 weeks
• First episode and age over 50
• First episode with red flags present
• AP, LATERAL AND SPOT LATERAL OF L-5

RADIOLOGY
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PLAIN FILMS
RADIOLOGY
SPOT LATERAL L-5
AP
LATERAL
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RADIONUCLETIDE BONE SCAN WITH TECHNESIUM PHOSPHATE
RADIOLOGY
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mri
RADIOLOGY
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CT SCAN
RADIOLOGY
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MYELOGRAM
RADIOLOGY
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DISCOGRAM
RADIOLOGY
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Develop a differential diagnosis and use Blood
test, EMG and Nerve conduction studies, or a
trial of treatment to confirm your suspicions
remember70 of low back pain is due to
lumbar strain, and is a diagnosis of exclusion
DI FFRENTIAL
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prevention
PREVENTION

• Back exercise for strengthening and flexibility
• Education about sitting, lifting, bending
• Proper surface for sleeping
• Weight reduction
• Smoking cessation
• Good mental health
• Back school

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Treatment
TREATMENT
Treat the underlying cause first Tumor,
Fracture, Arthritis, Infection, Osteoporosis ,
Congenital deformity, etc.
Treatment of Lumbar strain , spinal stenosis,
diskogenic pain, spinal instability,
degenerative disease symptomatically as long as
there are no progressive neurologic findings
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SYMPTOMATIC treatment
TREATMENT

• MEDICATION
• REST
• BRACES SUPPORTS
• PHYSICAL THERAPY
• 6. STEROID INJECTIONS
• 7. ACCUPUNCTURE

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MEDICATIONS
TREATMENT

• NSAID Ibuprofen, Aspirin, Naproxen, Celecoxib,
  etc.
• ANALGESICS- Acetophenemen, Opiates, Meperadine
• MUSCLE RELAXANTS Chlorzoxazone, Crisoprodol
• ANTIANXIETY Amitriptyline
• ANTICONVULSANTS - Carbamazepine

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BRACES
TREATMENT
EXTENTION BACK BRACE
PREVENTIVE WORK BRACE
LUMBOSACRAL CORSETTE
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PHYSICAL THERAPY
TREATMENT

• BACK EXERCISE
• MESSAGUE
• ELECTRIC STIMULATION
• HEAT/COLD
• PELVIC TRACTION
• ULTRASOUND
• MANIPULATION

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STEROID INJECTIONS
TREATMENT

1. EPIDURAL
2. FACET JOINT
3. TRIGGERPOINT
4. INTRAMUSCULAR

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Indications for Operative treatment
TREATMENT

• Progressive Neurologic Findings
• Unstable Spine
• Some Congenital Deformities
• Infection With Abscess Or Osteomylitis
• Symptoms That Are Unresponsive
• To Conservative Treatment
• Tumors
• Fractures

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THANK YOU