Overview of Low Back Pain Disorders

1
Overview of Low Back Pain Disorders

• R1 ???

2
EPIDEMIOLOGY

• At least 60-90 of US adults will have LBP at
  some time during their lifetime
• Definitions
• Pain in the lumbosacral region
• Between costal margin inf. gluteal flods
• With or without sciatica
• Duration
• Acute back pain 2-4? ??
• Subacute back pain 12? ??
• Chronic 12? ??

3
RISK FACTORS

• Biomechanical factors
• Wt lifting, lift rate, load position, reach
  distances, task asymmetry
• Psychosocial risk factors
• Mental concentration or demands, fob
  responsibility, lack of variety, job
  satisfaction, mental stress
• Personal factors
• Physical strength, genetics, anthropometry,
  gender, personality

4
RISK FACTORS(2)

• Back pain ?? ???
• Jobs requiring heavy lifting
• Use of jackhammers and machine tools
• Operation of motor vehicles
• Cigarette smoking
• Anxiety
• Depression
• Stressful occupations
• Women with multiple pregnancies
• Scoliosis
• Obesity
• Genetics
• personality

5
ANATOMY OF LUMBAR SPINE

• Motion segment
• 2 vertebrae intervertebral disc
• Pain generator
• Intervertebral disc
• Annulus fibrosus
• Numerous concentric rings of fibrocartilaginous
  tissue
• Nucleus pulposus
• Gelatinous loose material
• Bertebral endplate

6
INNERVATION OF LUMBAR SPINE

• Sinuvertebral or recurrent meningeal nerve
• Supply ventral half of vertebral column
• Dura mater, post. longi. lig., intervertebral
  discs, ant. longi. lig.
• Medial branch of post. primary ramus
• Supply dorsal parts of vertebral column
• Facet joint, vertebral arch, spinous process
• Br. Of ramus communicans n.
• Ventral and lat. side of annulus fibrosus
• Each disc innervated by 4
• Rt., Lt., sup., and inf. Ramus communicans n.

7
(No Transcript)
8
ETIOLOGY OF BACK PAIN

• Approximately 90 of LBP have nonspecific cause
• Referred pain
• No stiffness, movement of back does not increase
  pain
• Mechanical structural back pain etiologies
• Spondylosis
• Spondylolisthesis
• Spondylolysis defect in pars interarticularis
• True disc herniation
• Foraminal stenosis
• Facet arthropathy
• Spinal arthropathy
• Spinal stenosis typical neurogenic claudication
• Fracture
• Musculoligamentous lumbar strain or sprain
• Discogenic pain internal disc disruption,
  annular tear
• Congenital dis. severe kyphosis, severe
  scoliosis, flat spine synd.

9
ETIOLOGY OF BACK PAIN(2)

• Nonmechanical spinal etiologies
• Neoplastic and metastatic dis.
• Infection osteomyelitis, septic discitis,
  paraspinal or epidural abscess
• Infl. arthritis ankylosing spondylitis,
  Reiters synd., psoriatic spondylitis, IBD
• Pagets dis.
• Scheuermanns dis (osteochondrosis)
• Referred pain from visceral disorders
• Pelvic organs prostatitis, endometriosis, PID
• Renal dis. nephtolithiasis, phelonephritis,
  perinephtic abscess
• Vascular dis abd. aortic aneurysm
• G-I dis pancreatitis, cholecytitis, perforated
  bowel

10
GUIDELINESFOR MANAGING ACUTE BACK PAIN

• ??? self-limited process, 1-3?? ?? ???
• Comprehensive history physical exam.
• Red flags
• Possible Fx., tumor, infection, cauda equina synd
  ?? screening ?? ?
• ?? benign low back pain? sitting, bending,
  lfting, twisting?? mechanical dysfunction? pain
  ????, nonoperative treatment? ?? ???

11
(No Transcript)
12
Imaging studies

• ?? Imaging studies ??? ??
• Neurologic delicit
• History of trauma
• Pain does not subside spontaneously
• Pain is severe or unusual in character
• Systemic or other injuty is suspected
• History of cancer
• Corticosteroid use
• Durg or alcohol abuse
• Temperature greater than 38?
• Unexplained weight loss
• Sx sign ? ?? ??? ??

13
Imaging studies(2)

• Plain-film radiography
• Rarely useful in the initial evaluation with
  acute LBP
• AP and lat. Views of the lumbar spine
• AP view
• Misalignment of spinous process rotational
  injury
• Possible degenerative changes in pelvis ??
• Lateral view
• Dec. disc space height disc degeneration,
  infection, postsurgical condition, but, LBP
  etiology? ??? ??
• Ant. slippage(spondylolisthesis) of 5th vertebra
  on sacral base
• Oblique view
• Neural foramina, pars interarticularis ? ? ??
• Tumor, facet hypertrophy, spondylosis,
  spondylolisthesis
• Flextion-extension view
• Assessing ligamentous and bony injury in axial
  plane
• Fx ??? ?? ?? T-spine ???? ?
• T12, L2 ??? injury ?? ???
• Degenerative change Sx ??? ??? ???? ???
• Intervertebral narrowing irregular ossification
  of vertebral end plate ??? ?? ??

14
Imaging studies(3)

• Bone scintigraphy
• Suspicious of osteomyelitis, bony neoplasm,
  occult Fx ?? ??
• Detects biochemical changes
• Indicate bone turnover in
• Bone metastases, primary spine tumors, Fx,
  infarction, infection, other metabolic bone dis.
• SPECT(single-photon emission computed tomography)
• Benign malignant lesion ?? ??
• 3?? ???? lesion? location ? ? ??
• Pedicle? affect? lesion? strong indicator of
  malignancy
• Facet? affect? lesion? ?? benign

15
Imaging studies(4)

• Magnetic resonance imaging (MRI)
• Evaluation of spinal degenerative? modality of
  choice
• ??? contrast in distinction of bone, disc,
  ligaments, nerves, thecal sac, spinal cord
• Disc
• T1WI Fairly homogenous structure, isointense
  compared to muscle
• Long TR images become brighter
• Black on T1WI, white on T2WI
• CSF
• Dark in T1WI, white on T2WI
• Nucleus pulposus
• Brighter than annulus on T2WI
• Test of choice of neuroligic structures related
  to LBP
• Gold standard test in early soft tissue
  pathologies
• No known biohazard effects
• Only C/I ferromagnetic implants, cardiac
  pacemakers, intracranial clips

16
Imaging studies(5)

• Computed tomography (CT)
• Lumbar spine? osseous structure? neural canal??
  ?? ???
• Tumor, Fx, partial or complete dislocation ??? ??
• ??
• Less detailed images
• Nondisplaced Fx ?? ? ??
• Radiation exposure limit
• Adversely affected by patient motion
• ? spiral CT ?? ???? ??? exposure to radiation
  ??
• Electrodiagnostic studies
• ????? radiculopathy or pph. Neuropathy ??? ? ??

17
NONINVASIVE TREATMENTS

• In acute LBP little or no evidence that most of
  the popular treatment and therapies alter the
  natural course of the disease
• Rest
• Acute LBP?? ?????? ??? ?? ?? ??
• Current recommendation 2-3 days of bed rest in
  acute radiculopathy
• Pharmacologic therapy
• NSAIDs moderately effective for short-term
  symptomatic relief of acute LBP
• Evidence in chronic LBP is still lacking
• Medical C/I ?? ?? 2-4 ?? ??? ????
• Older types of NSAIDsdml ?? G-I prophylaxis ??
• Selective cyclooxygenase-2 inhibitor? peptic
  ulcer? kidney dis risk ?? ?? ??
• Narcotic.
• Short-term use? acute pain? ?? ??
• Muscle relaxant
• Significant effect in reducing back pain, muscle
  tension, and increased mobility after 1-2 weeks

18
NONINVASIVE TREATMENTS(2)

• Intraspinal injections
• Physical therapy
• General exercise programs may have beneficial
  effects on chronic LBP
• Passive physical therapies
• Heat, massage, electrical stimulation, ultrasound
• Temporary comfort
• Strengthening exercise program
• Facilitate weight loss, LBP? ??
• Bed rest?? continuation of normal activity? acute
  LBP?? ?? ???
• Extension, flexion, strengthening exercises?
  subacute and chronic LBP? postsurgical LBP? ???

19
NONINVASIVE TREATMENTS(3)

• Acupuncture
• Overall conclusion was unclear
• Alternative therapies (spinal manipulation)
• Exact role of spinal manipulation is not clear
• Could increase rate of recovery from acute
  uncomplicated LBP
• Insufficient data for chronic pain
• Biofeedback treatments
• Help the patient reduce muscle tension and pain
• Patient education
• ??? nature of their spine disorder their role
  in avoiding reinjury? ?? ???? ?? ??
• Appropriate postures for sitting, driving,
  lifting
• Weight loss healthy lifestyle

20
SURGICAL TREATMENT

• ?? 20?? ? ??? ??
• Rigid instrumentation systems, minimally invasive
  techniques, recombinant DNA, joint replacement ?
• ?? ???? ??? ???, ?? ?? ???? ?? ????? ??
• ??? LBP? degenerative changefh ?? neural
  compression or mechanical dysfunction? ???? ????
  ???? neurologic decompression and/or fusion? ??

21
Decompression

• Back pain? ???? disc degeneration? herniation?
  ???
• Degenerative changerk neurologic structure? ???
• Back leg pain from acute nerve compression in
  younger Pt
• Neurogenic claudication in older Pt
• Surgical decompression
• Decompress neurologic structures relieve pain
• Discectomy, less invasive microdiscectomy
  techniques, endoscopic discectomy ?
• Ix primary leg pain, positive SLR, imaging
  study
• Principles of surgical treatment
• Decompression
• Mobilization of the affected nerve root
• Removal of herniated fragment
• Endoscopic discectomy
• Release of ligamentum flavum, partial laminotomy,
  medial facetectomy, discectomy ???
• Discectomy?? minimum removal of noncontained
  herniation, vertical annulotomy for removal of
  contained herniation ???

22
Decompression(2)

• Older Pt.??? symptomatic spinal stenosis
  (neurogenic claudication) ?? ??
• Disc herniations/bulges, facet arthropathy,
  osteochondral spurs, ligament hypertrophy,
  spondylolisthesis ???
• Sx low back leg pain aggravated by standing
  walking
• Selective nerve root block
• Helpful diagnostically therapeutically
• Identify symptomatic levels, may predict response
  to op.
• Often requires decompression of central canal,
  lat. recess, and/or neural foramen
• Coexisting instability
• Spondylolisthesis ???, facet joint? 50 ?? ???
• Fusion procedure ??? ?? ??

23
Lumbar fusions

• Ix disabling mechanical LBP secondary to
  underlying disorder
• Spondylolysis, spondylolisthesis, degenerative
  arthritis, scoliosis ?
• Salvage procedure
• Painful degenerative joints are resected
• Dysfunctional motion segments stabilized
• Degenerative disc dis.??? spine fusion? ???
  controversial
• Achieving fusion? ?? ??? ??? ????? ??? nonunion?
  ?? worse outcome? ??

24
Lumbar fusions(2)

• Degenerative disc dis.?? APSFI(ant. post. Spinal
  fusion and instrumentation)?? pain-generating
  disc ??? ?? ???
• TLIF(transforaminal lumbar interbody fusion)??
  post. approach? circumferential fusion? ??? ????
  lower-risk ??
• Interbody space cylindrical cages, carbon fiber
  devices, bone ?
• Biomechanical principles obtaining rigid
  fixation, loading bone under compression,
  maintaining lumbar lordosis
• Biologic principles appropriate grafting
  material
• Autologous bone, recombinant human bone
  morphogenic protein

25
Disc replacement arthroplasty

• Spinal fusion? salvage procedure
• Reduces motion and increases stress and
  consequently degeneration at adjacent levels
• Disc replacement
• Remove painful and dysfunctional disc
• Restore physiologic motion
• ProDisc(semiconstrained device),
  Maverick(nonconstrained device), Flexcore ?
• Link SB Charite III m/c used prosthesis
• Nonconstrained design
• 2 cobalt-chrome endplates with sliding
  polyethylene core
• Increased motion in flexion extension, mobility
  in torsion, relative immobility in lateral
  bending
• Ix
• disabling LBP secondary to discogenic disc dis.
• ??? 6?? ??? ??? ???? ??? ?? ?? ??
• Exclusion criteria
• Nerve root compression, facet arthropathy

26
Spinal reconstruction

• Spine? structural integrity? ?????? deformity? ??
  normal spinal balance biomechanics? ????? ???
  ??
• Trauma, infection, tumor, scoliosis, kyphosis,
  failed spinal surgery emd
• Principles of reconstruction
• Resection soft tissue release to allow
  realignment
• Ant. column support with structural grafting,
  rigid fixation, biologic fusion
• ?? diseased tissue resection? malaligned segment?
  soft tissue release? ??
• Anterioly vertebral body resection(corpectomy)
  discectomy
• Corpectomy? structural support ?? ant. Column
  recunstruction ??
• Implants mesh cage or structural allograft or
  autograft
• ?? spinal deformity (90o ??? scoliosis?) ??? rib
  cage ??? ankylosed ?? rib head resection ??
  release ??
• Post. release ??? chevron osteotomy, rib
  resection or osteotomy, pedicle subtraction
  osteotomy ? ??

27
Spinal reconstruction(2)

• Spinal segment? ??? realigned ?? rigid fixation
  ??? ?
• Maintain alignment, effect successful fusion
• Modern instrumentation
• Hooks, sublaminar cables, pedicle screws
  connected by rods
• ? segmental instrumentation system
• Spinal fusion
• Long-term stability function ?? reconstruction
  procedure? primary goal
• Resection of articulations(disc space facet
  joint), decortication of fusion area, rigid
  stabilization, adequate volume of bone graft ??
• Biology of lumbar fusion bone graft? ??? 3 ??
• Precursor cells capable of transformation into
  bone-forming osteoblasts
• Osteoconductive materials
• Osteoinductive growth factors promote
  differentiation of progenitor cells into
  osteoblasts
• Autologous bone graft
• 3??? ?? ????? gold standard? ????
• Limitation in amount of graft, morbidity
  associated with harvesting
• Bone graft extenders (demineralized bone matrix,
  calcium carbonate, hydroxyapatite-tricalcium
  phosphate), bone graft substitutes,
  osteoinductive substitutes (BMP ?)