Department Of Orthopaedics & Traumatology. Sheed Suhrawardy Medical College Hospital, Dhaka-1207, Bangladesh.

BACK PAIN-

CME on -

Basic of

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Presenting By- Dr. Nabarun Biswas & Dr. Golam Mahamud Suhash,From Department Of Orthopedic & Traumatology, Shaheed Suhrawardy Medical College Hospital, Dhaka-1207. Bangladesh.

Prepared By-Dr. Md Nazrul IslamMBBS, M . sc. (B M E).

BACK PAIN

Low Back Pain

Definition-Low back pain or pain in the lumbo-sacral region is triggered by some combination of overuse, muscle strain, and injury to the muscles, ligaments, and discs that support the spine.

Low Back Pain

Epidemiology of low back pain-

• 60%–90% lifetime prevalence• 80%-90% have recurrent episode.• Second most common complaint to

prompt a medical evaluation• Leading cause of long-term work

disability• Disability and costs related to pain,

not to the disease process.

Low Back Pain

Natural history of low back pain-

• 80-90% resolves in 1 months

• 20-30% remains chronic.• 5-10% disabling

Low Back Pain Causes of

low back pain-Injury, inflammation/infection or overuse of muscles, ligaments, facet joints, and the sacroiliac joints.Pressure on nerve roots in the spinal canal. Nerve root compression can be caused by

A herniated disc, Osteoarthritis -which mostly affect the facet joints hypertrophySpondylolysis and spondylolisthesis..Spinal canal stenosis, or narrowing of the spinal canalFractures of the vertebrae.Spinal deformities, such as severe scoliosis or kyphosis.

Low Back Pain

Causes of low back pain(cont)-

Compression fractures. Compression fractures are more common among postmenopausal women with Osteoporosis.

Low Back Pain Causes of

low back pain(cont.)-

Less common spinal conditions that can cause low back pain include:

Ankylosing spondylosis Bacterial infection such as osteomyelitis/

TB Spinal tumour (primary or secondary) Pagets disease Failed back surgery syndrome. Use of steroids over a long period of time.

Low Back Pain Symptom of low Back

pain-The type, location, and severity of 

low back pain depends upon the cause

A. Due to local cause

B. Due to nerve root involvement

A. Symptom of local back sprain or

strain-

Muscle spasms, cramping, and stiffness.

Pain- mostly in the back and buttocks.

Low Back Pain

Symptom of low Back pain-2. Symptoms of nerve-root pressure- Leg pain-which is acute or chronic, mild to severe, sharp, burning or shooting in nature and this pain extends up to the ankle or foot . It may be constant or come and go and it is worsed by sneezing, coughing, straining, breath holding, walking or rest and during micturition and defaecation. This pain also depends on various position of patient such as forward or backward flexion.This is referred as Sciatica. (along the distribution of sciatic nerve)

• Sensory root involvement : pain, paraesthesia,

• Motor root involvement : muscle weakness, paresis (loss of power) of muscle, muscle wasting.

• Autonomic root involvement : Loss of bladder and bowel control known as cauda equina syndrome which requires immediate medical or surgical intervention. .

Symptom of low Back pain-

Low Back Pain

Symptoms due to arthritis of spine Pain and stiffness that are confined to

the back and hip region. This pain starts gradually and lasts longer than 3 to 6 months.

It is generally worse in the morning or after prolonged periods of inactivity. Arthritis pain gets better after some physical activities.

Low Back Pain

Symptom of low Back pain-

Symptoms or conditions that may occur with low back pain and require additional evaluation and treatment include:

• Depression• Unexplained weight loss.• Fever.• A history of cancer.• Bladder or bowel problems.• An illness or condition that affects the

immune system, such as diabetes, chemotherapy for cancer treatment, HIV (AIDS), or an organ transplant.

Low Back Pain Symptom of low Back

pain-

Risk factors that Pt cannot change-

• Being middle-aged or older.• Being male.• Having a family history of back pain.• Having had a previous back injury.• Having had a previous back surgery.• Being pregnant.• Having had compression fractures of the

spine.• Having spine problem from birth(congenital)

Low Back Pain

Risk factors of low back pain-

Risk factors that Pt can change-• Not getting regular exercise• Doing a job or other activity that requires

long periods of sitting, lifting heavy objects, bending or twisting, repetitive motions, or constant vibration

• Smoking• Excess body weight• Having poor posture. • Being under stress. • Having long periods of depression. • Using medicines long-term that weaken

bones, such as corticosteroids.

Low Back Pain Risk factors of low

back pain-

• History– Medical– Psychosocial– Family– Previous trials

• General examination– Musculoskeletal– Neurologic

Low Back Pain Diagnosis of low Back

pain-

Pain assessment: • Description• Duration• Intensity• Alleviating factors • Aggravating factors

Low Back Pain

Diagnosis of low Back pain-

• Neurologic exam– Gait. Motor, sensory and

reflexes • Regional exam of spine and leg

– Inspection for scoliosis or skin rash, palpation for bone tenderness

• Sciatic- and femoral-nerve stretching tests– SLR, reverse and contra lateral

SLR

Diagnosis of low Back pain-

Low Back Pain

• Strength tests:• L1,L2-Hip flexion (Psoas,Rectus femoris)• L2,3,4-Knee extension (Quadratus femoris)

• L2,3,4-Hip adductors (adductors and gracilis)• L5 --- Ankle/toe dorsiflexion(ant.tibialis,EHL)• L5---Hip abductors (Glutius medius,TFL)• S1—Ankle plantarflexion(soleus/gastroc.)• S1---Hip extensors (Glutius

maximus,Hamsrting)

Low Back Pain Diagnosis

of low Back pain-

Reflexes:

• L2,3,4-Quadratus femoris• L5—Medial hamstring• S1—AchillesSensation

• Pin prick-primarily spinothalamic tract

• Vibration/position sense-Dorsal columns Vibration tested with 256cps fork Position on 3-4th digit

Low Back Pain Diagnosis

of low Back pain-

• Guideline for imaging• 50 years of age.• congenital spine problems• The history and physical exam reveal signs of a

serious problem, such as( a fracture, tumor, infection, or damage or pressure on nerves.)

• History of arthritis in spine.• History of a previous spine injury or back surgery.• History of long-term steroid use or a history of

drug abuse.• Back pain > 4WKS Symptoms are worse.• Several episodes of severe pain.• Considering surgery.

Low Back Pain

Diagnosis of low Back pain-

Type of imaging• Lumbosacral x-ray studies with

flexion/ extension/oblique views

• MRI of the spine• CT with 3-D reconstruction• CT plus myelography

Low Back Pain Diagnosis of low back

pain by imaging-

Differential Diagnosis of low Back pain-

Low Back Pain

Low Back Pain Diagnosis of

low Back pain-

MRI of the spine if patient demonstrates

• “Red flags”• Neurologic deficits or progressive

neurologic signs and symptoms• Pain persisting more than 6 wk

Diagnosis of low Back pain-

Low Back Pain

General considerations• Primary therapy related to etiology• Patient expectations• Patient education related to pain

treatment• Pain treatment cost-effectiveness• Prevention of back pain exacerbations • Prevention of unnecessary surgery and

suffering (failed-back-surgery syndrome)

Low Back Pain Management of low

Back pain-

• Pharmacologic agents– Opioid analgesics– Anti-inflammatories– Adjuvants and nonopioid

analgesics• Nonpharmacologic therapies

– Rehabilitative– Interventional/surgical

Low Back Pain Management of

low Back pain-

Non opioid adjuvant analgesics• Antidepressants

– TCAs (nortriptyline, amitriptyline, desipramine)

– SSRIs (paroxetine, sertraline, fluoxetine)

– Venlafaxine• Alpha 2-adrenergic agonists

– Tizanidine, clonidine

Low Back Pain

Management of low Back pain-

• Comprehensive assessment of patients is essential to form the appropriate treatment plan.

• In the majority of cases, pharmacologic treatment is the main approach.

Low Back Pain Management of low

Back pain-

• Overall, 90% of patients will recover within 2 months without need for any invasive procedure.

• The management of acute back pain without sciatica or neurologic deficits calls for a conservative approach with analgesics and no bed rest.

Low Back Pain

Management of low Back pain-

• With sciatica and no neurologic deficits– Conservative management with analgesics– Bed rest for 2–3 d– Activities as tolerated– Neurologic consultation as needed

• With sciatica and positive neurologic deficit– Individualized length of rest– Analgesics– MRI study plus urgent neurologic or

emergent neurosurgical evaluation, according to progression of deficits and symptoms

Low Back Pain

Management of low Back pain-

Interventional/Surgical

• Disctectomy• Decompression (laminectomy,

foraminotomy)• Spinal stabilization • Vertebroplasty• Injections Epidural procedures Z- joints block Medial branch block

Low Back Pain

Management of low Back pain-

Who needs Surgery-

• Unstable spin• Acute fracture with neurological

deficit• Severe stenosis• After failure of aggressive non-

operative Rx• Tomour• Progressive neurological deficit.

Low Back Pain

Management of low Back pain-

Rehabilitative therapy-• Exercises for strength and

flexibility• Weight-control management• Behavioral relaxation

techniques• Alternative medicine and

physiatric modalities

Low Back Pain Management

of low Back pain-

• Exercise • Protect your back while sitting.• Try different sleeping position• Wear low-heeled shoes.• Maintain body weight.• Avoid Smoking –which increases

osteoporosis• Eat a nutritious diet. Getting plenty

of calcium, phosphorus, and vitamin D may help prevent osteoporosis.

• Manage the stress in life

Low Back Pain Prevention of low

back pain-

Low Back Pain Indication Of

Referral To A Specialist-

Schematic Diagram Of Management Of Low Back Pain-

Low Back Pain

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