Low Back Pain and Low Back Pain and Disorders of the Lumbar Disorders of the Lumbar

SpineSpine

Risk FactorsRisk Factors

Occupational Factors (lifting-pulling-pushing-slippingOccupational Factors (lifting-pulling-pushing-slipping Sitting-vibration-dissatisfying)Sitting-vibration-dissatisfying)

Patient-Related FactorsPatient-Related Factors Age(55years old)Age(55years old) SexSex Anthropometric FactorsAnthropometric Factors Postural FactorsPostural Factors

Muscle StrengthMuscle Strength SmokingSmoking PsychosocialPsychosocial

EVALUATION OF THE PATIENT EVALUATION OF THE PATIENT WITHWITH

LOW BACK PAINLOW BACK PAIN Clinical EvaluationClinical Evaluation History(mode of onset-provoking and relieving History(mode of onset-provoking and relieving

factors-effect of posture –inactivity- exertion- rest factors-effect of posture –inactivity- exertion- rest cough -sneeze –presenceat night and interference cough -sneeze –presenceat night and interference with sleep-course-ppn-weakness-urinary with sleep-course-ppn-weakness-urinary symptom-types of treatments implemented-PH)symptom-types of treatments implemented-PH)

MSK ExaminationMSK Examination Neurological ExaminationNeurological Examination Straight-Leg Raising TestStraight-Leg Raising Test

15>AGE>5515>AGE>55 TRAUMATRAUMA PAIN AT NIGHT PAIN AT NIGHT HISTORY OF CANCERHISTORY OF CANCER WEIGHT LOSSWEIGHT LOSS DRUG ABUSEDRUG ABUSE FECAL OR URIN INCONTINENCEFECAL OR URIN INCONTINENCE SADDLE ANESTHESIASADDLE ANESTHESIA PROGRESSIVE MOTOR WEAKNESSPROGRESSIVE MOTOR WEAKNESS MARKED MORNING STIFNESSMARKED MORNING STIFNESS PERIPHERAL JOINT INVOLVEMENTPERIPHERAL JOINT INVOLVEMENT SKIN RASH-COLITIS-URETHRAL DISCHARGESKIN RASH-COLITIS-URETHRAL DISCHARGE

Mechanical Low Back PainMechanical Low Back Pain

A A descriptivedescriptive TERM TERM It does It does not point to a single or particular causenot point to a single or particular cause.. stress or strain to the back muscles, tendons, and stress or strain to the back muscles, tendons, and

ligamentsligaments chronic, dull, aching pain of varying intensity that affects chronic, dull, aching pain of varying intensity that affects

the lower spine and the lower spine and might spread to the buttocksmight spread to the buttocks. . worsens during the dayworsens during the day.. no associated neurological symptoms or signsno associated neurological symptoms or signs, , correction of static or dynamic postural abnormalitiescorrection of static or dynamic postural abnormalities is is

helpful. helpful. An exercise program consisting of An exercise program consisting of abdominal and back abdominal and back

strengthening exercisestrengthening exercise is necessary, is necessary, and patients often and patients often improve quicklyimprove quickly..

OsteoarthritisOsteoarthritis occurs with occurs with aging aging and can begin during and can begin during the third decade of lifethe third decade of life..If the disease is If the disease is symptomaticsymptomatic, the associated pain is , the associated pain is centered in the lower back centered in the lower back

and is often and is often increased with movementincreased with movement of the spine. of the spine.

Range of motionRange of motion of the spine may be limited. Pain is often relieved by rest. of the spine may be limited. Pain is often relieved by rest. Hypertrophic changes and spursHypertrophic changes and spurs can compress can compress nerve rootsnerve roots and cause and cause

additional radicular painadditional radicular pain. . Radiographs,Radiographs, particularly after the early stages, are diagnostic. particularly after the early stages, are diagnostic. When muscle support is poor, the application of When muscle support is poor, the application of an elastic supportan elastic support to control to control

pain is advisable. The back support can be used pain is advisable. The back support can be used for 6 weeksfor 6 weeks while attempts while attempts are made to improve the strength of the supporting muscles. are made to improve the strength of the supporting muscles.

Exercises include Exercises include abdominal and back muscle strengthening exercisesabdominal and back muscle strengthening exercises (preferably isometric exercise (preferably isometric exercise

Lumbar Disk Syndrome and Lumbar Disk Syndrome and Lumbosacral radiculopathiesLumbosacral radiculopathies

Lumbar disk syndrome is a Lumbar disk syndrome is a common causecommon cause of acute, chronic, or recurrent low of acute, chronic, or recurrent low back pain, particularly in back pain, particularly in young to middle-aged men,young to middle-aged men, but it also occurs in but it also occurs in women, older persons, and even adolescents, especially if they are involved in women, older persons, and even adolescents, especially if they are involved in strenuous physical activitystrenuous physical activity..

Overall, the mean age of the patient with lumbar disk herniation is the Overall, the mean age of the patient with lumbar disk herniation is the early 40searly 40s.. Disk herniation can occur in the midline, but it often occurs to one side. Disk herniation can occur in the midline, but it often occurs to one side. Pain may be Pain may be unilateral, bilateral, or bilateral but more prominent on one side.unilateral, bilateral, or bilateral but more prominent on one side. Irritation or compression of an adjacent nerve root can occur, as is often the case Irritation or compression of an adjacent nerve root can occur, as is often the case

with laterally extruded ("squeezed toothpaste") disk herniations (Figs. 40-10 and with laterally extruded ("squeezed toothpaste") disk herniations (Figs. 40-10 and 40-11).40-11).

Different degrees and types of disk herniation can occur. Different degrees and types of disk herniation can occur. Bulging DiskBulging Disk. A bulge and convexity of the disk beyond the adjacent vertebral . A bulge and convexity of the disk beyond the adjacent vertebral

disk margins, but with an disk margins, but with an intact annulus fibrosus and Sharpey's fibersintact annulus fibrosus and Sharpey's fibers.. ProlapsedProlapsed Disk.Disk. The disk herniates posteriorly through an incomplete The disk herniates posteriorly through an incomplete

defect in the annulus fibrosus.defect in the annulus fibrosus.

ExtrudedExtruded Disk.Disk. The disk herniates posteriorly through a The disk herniates posteriorly through a complete complete defectdefect in the annulus fibrosus in the annulus fibrosus

Sequestered DiskSequestered Disk. Part of the nucleus pulposus is extruded through a . Part of the nucleus pulposus is extruded through a complete defect in the annulus fibrosus and complete defect in the annulus fibrosus and has lost continuity with the has lost continuity with the present nucleus pulposuspresent nucleus pulposus..

The pain The pain often radiates into the buttock.often radiates into the buttock. the the posterior thighposterior thigh,and ,and lateral calflateral calf

or to or to lateral or medial malleolilateral or medial malleoli(in cases of L5 or S1 radiculopathies).(in cases of L5 or S1 radiculopathies). The pain radiates to the The pain radiates to the anterior thighanterior thigh in L3or L4 radiculopathies. in L3or L4 radiculopathies.

When the disk is extruded, the low back pain is sometimes decreased or even When the disk is extruded, the low back pain is sometimes decreased or even relieved, relieved, but radicular limb symptomsbut radicular limb symptoms become more prominent. become more prominent.

The most common levels of lumbar disk protrusion, herniation, or extrusion, in The most common levels of lumbar disk protrusion, herniation, or extrusion, in decreasing order of frequency, are decreasing order of frequency, are L5-Sl, L4-L5, L3-L4, and L2-L3L5-Sl, L4-L5, L3-L4, and L2-L3. .

Midline disk protrusion may cause Midline disk protrusion may cause low back pain but no significant low back pain but no significant radiculopathy.radiculopathy.

Large midline disk herniationsLarge midline disk herniations can cause can cause bilateral radiculopathiesbilateral radiculopathies or or cauda equine syndromecauda equine syndrome severe enough to produce sphincter severe enough to produce sphincter problems. problems.

Upper lumbar radiculopathiesUpper lumbar radiculopathies are less commonly caused by disk are less commonly caused by disk disease. When upper lumbar radiculopathy is evaluated, other disease. When upper lumbar radiculopathy is evaluated, other etiologic factors, particularly etiologic factors, particularly neoplastic disease,neoplastic disease, should be ruled out. should be ruled out.

Examination of the backExamination of the back

paraspinal muscle spasmparaspinal muscle spasm, , loss of lumbar lordosisloss of lumbar lordosis, ,

positive positive straight-leg-raising teststraight-leg-raising test, and, sometimes, , and, sometimes, crossed crossed straight-leg-raising signstraight-leg-raising sign in cases of in cases of L5 or S1 radiculopathiesL5 or S1 radiculopathies. .

The The chin-chestchin-chest maneuver might cause low back pain because of maneuver might cause low back pain because of upward traction on the cord and lower nerve roots. upward traction on the cord and lower nerve roots.

DorsiflexionDorsiflexion of the foot can also cause stretching of the sciatic nerve and of the foot can also cause stretching of the sciatic nerve and therefore stretching of the attached tendon nerve root, leading to pain. The therefore stretching of the attached tendon nerve root, leading to pain. The same findings may be noted when the patient tries to perform same findings may be noted when the patient tries to perform heel-walkingheel-walking or or tries to tries to bend forwardbend forward..

Coughing, sneezing, or straining causes an increaseCoughing, sneezing, or straining causes an increase in abdominal in abdominal pressure leading to distention of epidural and intervertebral veins. pressure leading to distention of epidural and intervertebral veins.

MRI has become a major diagnostic tool in the diagnosis of herniated lumbar MRI has become a major diagnostic tool in the diagnosis of herniated lumbar disks disks

It is also very useful for demonstrating It is also very useful for demonstrating several nondiscogenic entitiesseveral nondiscogenic entities. . However, some herniated disks may be missed by MRI.However, some herniated disks may be missed by MRI.

ElectromyographyElectromyography is very helpful for localizing the is very helpful for localizing the level of involvementlevel of involvement, , determining whether determining whether root involvement is single or multipleroot involvement is single or multiple, and , and differentiating a differentiating a multiple root from a plexus lesionmultiple root from a plexus lesion..

Most patients with discogenic low back pain respond to Most patients with discogenic low back pain respond to conservative conservative managementmanagement..

Operation is considered when Operation is considered when definite radiculopathydefinite radiculopathy and and neurological neurological deficitsdeficits are present, especially when they are are present, especially when they are persistentpersistent or or progressiveprogressive. .

However, in the spectrum of discogenic low back pain, patients in this group However, in the spectrum of discogenic low back pain, patients in this group are a are a definite definite minorityminority. .

Large midline disk protrusionsLarge midline disk protrusions with with cauda equinacauda equina syndrome syndrome require require urgent urgent treatmenttreatment and decompression. . and decompression. .

However, in many patients with lumbar disk syndrome, the major difficulty is However, in many patients with lumbar disk syndrome, the major difficulty is low back pain with only mild, slight, or no evidence of radiculopathylow back pain with only mild, slight, or no evidence of radiculopathy . .

The standard surgical procedure is open The standard surgical procedure is open laminectomy and discectomylaminectomy and discectomy. .

Posttraumatic Compression Posttraumatic Compression FractureFracture

Posttraumatic compression fracture usually results from Posttraumatic compression fracture usually results from compressive compressive flexion trauma. flexion trauma.

It can also occur It can also occur spontaneouslyspontaneously in patients with in patients with osteoporosis, osteoporosis, osteomalacia, multiple myeloma, hyperparathyroidism, and osteomalacia, multiple myeloma, hyperparathyroidism, and metastatic cancermetastatic cancer. .

The The upper lumbar spine or the middle to lower thoracicupper lumbar spine or the middle to lower thoracic spine is spine is most commonly affected. most commonly affected.

The The painpain usually is present usually is present immediately after the fracture and is immediately after the fracture and is often localizedoften localized. .

There may be accompanying There may be accompanying paraspinal muscle spasmparaspinal muscle spasm, and the , and the range of motion of the related level of the spine is limitedrange of motion of the related level of the spine is limited..

Plain radiography, CT, MRI, or bone scanning may be needed-to Plain radiography, CT, MRI, or bone scanning may be needed-to establish the diagnosis.establish the diagnosis.

Posttraumatic Compression Posttraumatic Compression FractureFracture

Sedative rehabilitative measuresSedative rehabilitative measures, especially in the , especially in the acute phaseacute phase, , including application of including application of cold for the first 24 to 48 hourscold for the first 24 to 48 hours, , analgesics, analgesics, and muscle relaxants, are often necessaryand muscle relaxants, are often necessary. .

The pain can be managed with use of a The pain can be managed with use of a back supportback support, such as a , such as a thoracolumbar supportthoracolumbar support that functions on the basis of that functions on the basis of three-point three-point contactcontact. .

For For provision of extension provision of extension in cases of thoracic compression in cases of thoracic compression fractures, the three points of contact are the base of the sternum, the fractures, the three points of contact are the base of the sternum, the symphysis pubis, and the lumbar spine, as in the symphysis pubis, and the lumbar spine, as in the Jewett braceJewett brace

When When therapeutic exercisestherapeutic exercises are to be prescribed. are to be prescribed. extensionextension rather rather than flexion exercises should be utilized. than flexion exercises should be utilized.

Flexion exercises can increase the incidence of vertebral body Flexion exercises can increase the incidence of vertebral body wedging and compression fractures. Extension exercises are effective wedging and compression fractures. Extension exercises are effective for strengthening back muscles at any age. for strengthening back muscles at any age.

Spondylolysis and Spondylolysis and SpondylolisthesisSpondylolisthesis

Spondylolysis refers to a bony defect in the Spondylolysis refers to a bony defect in the pars pars interarticularisinterarticularis. .

Bilateral spondylolysisBilateral spondylolysis of the lumbar spine can lead to of the lumbar spine can lead to anterior slipping of the vertebral body on its adjacent anterior slipping of the vertebral body on its adjacent vertebravertebra and and cause spondylolisthesiscause spondylolisthesis (in Greek, spondylo (in Greek, spondylo means "vertebra" and listhesis means "sliding on a slippery means "vertebra" and listhesis means "sliding on a slippery surface").surface").

Five types of spondylolisthesis: (1) dysplastic, (2) Five types of spondylolisthesis: (1) dysplastic, (2) isthmic (3) degenerative, (4) traumatic, and (5) isthmic (3) degenerative, (4) traumatic, and (5) pathological. To these categories, a sixth category is pathological. To these categories, a sixth category is sometimes added: postsurgical or iatrogenic sometimes added: postsurgical or iatrogenic spondylolisthesis.spondylolisthesis.

Spondylolysis or spondylolisthesis Spondylolysis or spondylolisthesis maymay cause cause back painback pain. .

However, the presence of a pars defect (spondylolysis) or However, the presence of a pars defect (spondylolysis) or even spondylolisthesis in a patient with back pain does even spondylolisthesis in a patient with back pain does not not necessarily indicate a cause-and-effect relationshipnecessarily indicate a cause-and-effect relationship. .

Spondylolisthesis is Spondylolisthesis is two to four times more common in two to four times more common in malesmales. .

The pars defect is at The pars defect is at L5 in 67% of personsL5 in 67% of persons, at , at L4 in 15% L4 in 15% to 30to 30%, and at %, and at L3 in 2%.L3 in 2%.

It is It is rare in the cervical regionrare in the cervical region. .

Spondylolisthesis can also cause Spondylolisthesis can also cause compression of nerve roots and lead to compression of nerve roots and lead to radicular pain or neurological deficits in radicular pain or neurological deficits in the lower extremitiesthe lower extremities. .

The The lumbar lordosislumbar lordosis is often is often exaggeratedexaggerated in patients with spondylolisthesis, and in patients with spondylolisthesis, and range range of motion of motion of the lumbar spine may be of the lumbar spine may be limitedlimited. .

For grades 1 and 2 spondylolisthesis and in older For grades 1 and 2 spondylolisthesis and in older patients, patients, nonsurgical treatment is nonsurgical treatment is recommendedrecommended.“.“

The physical therapeutic procedures consist of The physical therapeutic procedures consist of application of application of heat and massageheat and massage for for reduction of reduction of pain and stiffnesspain and stiffness. .

Special attention can be given to Special attention can be given to reducing the reducing the tightness of the hip flexors, hamstrings, and tightness of the hip flexors, hamstrings, and Achilles tendonsAchilles tendons..

A program of A program of stretching exercisesstretching exercises is is recommended. recommended. During stretching of the back During stretching of the back and lower extremities, flexion of one hip and lower extremities, flexion of one hip (related knee) at a time helps reduce the strain (related knee) at a time helps reduce the strain on the lumbar spineon the lumbar spine..

LUMBAR CANAL STENOSISLUMBAR CANAL STENOSIS

DJD is the most common causeDJD is the most common cause Pseudo claudication is the most common Pseudo claudication is the most common

manifestation and often is bilateralmanifestation and often is bilateral Sensory symptoms(66%)Sensory symptoms(66%) LBP(70%)LBP(70%) DTR AB.(50%)DTR AB.(50%) Weakness(40%)Weakness(40%)

Level of stenosis:Level of stenosis: L4-5 L3-4 L2-3 L5-S1 T12-L1L4-5 L3-4 L2-3 L5-S1 T12-L1 Treatment: Treatment:

strengthening the abdominal and strengthening the abdominal and lumbar flexorslumbar flexors

Abdominal binderAbdominal binder NSAIDSNSAIDS SurgicalSurgical

AS.AS.

It mainly affects spineIt mainly affects spine Sacroiliitis is usually the first manifestationSacroiliitis is usually the first manifestation Age 20-35Age 20-35 Males>femalesMales>females HLA-B27+(80-90%)HLA-B27+(80-90%) Morning stiffness & pain in the lower back Morning stiffness & pain in the lower back

improve with activityimprove with activity

BACK EXT.EXC.BACK EXT.EXC. Deep breathing Exc.Deep breathing Exc. Posture trainingPosture training ROM of the proximal jointsROM of the proximal joints Stretching EXC.Stretching EXC. Flexed Posture to be avoidedFlexed Posture to be avoided HEAT & MASSAGE before EXC.HEAT & MASSAGE before EXC. Evaluation of chest expantion(<5cm PFT)Evaluation of chest expantion(<5cm PFT) NSAIDNSAID

NEOPLASTIC DISEASENEOPLASTIC DISEASE

HALLMARK:pain at rest particularly noctural HALLMARK:pain at rest particularly noctural painBony metastasis is the most common painBony metastasis is the most common causecause

Sometimes spInal metastasis is the first Sometimes spInal metastasis is the first manifestation of cansermanifestation of canser

Lung-prostate-breastLung-prostate-breast

LBP in pregnancyLBP in pregnancy

Prevalence at 49-76%Prevalence at 49-76% Risk factors: Risk factors:

History of prior LBP History of prior LBP Previous pregnancy related LBP Previous pregnancy related LBP

LBP during mensesLBP during menses Pregnant woman s agePregnant woman s age The risk of IBP during pregnancyThe risk of IBP during pregnancy decreases with decreases with

ageage Pain has a peak at 36 weeks then decreasesPain has a peak at 36 weeks then decreases

Sacroiliac painSacroiliac pain Nacturnal back painNacturnal back pain Mechanical painsMechanical pains

LBP of pregnancy may not disappear with LBP of pregnancy may not disappear with deliverydelivery

Other causeOther cause Remission of RARemission of RA

PROPHYLAXISPROPHYLAXIS TREATMENTTREATMENT