Understanding Understanding Low BackacheLow Backache& its & its basis of basis of treatment treatment

Bhaskar BorgohainBhaskar Borgohain MS ortho, DNB ortho, Fellow (Arthroplasty)MS ortho, DNB ortho, Fellow (Arthroplasty) Asst Professor, Department of Orthopaedics. Asst Professor, Department of Orthopaedics. NEIGRIHMSNEIGRIHMS

MOVEMENT IS LIFE

LIFE IS MOVEMENT

PAINLESS MOVEMENTPAINLESS MOVEMENTMEANS MEANS

ENJOYING A ENJOYING A QUALITY OF LIFEQUALITY OF LIFE

PAINFUL MOVEMENTSPAINFUL MOVEMENTSMEANSMEANS

JUST HAVING A LIFEJUST HAVING A LIFEOR EVEN WORSEOR EVEN WORSE

Biomechanics is nothing but the scientific Biomechanics is nothing but the scientific study of the movements of the spine;study of the movements of the spine;

in health & diseasein health & disease

Movements are so essential or at times so Movements are so essential or at times so bizarrebizarre

Low back: Lumbo-sacral SpineLow back: Lumbo-sacral Spine

Anatomically Multisegmental column: Anatomically Multisegmental column: Connects upper torso to the pelvisConnects upper torso to the pelvis

Function: Maintains upright position (Function: Maintains upright position (stabilitystability) ) Yet allow great Yet allow great flexibilityflexibility for actions: 5 Discs for actions: 5 Discs During all ROMs provide a During all ROMs provide a protective conduitprotective conduit

for neurological structures within for neurological structures within Practically No rotation possible: FacetsPractically No rotation possible: Facets

Functional components of lumbar Functional components of lumbar spinespine

Each Lumbar vertebra Each Lumbar vertebra has 3 Componentshas 3 Components

Body : To bear weightBody : To bear weight The Neural Arches: The Neural Arches:

To protect the neural To protect the neural elementselements

Bony Processes: To Bony Processes: To increase efficacy of increase efficacy of spinal muscle actionsspinal muscle actions

SPINAL STABILITY SYSTEMSPINAL STABILITY SYSTEM

3 Interrelated subsystem3 Interrelated subsystem ActiveActive: Actively contracting muscles : Actively contracting muscles

(Erectors / Abdominals)(Erectors / Abdominals) PassivePassive: Bone, Joints, Ligaments, : Bone, Joints, Ligaments,

Passively elongated musclesPassively elongated muscles NeuralNeural ( (ControlControl): Neural elements within ): Neural elements within

the active & passive subsystem giving the active & passive subsystem giving Dynamic stabilityDynamic stability

LIMITATIONSLIMITATIONS

Cadaveric:Cadaveric: Muscle contarctionsMuscle contarctions Neural controlNeural control Dynamic balancingDynamic balancing Translating lab finding to real time Translating lab finding to real time

situationssituations Clinical implicationsClinical implications

Components of Lumbar SpineComponents of Lumbar Spine

Normal biomechanics of spineNormal biomechanics of spine

Photo of a gymnastPhoto of a gymnast Endless potentialEndless potential Elastic limits: Young’s modulus Elastic limits: Young’s modulus Pathobiomechanics: LBAPathobiomechanics: LBA

Pain sensitive structures of the Pain sensitive structures of the spinespine

Ligaments: PLLLigaments: PLL Nerves: sinuvertebral nerveNerves: sinuvertebral nerve Facet joint capsuleFacet joint capsule PeriosteumPeriosteum Meningeal coveringsMeningeal coverings MusclesMuscles

LBA: The grey zoneLBA: The grey zone Biological enigmaBiological enigma Exact cause: 12-15%Exact cause: 12-15% Evolutional paradoxEvolutional paradox Proud spine in HealthProud spine in Health Terrible back in DiseaseTerrible back in Disease Back Abuse/ OveruseBack Abuse/ Overuse

Epidemiology & Natural history Epidemiology & Natural history

Over 80% of population experience some back Over 80% of population experience some back pain in their lifetime pain in their lifetime

(Quebec task force study on spinal disorders)(Quebec task force study on spinal disorders) Overall Prevalence 18%, Annual incidence 15-Overall Prevalence 18%, Annual incidence 15-

20%(USA)20%(USA) Good news: 50% recover in 2 weeks; 90% in 6 Good news: 50% recover in 2 weeks; 90% in 6

wkswks Bad news: Only 1% chronically disabledBad news: Only 1% chronically disabled Ugly truth: 80% Hospital resources drainedUgly truth: 80% Hospital resources drained

Simple Mechanical Backache Simple Mechanical Backache Vs Vs

Sinister BackacheSinister Backache

Green flagGreen flag Noninflammatory Noninflammatory

backachebackache No constitutional No constitutional

symptomssymptoms No obvious spinal No obvious spinal

deformitydeformity No neurological deficits or No neurological deficits or

tension signstension signs Not in Extremes of ageNot in Extremes of age

Red flagRed flag InflammatoryInflammatory Constitutional symptomsConstitutional symptoms Spinal deformitySpinal deformity Neurological deficits or Neurological deficits or

tension signstension signs Extremes of ageExtremes of age

MECHANICAL BACKACHEMECHANICAL BACKACHE

Nothing is gravely Nothing is gravely wrong except the wrong except the backache itselfbackache itself

Non-inflammatory, non-Non-inflammatory, non-infective & non-infective & non-neoplastic pathology neoplastic pathology

Lumbar Disc disease: Lumbar Disc disease: includedincluded

Dull backache Dull backache aggravated by activityaggravated by activity

Physical signs often Physical signs often slightslight

Neurological deficit nilNeurological deficit nil Extensive radiating Extensive radiating

pain to lower limbs pain to lower limbs absentabsent

IMPORTANCE OF IMPORTANCE OF BIOMECHANICS OF SPINE BIOMECHANICS OF SPINE

Stability Vs MobilityStability Vs Mobility Spinal motion Spinal motion

segmentssegments Disc & Facet joints Disc & Facet joints

close to nerve rootsclose to nerve roots Compressible gelCompressible gel Mobile Ball bearing Mobile Ball bearing

actionaction

BIOMECHANICAL ANATOMY BIOMECHANICAL ANATOMY

Hourglass connectionHourglass connection Dynamic balanceDynamic balance Abdominal muscle Vs Abdominal muscle Vs

erector spinae group erector spinae group of muscleof muscle

Intrathoracic pressure Intrathoracic pressure and intrabdominal and intrabdominal pressurepressure

Dynamic balanceDynamic balance

INTRADISCAL PRESSUREINTRADISCAL PRESSURE

IDP changes with IDP changes with positionposition

Sitting worse, Sitting worse, Standing better ,lying Standing better ,lying supine bestsupine best

After 6 hours After 6 hours statistically significant statistically significant reduction of normal reduction of normal disc heightdisc height

DDD (Degenerative Disc disease) DDD (Degenerative Disc disease) PathobiomechanicsPathobiomechanics

Loss of water content Loss of water content Abnormal stresses / Abnormal stresses /

biomechanicsbiomechanics Further degenerationFurther degeneration Facet degenerationFacet degeneration Disc prolapse: Weak Disc prolapse: Weak

PLLPLL Discogenic back painDiscogenic back pain

Poor blood supply: poor healing

WHOOP STRESSWHOOP STRESS

DISC SPACE LOSS: SEQUELDISC SPACE LOSS: SEQUEL

Sequel of Collapse of disc space: Sequel of Collapse of disc space: Distorted attempt to stabilityDistorted attempt to stability

Segmental spinal instability: Segmental spinal instability: Motion segment Motion segment abnormality-abnormality- All column disturbances All column disturbances

Facetopathy: Abnormal stress on facet jointsFacetopathy: Abnormal stress on facet joints Vertebral end plate sclerosisVertebral end plate sclerosis Ligamentum flavum hypertrophyLigamentum flavum hypertrophy Secondary canal stenosisSecondary canal stenosis LBA: Final common pathwayLBA: Final common pathway

DISC DESSICATIONDISC DESSICATIONPoor vascularity: Poor healingPoor vascularity: Poor healing

Discogenic back painDiscogenic back pain Axial low back painAxial low back pain Sinuvertebral nerve arise from dorsal root Sinuvertebral nerve arise from dorsal root

ganglion: non-segmental innervationsganglion: non-segmental innervations S.V.N. Innervates posterior annulus close S.V.N. Innervates posterior annulus close

to PLL is irritatedto PLL is irritated Disc bulges on axial compressionDisc bulges on axial compression Axial pain begins d/t signal carried by Axial pain begins d/t signal carried by

paravertebral sympathetic trunkparavertebral sympathetic trunk

Discogenic back painDiscogenic back pain

Mangement Mangement

Goal: Early return to workGoal: Early return to work Tailored to each patientTailored to each patient Interdisciplinary approachInterdisciplinary approach Modify activity in acute phaseModify activity in acute phase Confirming the diagnosisConfirming the diagnosis

Chronic Low BackacheChronic Low Backache

ABNORMAL POSTUREABNORMAL POSTURE

Lx lordosisLx lordosis Infancy Vs adulthoodInfancy Vs adulthood Muscle weaknessMuscle weakness Muscle fatigueMuscle fatigue

MODALITIES OF MANGEMENTMODALITIES OF MANGEMENT

Touching the back!Touching the back! Counseling: Back SchoolingCounseling: Back Schooling Posture care: Do & Don’t list Posture care: Do & Don’t list Use of firm mattressUse of firm mattress Avoiding cumulative microtrauma to Avoiding cumulative microtrauma to

spinespine Developing positive attitude: DepressionDeveloping positive attitude: Depression

Bed rest: Contradictory to the goalBed rest: Contradictory to the goal Bed rest of > 2days has serious implicationsBed rest of > 2days has serious implications 3% of muscle bulk/ mass is lost daily3% of muscle bulk/ mass is lost daily 6% of bone demineralized in 2 weeks6% of bone demineralized in 2 weeks Restriction of social activity & inability to carry Restriction of social activity & inability to carry

out responsibilities PPT depression, illness out responsibilities PPT depression, illness behavior & lack of motivationbehavior & lack of motivation

Adequate sleep: of course yes, endorphin/ Adequate sleep: of course yes, endorphin/ melatoninmelatonin

MAN Vs SUPERMAN?MAN Vs SUPERMAN?

““Man is a social animal”Man is a social animal” Anatomically & Physiologically we are nothing Anatomically & Physiologically we are nothing

but but AnimalsAnimals We are probably the only Animals that sit for 5 We are probably the only Animals that sit for 5

hours in the computer when the body is asking hours in the computer when the body is asking for rest & sleep!for rest & sleep!

Man cannot run faster than a cheetah but he can Man cannot run faster than a cheetah but he can drive at 100km/hour and stop in less than a drive at 100km/hour and stop in less than a secondsecond

Brunt is taken by the Spine,Discs and LigamentsBrunt is taken by the Spine,Discs and Ligaments

BACK SCHOOL - IBACK SCHOOL - I

Don't try to be supermanDon't try to be superman Anatomically & Physiologically we are manAnatomically & Physiologically we are man Maintain good postureMaintain good posture Take frequent break at workTake frequent break at work Use your back but don't abuse itUse your back but don't abuse it

BACK SCHOOL - IIBACK SCHOOL - II

Smoke at your own perilSmoke at your own peril Modify your activity to give rest to the tired Modify your activity to give rest to the tired

backback Never flog a tired horseNever flog a tired horse

“ “Single footstep of a man a giant leap for Single footstep of a man a giant leap for the man’s back”the man’s back”

Medications Medications

NSAIDs: 1NSAIDs: 1STST Line Line Narcotics: Not beyond Narcotics: Not beyond

2 weeks2 weeks Muscle relaxant: No Muscle relaxant: No

rolerole Antidepressant :Only Antidepressant :Only

if >3 monthsif >3 months

Trigger point Trigger point injections: No roleinjections: No role

Spinal manipualation: Spinal manipualation: Controversial OR Controversial OR contraindicated if disc contraindicated if disc herniationherniation

SIMPLE BACKACHE IS NOT SIMPLE BACKACHE IS NOT SIMPLESIMPLE

Functional restoration program involv. Functional restoration program involv. interdisciplinary approach if no narcotics or interdisciplinary approach if no narcotics or surgery neededsurgery needed

Psychological evaluation or Psychiatric Psychological evaluation or Psychiatric analysis whenever possibleanalysis whenever possible

Treat co morbid condition that may Treat co morbid condition that may aggravate LBAaggravate LBA

SIMPLE BACKACHE IS NOT SIMPLESIMPLE BACKACHE IS NOT SIMPLE Malingerers backache: Malingerers backache:

Compensation Compensation

Hoover’s TestHoover’s Test Simulation Rotation TestSimulation Rotation Test Pelvic Compression TestPelvic Compression Test Sitting SLR TestSitting SLR Test Adams anterior bending testAdams anterior bending test Sickness absenteeismSickness absenteeism

SIMPLE BACKACHE IS NOT SIMPLESIMPLE BACKACHE IS NOT SIMPLE Referred pain: High index of Referred pain: High index of

suspicionsuspicion Hips: Compensatory painHips: Compensatory pain Pelvic organsPelvic organs S.I. Joints or pelvisS.I. Joints or pelvis Renal & Retroperitoneal tumorRenal & Retroperitoneal tumor Vascular: aneurysmVascular: aneurysm

Cure Vs Curiosity in BackacheCure Vs Curiosity in Backache

Can we Can we curecure backache :yes backache :yes Can we cure spondylosis: noCan we cure spondylosis: no Does all disc prolapse need operation: noDoes all disc prolapse need operation: no Is it possible to have a Is it possible to have a normal normal life after a life after a

disc prolapse: yesdisc prolapse: yes Can physiotherapy improve spinal Can physiotherapy improve spinal

biomechanics: yesbiomechanics: yes

Physical therapyPhysical therapy Exercises : once acute phase is overExercises : once acute phase is over Heat/Infrared/ US TherapyHeat/Infrared/ US Therapy Electric StimulationElectric Stimulation IFT: only if acute phase is overIFT: only if acute phase is over TENS: only if acute phase is overTENS: only if acute phase is over C fibre & Gate theoryC fibre & Gate theory Endorphin?Endorphin?

Thermal therapyThermal therapy

Heat : SuperficialHeat : Superficial Infrared: Deep Infrared: Deep US Therapy: Deep US Therapy: Deep

Increase circulationIncrease circulation Wash off cytokinesWash off cytokines Promote healingPromote healing Relieve spasmRelieve spasm CounterirritantCounterirritant Touch Touch

Pregnancy Pregnancy

Pregnancy aggravates LBAPregnancy aggravates LBA Weight Gain & Pull Of AbdomenWeight Gain & Pull Of Abdomen Address LBA appropriately FirstAddress LBA appropriately First Surgery if indicated: Do FirstSurgery if indicated: Do First Ligament LaxityLigament Laxity OsteomalaciaOsteomalacia PhysioTh: Impractical (3PhysioTh: Impractical (3rdrd Trimester) Trimester)

Facet injectionsFacet injections

Limited Indications: Not a common source Limited Indications: Not a common source of pain of pain

Pain in spinal extension & radiation to Pain in spinal extension & radiation to back of thigh that ends above knee levelback of thigh that ends above knee level

Multiple Joints and Peculiar nerve supplyMultiple Joints and Peculiar nerve supply Doesn’t Change the Pathology: AdjunctDoesn’t Change the Pathology: Adjunct

Epidural steroids/blockEpidural steroids/block

Controversial indicationsControversial indications Decreases sciatic painDecreases sciatic pain Unpredictability: Inoperable patientUnpredictability: Inoperable patient Undermines the actual diseaseUndermines the actual disease Complications & Wrong diagnosisComplications & Wrong diagnosis

Surgery: Laminectomy:Surgery: Laminectomy:

Cauda equina syndrome: Hemilaminectomy Cauda equina syndrome: Hemilaminectomy Single Laminectomy : 14% overall instabilitySingle Laminectomy : 14% overall instability Cadaver study (Punjabi): Cadaver study (Punjabi):

Unilat. Or B/L facetectomy increasedUnilat. Or B/L facetectomy increased

63% Flexion,63% Flexion,

78% extension,78% extension,

15% lateral bending &15% lateral bending &

126% axial rotation126% axial rotation

Surgery: Spinal fusionSurgery: Spinal fusion

Rigid stabilization: Rigid stabilization: Spinal fusion Spinal fusion ++ Facetal FusionFacetal Fusion

Halts abnormal Halts abnormal biomechanics at biomechanics at fused levelfused level

ALIF or PLIF ALIF or PLIF Post. or PostlateralPost. or Postlateral Intertransverse fusionIntertransverse fusion

Posterior: Rods & Posterior: Rods & pedicular Screws pedicular Screws

Anterior: Rods & Anterior: Rods & ScrewsScrews

Address secondary Address secondary causes:causes:

3603600 0 FusionFusion

Surgery: Spinal fusionSurgery: Spinal fusion

Persistent disabling Persistent disabling Discogenic axial lowDiscogenic axial low back painback pain in absence of other organic or in absence of other organic or psychological component: psychological component: 70-80%70-80%

Multilevel discectomyMultilevel discectomy Documented instabilityDocumented instability

DISC PROLAPSE: SURGICAL DISC PROLAPSE: SURGICAL INDICATIONS INDICATIONS

Acute neurological complicationsAcute neurological complications Gradual but progressive neurological Gradual but progressive neurological

deteriorationdeterioration Persistent radiating pain despite strict bed Persistent radiating pain despite strict bed

rest and medication for 3- 4 weeksrest and medication for 3- 4 weeks

Why 3 - 4 Wks: TNF,CytokinesWhy 3 - 4 Wks: TNF,Cytokines

CONTAINED DISCS UNCONTAINED DISCS

BULGE PROTRUSION EXTRUTION SEQUESTRATION

DISC: TYPES OF INTERVENTIONSDISC: TYPES OF INTERVENTIONS

Chymopapain InjectionChymopapain Injection (Europe): Anaphylaxis(Europe): Anaphylaxis

MicrodiscectomyMicrodiscectomy: Good : Good optionoption

Open discectomyOpen discectomy: : Objectivity + Complete Objectivity + Complete Neural decompressionNeural decompression

Laser discectomy: Laser discectomy: Contained discContained disc

Endoscopic discectomy:Endoscopic discectomy: Intradiscal electrothermal Intradiscal electrothermal

therapytherapy: Thermally ablate : Thermally ablate the sinuvertebral nerve the sinuvertebral nerve fibre of posterior annulusfibre of posterior annulus

Endoscopic discectomy: Endoscopic discectomy: Transperitoneal video-assistedTransperitoneal video-assisted

Technically Technically demanding: demanding:

ComplicationsComplications Overall: 4.7% Overall: 4.7% cf cf

2.3%2.3% Vascular injury: 2.1% Vascular injury: 2.1%

to 25%to 25%

Retrograde Retrograde ejaculation: ejaculation: << 9.4% 9.4%

DVTDVT Visceral injury, Visceral injury, Paralytic ileusParalytic ileus

Dynamic stabilizationDynamic stabilization

Fusion may fail to relieve Fusion may fail to relieve painpain

Preserve movements of Preserve movements of motion segmentmotion segment

Instruments or artificial Instruments or artificial ligaments to control ligaments to control movementsmovements

Load sharing during Load sharing during movementsmovements

Don’t remove or disturb Don’t remove or disturb normal anatomynormal anatomy

Augmenting weak Augmenting weak ligaments and muscles ligaments and muscles without fusion without fusion

Graf ligament Graf ligament recontruction: mimic recontruction: mimic normal biomechanicsnormal biomechanics

Interspinous Spacer Interspinous Spacer (DIAM): no osteoporosis(DIAM): no osteoporosis

Disc replacementDisc replacement

Aim: Painless, Mobile and Stable Spine,Aim: Painless, Mobile and Stable Spine, Replaces anatomical structuresReplaces anatomical structures Correct Soft tissue tensioning crucial for Correct Soft tissue tensioning crucial for

maintaining spinal stabilitymaintaining spinal stability Pain causing structures are physically Pain causing structures are physically

removed at surgeryremoved at surgery Long term Safety: FDA ( MoM / MoP)Long term Safety: FDA ( MoM / MoP)

Gene transferGene transfer

Biochemical changes in nucleusBiochemical changes in nucleus Adenovirus as vector: rat modelAdenovirus as vector: rat model IRAP (interleukin receptor antagonist) or IRAP (interleukin receptor antagonist) or

Lac Z geneLac Z gene Increase synthesis of PGIncrease synthesis of PG Immune privileged cells of nucleusImmune privileged cells of nucleus Prophylactic injections?Prophylactic injections?

ALTERNATIVE THERAPYALTERNATIVE THERAPY

Too many options means too little knownToo many options means too little known The exact cause found in only 12-15%The exact cause found in only 12-15% Biofeedback: No role after 2 weeks of trialBiofeedback: No role after 2 weeks of trial Acupuncture: No role after 2 weeks of trialAcupuncture: No role after 2 weeks of trial Massage: breakdown adhesions Massage: breakdown adhesions YogaYoga Endorphin!Endorphin!

Summary Summary LBA In man is a biological LBA In man is a biological

enigmaenigma Mobility leads to repetitive Mobility leads to repetitive

cumulative microtraumacumulative microtrauma Microtrauma PPT Microtrauma PPT

degenerative changesdegenerative changes Microtauma progresses Microtauma progresses

to macrotrauma in to macrotrauma in prolonged back abuseprolonged back abuse

Degeneration reduces Degeneration reduces mobility Decrease mobility Decrease mobility causes muscle mobility causes muscle atrophyatrophy

Abnormal segmental Abnormal segmental motion startsmotion starts

Abnormal biomechanics Abnormal biomechanics evolvesevolves

& encroaches neural & encroaches neural elementselements

Secondarily encroaches Secondarily encroaches neural elementsneural elements

Low back Pain beginsLow back Pain begins

Thank you