Low Back Pain and Disorders

8/12/2019 Low Back Pain and Disorders

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Low Back Pain and

Disorders o f the Lumbar

Spine


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Risk Facto rs

Occupational Factors (lifting-pulling-pushing-slipping

Sitting-vibration-dissatisfying)

Patient -Related Facto rs

Age(55years old) Sex

Anthropometric Factors

Postural Factors

Muscle Strength

Smoking

Psychosocial


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15>AGE>55

TRAUMA

PAIN AT NIGHT

HISTORY OF CANCER

WEIGHT LOSS DRUG ABUSE

FECAL OR URIN INCONTINENCE

SADDLE ANESTHESIA

PROGRESSIVE MOTOR WEAKNESS

MARKED MORNING STIFNESS

PERIPHERAL JOINT INVOLVEMENT

SKIN RASH-COLITIS-URETHRAL DISCHARGE


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Mechanical Low Back Pain

A descriptiveTERM

It does not point to a single or particular cause.

stress or strain to the back muscles, tendons, andligaments

chronic, dul l , aching pain of vary ing intensi ty that affects

the lower spine and m ight sp read to the butto cks.

worsens dur ing the day.

no associated neurological symptoms or signs,

correction of static or dynamic postural abnormalitiesishelpful.

An exercise program consisting of abdominal and backstrengthening exerciseis necessary, and patients often

improve quickly.


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Osteoarthritis

occurs with aging and can begin during the third decade of life.

If the disease is symptomatic, the associated pain is centered in the lower backand is often increased with movementof the spine.

Range of motionof the spine may be limited. Pain is often relieved by rest.

Hypertrophic changes and spurscan compress nerve rootsand causeaddit ion al radicu lar pain.

Radiographs,particularly after the early stages, are diagnostic.

When muscle support is poor, the application of an elastic supportto controlpain is advisable. The back support can be used for 6 weekswhile attemptsare made to improve the strength of the supporting muscles.

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


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Lumbar Disk Synd rome and

Lumbosacral radiculopathies Lumbar disk syndrome is a common causeof acute, chronic, or recurrent low

back pain, particularly in young to middle-aged men,but it also occurs inwomen, older persons, and even adolescents, especially if they are involved inst renuo us phys ical act iv ity.

Overall, the mean age of the patient with lumbar disk herniation is the early 40s.

Disk herniation can occur in the midline, but it often occurs to one side.

Pain may be 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

with laterally extruded ("squeezed toothpaste") disk herniations (Figs. 40-10 and40-11).

Different degrees and types of disk herniation can occur.

Bulging Disk. A bulge and convexity of the disk beyond the adjacent vertebral

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

in the annulus fibrosus.


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Extruded Disk.The disk herniates posteriorly through a complete defectin the annulus fibrosus

Sequestered Disk. Part of the nucleus pulposus is extruded through acomplete defect in the annulus fibrosus and has lost continuity with thepresent nucleus pulposus.

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

or to lateral or medial malleoli(in cases of L5 or S1 radiculopathies).

The pain radiates to the anterior thighin L3or L4 radiculopathies.

When the disk is extruded, the low back pain is sometimes decreased or even

relieved, but radicular limb symptomsbecome more prominent.

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


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Midline disk protrusion may cause low back pain but no significantradiculopathy.

Large midline disk herniations can cause bilateralradiculopathiesor cauda equine syndromesevere enough toproduce sphincter problems.

Upper lumbar radiculopathiesare less commonly caused by diskdisease. When upper lumbar radiculopathy is evaluated, otheretiologic factors, particularly neoplastic disease,should be ruled out.

Examination of the back

paraspinal muscle spasm, loss of lumbar lordosis,

positive straight-leg-raising test, and, sometimes, crossedstraight-leg-raising signin cases of L5 or S1 radiculop athies.

The chin-chestmaneuver might cause low back pain because ofupward traction on the cord and lower nerve roots.


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Dorsiflexionof the foot can also cause stretching of the sciatic nerve andtherefore stretching of the attached tendon nerve root, leading to pain. Thesame findings may be noted when the patient tries to perform heel-walkingortries to bend forward.

Coughing, sneezing, or straining causes an increasein abdominal

pressure leading to distention of epidural and intervertebral veins.

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

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

Electromyographyis very helpful for localizing the level of involvement,determining whether root involvement is single or multiple, anddifferentiating a mu lt ip le root f rom a plexus les ion.


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Most patients with discogenic low back pain respond to conservativemanagement.

Operation is considered when definite radiculopathyand neurologicaldeficitsare present, especially when they are persistentor progressive.

However, in the spectrum of discogenic low back pain, patients in this groupare a definite minority.

Large midline disk protrusionswith cauda equinasyndromerequire urgenttreatmentand decompression. .

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

The standard surgical procedure is open laminectomy and discectomy.


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Posttraumatic Compression

Fracture Posttraumatic compression fracture usually results from compressive

flexion trauma.

It can also occur spontaneouslyin patients with osteoporosis,osteomalacia, multiple myeloma, hyperparathyroidism, andmetastatic cancer.

The upper lumbar spine or the middle to lower thoracicspine ismost commonly affected.

The painusually is present immediately after the fracture and isoften localized.

There may be accompanying paraspinal muscle spasm, and the

range of motion of the related level of the spine is limited.

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


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Posttraumatic Compression

Fracture Sedative rehabilitative measures, especially in the acute phase,

including application of cold for the first 24 to 48 hours, analgesics,and muscle relaxants, are often necessary.

The pain can be managed with use of a back support, such as athoracolumbar supportthat functions on the basis of three-point

contact. For provision of extension in cases of thoracic compression

fractures, the three points of contact are the base of the sternum, thesymphysis pubis, and the lumbar spine, as in the Jewett brace

When therapeutic exercisesare to be prescribed. extensionrather

than flexion exercises should be utilized. Flexion exercises can increase the incidence of vertebral body

wedging and compression fractures. Extension exercises are effectivefor strengthening back muscles at any age.


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Spondylo lys is and

Spondylo l is thesis

Spondylolysis refers to a bony defect in the parsinterarticularis.

Bilateral spondylolysisof the lumbar spine can lead to

anterior slipping of the vertebral body on its adjacentvertebraand cause spondylolisthesis(in Greek, spondylomeans "vertebra" and listhesis means "sliding on a slipperysurface").

Five types of spondy lol isthesis: (1) dysp last ic, (2)

isthm ic (3) degenerative, (4) traumatic, and (5)patho log ical . To these catego ries, a sixth catego ry issom et imes added: postsurg ical or iatrogenicspondylol is thesis .


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Spondylolysis or spondylolisthesis maycause back pain.

However, the presence of a pars defect (spondylolysis) oreven spondylolisthesis in a patient with back pain does not

necessari ly indicate a cause-and-effect relat ionsh ip.

Spondylolisthesis is two to four times more common inmales.

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

It is rare in the cervical region.


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Spondy lol is thesis can also cause

compression o f nerve roots and lead to

radicu lar pain or neuro log ical defic i ts in

the lower extrem it ies.

The lumbar lordos isis often exaggeratedin patients with spondylolisthesis, and range

of motion of the lumbar spine may be

limited.


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For grades 1 and 2 spondylolisthesis and in olderpatients, nonsurgical treatment isrecommended.

The physical therapeutic procedures consist ofapplication of heat and massagefor reduction ofpain and stiffness.

Special attention can be given to reduc ing thet ightness o f the hip f lexo rs, hams tr ings, and

Achi l les tendons.

A program of stretching exercisesisrecommended. Dur ing stretch ing o f the backand lower extrem it ies, f lexion o f one hip

(related knee) at a time helps reduce the strain

on the lumbar sp ine.


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LUMBAR CANAL STENOSIS

DJD is the most common cause

Pseudo claudication is the most common

manifestation and often is bilateral Sensory symptoms(66%)

LBP(70%)

DTR AB.(50%) Weakness(40%)


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Level of stenosis:

L4-5 L3-4 L2-3 L5-S1 T12-L1

Treatment:strengthening the abdominal and lumbarflexors

Abdominal binder

NSAIDS Surgical


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AS.

It mainly affects spine

Sacroiliitis is usually the first manifestation

Age 20-35

Males>females

HLA-B27+(80-90%)

Morning stiffness & pain in the lower backimprove with activity


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BACK EXT.EXC.

Deep breathing Exc.

Posture training

ROM of the proximal joints Stretching EXC.

Flexed Posture to be avoided

HEAT & MASSAGE before EXC. Evaluation of chest expantion(


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NEOPLASTIC DISEASE

HALLMARK:pain at rest particularly noctural

painBony metastasis is the most common

cause

Sometimes spInal metastasis is the first

manifestation of canser

Lung-prostate-breast


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LBP in pregnancy

Prevalence at 49-76%

Risk factors:

History of prior LBP

Previous pregnancy related LBP

LBP during menses

Pregnant woman s age

The risk of IBP during pregnancydecreases withage

Pain has a peak at 36 weeks then decreases


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Sacroiliac pain

Nacturnal back pain

Mechanical pains


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LBP of pregnancy may not disappear with

delivery

Other cause Remission of RA


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PROPHYLAXIS

TREATMENT

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Low Back Pain and Disorders