Introduction to LOW BACK PAIN
Introduction to LBPThe patient complaint is a symptom not a diagnosisSecond to Common Cold ,LBP is the most prevalent affliction of man70-80% of the world’s population experience LBP sometimes in their livesMost patients have a mechanical cause for their back pain (Muscle strain or Annular tear)
Causes of Low Back Pain
I- Mechanical Disorders Back Strain Acute Herniated Nucleus Pulposus Osteoarthritis / Spinal Stenosis Spondylolysis/Spondylolisthesis Adult ScoliosisII-Rheumatologic Disorders
Ankylosing SpondylitisReiter’s DiseasePsoriatic ArthritisEnteropathic ArthritisBehcet’s SyndromeFamilial Mediterranean FeverII-Rheumatologic Disorders
Rheumatoid ArthritisWhipple’s DiseaseDiffuse Idiopathic skeletal Hyperostosis (DISH)Vertebral OsteochondritisPolymyalgia RheumaticaFibromyalgiaIII-Infections
Vertebral Osteomyelitis Intervertebral Disk Space Infection Pyogenic Sacroilitis Herpes ZosterIV-Benign Tumors
Osteoid Osteoma Osteoblastoma Osteochondroma Giant Cell Tumor Aneurysmal Bone Cyst Hemangioma Eosinophilic Granuloma Gauchers diseaseV-Malignant Tumors
Multiple Myeloma Chondro Sarcoma Skeletal Metastasis Intra Spinal Neoplasm
VI-Endocrinological and Metabolic Disorders
Osteoporosis Osteomalacia Parathyroid Disease Pituitary Disease Heritable Genetic Disorders (Marfans Syndrome , Ehlers- Danlos Achondroplasia , Mucopolysarcoidosis syndrome )VII – Hematological Disorders Hemoglobinopathies Myelofibrosis Mastocytosis
VIII- Neurological and Psychiatric DisordersNeurological Disorders Psychiatric Disorders Malingering
IX-Referred Pain
Vascular Disorders Genitourinary Disease Gastrointestinal DiseaseX-Miscellaneous Disease
Paget’s Disease of BoneInfective EndocarditisVertebral SarcoidosisRetroperitoneal FibrosisClinical Evaluation of LBP
History Chief complaint ,Age, Sex and Duration Family History , social / occupational History Past Medical History , review of systems Present Illness : Duration and Frequency Location and Radiation Aggravating and Alleviating Factors Time of the day Quality and IntensityLoss of normal Lordosis
Physical Examination
Tests used in LBP Single straight leg raising test ( SLR ) test Bilateral SLR test Schober test Confirmatory SLR testSingle SLR test
Dynamics of the single SLR test : Tension is applied to the sciatic roots at 30 degree of elevation Sciatic roots are maximally tightened over a herniated disc between 30 and 70 degree Now additional tension is then generated with angle greater than 70 pain elicited this height of elevation may be articular or muscular in originBilateral SLR Test
The movement from 0 to 70 degree places stress on the Sacroiliac joints Above 70 stress is placed on structures in the lumbar spine Patients with psychogenic pain and positive Single SLR test frequently develop pain at a smaller degree of elevation during the Bilateral testSchober test
Measuring forward flexion of the lumbar spine 5 cm is the normal expansion This test is used in patients with Spondyloarthropathies to monitor response to therapyConfirmatory SLR test
Confirmatory SLR test A- the leg is raised until radicular symptoms are elicited B- the leg is lowered until pain is relieved The foot is then dorsiflexed , if this re-creates radicular pain , the test result is considered positiveLaboratory Tests
ESR , WBC, Platelet count, S.Calcium and Phosphorus, S.Alkaline PhosphataseS.Uric acid , S.Glucose Total protein and Serum AlbuminImmunological tests … HLA , Rh Factors Other Tests CSF , Synovial fluid , Urinalysis Biopsy SpecimensRadiological Evaluations
Plain x-ray of L.S.Spine Radionuclide Imaging (bone scan) Computerized Tomography (CT Scan) Myelography Magnetic Resonance Imaging (MRI) Other Teqniques : Tomography , Discography , Epidural Venography & Ultrasonography EMG study
TREATMENT
Medical therapyBed Rest 10 -14 daysThe lowest intradiscal pressures are recorded in the supine positionTraction : Is non – standarized conservative treatment modality for LBP and sciaticaThe basic premise of the traction is that unloading the components of the spine by stretching the muscles , ligaments and functional spinal units will decrease intradiscal pressure , thereby relieving symptomsTREATMENT
Cold (Cryotherapy ) Therapeutic cold will reduce : Pain Swelling Muscle spasm during the acute stage Reduces local metabolic activity Decrease muscle spindle activity Slows nerve conductionTREATMENT
Heat ( Thermotherapy ) I- Superficial Heat : penetrates to the level of the subcutaneous tissue Hydrocollator packs ,heating pads infrared heat and whirl pools generate superficial heat Infrared Heating II- Deep Heat : penetrates to structures below the subcutaneous tissue Short wave (Diathermy) Ultrasound generate deeper heatTREATMENT
Soft tissue injections : The local anesthetics produce their effect by blocking the depolarization of nerves inhibiting the flux of sodium ions across the membranes Side effects : systemic allergic reactions neurological toxicities range from dizziness to grand mal seizures , when high concentrations of anesthesia reach the C.N.STREATMENT
Epidural Corticosteroid injectionFor Lumbar nerve compression use of corticosteroids in the epidural space as inti-inflammatory effect on the nerve root and it’s surrounding connective tissueTREATMENT
Facet joint injection Patients with facet joint arthritis may develop pain that simulates radicular pain , the procedure requires placement of the spinal needle Corset and Braces In regard to decrease the movement of the spinePhysical therapy and Exercises
Reasons for prescription of exercise for LBP Decrease pain Strengthen weakness Stretch contracted muscles Decrease mechanical stress to spinal structures Improve fitness to prevent injury Stabilize hypermobile segment Improve posture Improve mobility