Tutorial

Tutorial :

باطنية
د. وميض العمري

عدد الاوراق (5)

16-10-2012

Low back pain (LBP)

Anatomy

Pain between the lower costal margins and the gluteal folds .

Annual US prevalence is 15-20%
2nd most common symptomatic reason for visits to primary care physicians.
90% of all episodes will resolve within 6 weeks regardless of treatment . Around 20% become chronic / recurrent . 5-10% become disabling .
90% of all persons disabled for more than 1 year will never work again without intense intervention
Most common cause of disability in people younger than 45.


DEFINITIONS
Acute LBP: Back pain <6 weeks duration
Subacute LBP: back pain >6 weeks but <3 months duration
Chronic LBP: Back pain disabling the patient from some life activity >3 months
Recurrent LBP: Acute LBP in a patient who has had previous episodes of LBP from a similar location, with asymptomatic intervening intervals

RISK FACTORS FOR LBP

Several risk factors
Lack of muscle tone
Excess body weight
Poor posture
Prolonged periods of sitting
Repetitive heavy lifting
Vibration
Tall stature
Congenital abnormalities
Cigarette smoking
Stress

IMPORTANT HISTORY TOPICS IN LBP

The exact site of pain .
Pain duration .
Radiation .
Precipitating / preceding factors and their timings .
Continuity of pain .
Aggravating and relieving factors .
Sneezing / straining pain / electric shock like pain .
Leg numbness .
Sphincter discontrol .
Tendency to fall .
Constitutional (general symptoms)
Relevant extraspinal symptoms (eyes , bowel , urinary , joints , tendons )
Severity and impact .


SPINAL VS. VISCERAL CAUSES
10% visceral Causes
Abdominal / Pelvic
Renal
Posterior DU
Pancreas
Retroperitoneal lesions
Retroverted uterus
Endometriosis
Torsion of a mass : cyst , fibroid
Aneurysm
Pelvic inflammation
Cystitis , Prostatitis

PITFALLS IN LBP POINTS IN FAVOR OF SPINAL PAIN

Mechanical symptoms .
Radiation to lower limbs specially to the knee & below knee .
Relevant neurological symptoms : numbness , weakness , giving way , twists & falls .
Central pain specially with tenderness .
Scoliosis / Spinal limitation .
Relevant extraspinal manifestations .
Positive clinical tests ( e.g. SLRT ... ) .


WARNING FEATURES (RED FLAG)
Age under 20 to over 50 .
Persistent / Writhing pain .
Progressive symptoms or disability .
Unexplained systemic features .
Neurological : significant bi-radicular or multilevel features / saddle numbness or anaesthesia / sphincter dysfunction .
Tender spinal deformity .
P.M.H.: cancer / TB / Infection risks ( surgery etc ) / Porosis risks / Hematological diseases / G.A.
Clinical or investigative evidence of infection or cancer .

LBP REASSURING FEATURES

Mechanical symptoms .
Physical precipitating factors .
Relief periods .
No systemic manifestations .
No or minor root symptoms .
Age 20 55 years

MECHANICAL / DEGENERATIVE LBP ETIOLOGIES (>90%)

The lesion could be in the intervertebral disk , spinal bones , facet joints , spinal ligaments or all of them .
Lumbar strain (70%)
Degenerative disc and facets (osteoarthritis , 10%)
Herniated disc (4%)
Spinal Stenosis (3%)
Osteoporotic compression fracture (4%)
Traumatic fracture (<1%)
Congenital disease (<1%)
Kyphosis
Scoliosis
X-RAY
L5 S1 space narrowing (disc herniation) .
Secondary L5 S1 osteoarthritis .



MRI DEMONSTRATING LUMBAR DISC HERNIATION





COMPRESSION FRACTURE
The commoner causes :
Osteoporosis (fragility fracture) .
Major trauma .





NON MECHANICAL LBP ETIOLOGIES

Neoplastic
Multiple myeloma
Metastatic carcinoma
Lymphoma / Leukemia
Infective
Osteomyelits or infective spondylitis
Septic diskitis
Epidural abcess
Inflammatory spondylitis
Ankylosing spondylitis
Psoriatic spondylitis
Reiters syndrome
Inflammatory bowel disease


SPINAL TUMORS
Osteoid Osteoma or Osteoblastoma
Night Pain relieved by NSAIDs.
Get a fine cut CT scan.

DIFFERENTIATION BETWEEN INFLAMMATORY SPONDYLITIS & MECHANICAL LBP IN A YOUNG ADULT


INTERVERTEBRAL LUMBAR DISC DAMAGECLINICAL MANIFESTATIONS



IMAGING OR NOT?

Low yield without RED FLAGS present.
Abnormal findings in Asymptomatic.
Without Red Flags!
Acute pain : symptomatic treatment for 4 weeks, re-evaluate. Image if pain continues.
Subacute pain : Pain for >4wks. Failed symptomatic treatment. Image.
Significant new symptoms in chronic LBP .

MRI INDICATIONS IN LBP

Suspicion of a more serious condition e.g spinal stenosis , malignancy , infective spondylitis , surgical failure.
Planning for surgery .












PAGE 

PAGE 10

 EMBED Unknown 


90% Musculoskeletal Causes :
Mechanical
Degenerative
Inflammatory
Infective
Neoplastic


 EMBED PowerPoint.Slide.8 


 EMBED PowerPoint.Slide.8 


 EMBED PowerPoint.Slide.8