Low back pain

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Low back pain :

Low back pain Presented by : IZZELDIEN HASSAN BAYIN MR : MUBARAK AWAADA UNIT

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It is very common symptoms in general population . According to the Quebec task force on spinal disorders , over 80% of the population experience some back pain at some time . The annual incidence of LBP is 15-20 % , males affected more than females . Pain is usually self-limiting with 50 % of affected patients recovering by 2 weeks .and 90% recovering by 6 weeks , only 1% is chronically disabled by back symptoms .

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If the pt stay off- work for more than 2 years because of problems of the lower back , he is unlikely to return to work at all . LBP is the most common reason for visits to the orthopedics surgeon . The patients who have LBP , have increased divorce rate , more problems with headache , GIT ulcers , and higher rate of alcoholism than the average population . There is association between chronic LBP and some psychiatric diseases .

ETIOLOGY & PATHOPHYSIOLOGY :

The exact cause of symptoms is found in only 12-15% of pt. The understanding of the anatomy of the back is important ,because LBP may originate from : the disc, vertebral body, or posterior elements or may be unrelated to the spine . Functional spinal unit or motion segment consist of two adjacent vertebrae and the intervertebral disc, which together form a 3-joint complex with the disc in front and 2 facet joints posteriorly , the motion segment involves joint capsules , Ligaments, muscles ,nerves and vessels as well, change in one joint affect the other two . Disc degeneration leads to disc space narrowing , end-plate sclerosis , abnormal stress on facet joints and ultimately facet degeneration . ETIOLOGY & PATHOPHYSIOLOGY

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Intervertebral disc act as pain generator , the posterior portion of the annulus fibrosus is innervated by fibers of the sinuvertebral nerve, which is a branch of dorsal root ganglion , irritation of the nerve responsible for axial back pain ( decompression of the nerve root at one level is unlikely to help with LBP symptoms .

PRINCIPLES OF DIAGNOSIS :

HISTORY & PHYSICAL EXAMINATION: WHAT IS THE PROBLEM ? WHICH AREAS ARE AFFECTED ? -Leg & buttocks pain are due to nerve root irritation. HOW MUCH DOES THE PAIN INTERFERE WITH SITTING , STANDING, WALKING ? Axial LBP is mechanical . PRINCIPLES OF DIAGNOSIS

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WERE THERE PREVIOUS EPISODES ? HOW LONG DID THEY LAST ? Pain considered acute if it lasts less than 6 weeks , chronic if it lasts longer than 12 weeks . ARE THERE BOWEL OR BLADDER SYMPTOMS ? -Cauda Equina syndrome .

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Physical examination is subjective and requires the patient's interpretation and cooperation . Diagnostic significance of range –of motion measurements of the spine is questionable ; +ve result in straight leg raising test is highly suggestive of nerve root irritation in young pt , but less reliable in older pt . In addition to noting a general impression of the pt and testing for sensory and motor deficiet , check the patient response to local touch ,axial loading and simulated rotation , also record the presence of other non-organic signs , pt with chronic LBP demonstrate illness behaviour and score high in non-organic signs .

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The most common cause is a lumbar strain after lifting or twisting event , or without known trauma , pt usually present with localized pain in the L/S area . In some cases radiating to buttocks , O/E there is spasm in paraspinal muscles and restriction of movement .

IMAGING STUDIES ::

RADIOGRAPHY : NOT necessary during the initial evaluation, they are indicated in patient who are older than 50 yrs and have history of trauma , cancer ,weight loss ,pain at rest, drug abuse , neurological deficiet or fever . Radiograph may appear normal , or demonstrate disc space narrowing ,osteophytes , or localized instability on lateral flexion-extension views. No relation between LBP and presence of disc space narrowing , transitional vertebra, disc vacum sign ,claw spurs , lumbar lordosis or spina bifida occulta . IMAGING STUDIES :

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Other studies : -if plain radiographs are unsuccessful in establishing the cause of the patient's problem and the pt has not responded to conservative therapy , additional imaging study may be helpful . MRI : is noninvasive and excellent in assessing compromise of the neural structures, enhanced MRI is extremely sensitive and specific test for discitis ,spinal osteomylitis , and epidural abscess.

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Caution in interpreting the results of the MRI is necessary (+ve finding are seen in asymptomatic patients who undergo MRI LUMBAR SPINES : disc herniation was found in 17% of those younger than 40 yrs . 22% between 40-59 yrs, and 36% of older than 60 %). CT SCANNING , WITH OR WITHOUT MYELOGRAPHY , especially in patients have had spinal instrumentation .or pt in critical condition ,In volunteers disc herniation was found in 35.4 % DISCOGRAM , especially if the disc degeneration is suspected to be the cause ,dye injected in to the nucleus pulposus then CT SCAN is taken( controversial )

PRINCIPLES OF TREATMENT :

The goal is early return to work , most patients can simply modify their activity during active phase . If serious pathological condition has been ruled out , more aggressive approach is warranted because bed rest for more than 2 days has serious side effect : body in catabolic state , 3% of muscle bulk is lost daily ,6% of bone is demineralized in 2 weeks , and restriction of social activities lead to illness behavior , depression , and loss of interest and motivation . Patient with acute LBP should avoid sitting and lifting . PRINCIPLES OF TREATMENT

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Mild analgesics and anti-inflammatory agents are useful in acute phase . No evidence the following treatment modalities are useful in the management of acute LBP :transcutaneous electrical nerve stimulation (TENIS) ,traction , manipulation in the presence of radical signs, acupuncture , narcotics for longer than 2 weeks, trigger point injection and muscle relaxant . Pt who have pain more than 3 weeks occasionaly benefit from anti-depressant medication

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If no narcotic analgesics are needed, surgery has ruled out , pt candidates for a functional restoration programme with physical therapist , psychologist and medical professionals. Patient with pain of discogenic origin can benefit from complete discectomy and interbody fusion .good to excellent outcomes have been reported in up to 70-80 % of pt. Disc replacement has enjoyed anew resurgence in interst .

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