Low Back Pain

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How to diagnose LBP and basic conception on LBP

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Low Back Pain : Diagnosis and Treatment:

Low Back Pain : Diagnosis and Treatment DR.SAYEED UDDIN HELAL MBBS, MPH, CCD (Diabetology) MS in Neurosurgery (In course) Zhengzhou University, PR China .

IMPORTANCE BACK PAIN:

The annual cost for back pain in USA is between $20 and $50 billion. Most common cause of disability in patients under 45 years of age. The second most common reason for visiting a physician in USA. 1% of the US population is chronically disabled due to back pain. IMPORTANCE BACK PAIN

ANATOMY OF THE SPINE:

Vertebral bodies of spine are separated anteriorly by intervertebral discs (IVD). IVD are composed of central gelatinous nucleus pulposus (NP) surrounded by a tough cartilagenous ring, the annulus fibrosis(AF). It is responsible for 25% of spinal column length. They are largest in cervical and lumber region. Elasticity of discs will gradually lost with age. Neucleus pulposus is not pain sensitive. NP and AF both are devoid of innervations. ANATOMY OF THE SPINE

Pain sensitive structures of the spine:

Periosteum of vertebrae Dura Facet joints Annulus fibrosus Epidural veins Posterior longitudinal ligaments Pain sensitive structures of the spine

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Pain sensation is conveyed by the sinuvertebral nerve that arises from the spinal nerve at each spine segments and reenters the spinal canal through the intervertebral foramen at the same level.

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Inflammation and production of proinflammatory cytokines within the protruding or ruptured disk may trigger or perpetuate back pain. Ingrowth of nociceptive pain nerve fibres into inner portions of a diseased disk may be responsible for chronic “ diskogenic ” pain.

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Nerver root injury ( radiculopathy ) from disk herniation may be due to compression, inflammation, or both; pathologically, demyelination and axonal loss are usually present.

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Types of pain: Local Referred- spine origin affected posture, visceral origin affected does not Pain of spine: upper lumber spine- referred to lumber region, groin, ant thigh lower lumber spine- referred to buttock, post thigh, calves or feet

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Muscle spasm (mechanical): accompanied by abnormal posture, taut paraspinal muscles, flattening of lumber lordisis , dull pain. Having no neurological deficit. Forward bending( Finger-toe test) : limited. Associated with occupation-4 conditions: long sitting, long standing, Under AC, weight lifting No radiculopathy , if complain radiculopathy that is usually on both sides. Usually worsen when bending, at morning muscles of back more stiff, no claudication pain. Xray show: straightening of lumber spine

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Radiculopathy : Think about origin – upper or lower lumber, sacral or dorsal by test. Pain from dorsal spine- forward bending limited, local terderness with pain, uneasy to sit long time, lower dorsal pain radiates to front of thigh. Pain from upper lumber- forward bending limited, radiates to front of thigh, flattening of paraspinal muscle, taut muscle. Pain from lower lumber- radiates to buttocks, posterior thigh, calves even foot. Over with hip pain. Hip pain reproduced by Patrick sign, Thomas test, tapping the heel with palm while the leg is extended.

SYMPTOMS OF SIMPLE MECHANICAL LBP:

Pain varies with physical activities, usually improves with rest Sudden onset, precipitated by lifting or bending Recurrent episodes Age 20-50 Pain limited to back or upper leg, not beyond knee Para spinal muscle spasm and tenderness, uneasy n discomfort at early morning No clear-cut nerve root distribution Systemically well Prognosis good, if diagnosis early and accurately (90% recovery at 6 weeks SYMPTOMS OF SIMPLE MECHANICAL LBP

FEATURES OF NERVE ROOT PAIN:

Unilateral leg pain worse than LBP Pain radiates beyond knee Paraesthesia in same distribution Nerve irritation signs (SLR-<45º severe <30º) Motor, sensory or reflex signs ( usually limited to one nerve root) Prognosis reasonable (50% recovery at 6 weeks) FEATURES OF NERVE ROOT PAIN

FEATURES OF CES:

Difficulty in micturation Loss of anal sphincter tone or fecal incontinence Saddle anesthesia Progressive motor weakness/ gait disturbance Sensory level found FEATURES OF CES

Neurological Examination: :

Search for… weakness with/out pain muscle atrophy deep tendon jerk change diminished sensation in legs sign of spinal cord injury abdominal pain Neurological Examination:

Physical signs in Lumber root compression:

Disc level Root Sensory loss Weakness Reflex loss L3/L4 L4 Inner calf Inversion of foot knee L4/L5 L5 Outer calf and dorsum of foot Dorsiflexion of hallux / toes L5/S1 S1 Sole and Lateral foot Planter flexion Ankle Physical signs in Lumber root compression

Basic conception on SLR:

SLR: positive or negative Types: 1.Normal- Passive movement of each leg straightly upto 80°Flexion. 2.Crossed-less sensitive but more specific for disc herniation 3.Reverse- passively extending each leg while standing which stretches L 2- L 4 nerve roots and femoral nerve (positive when back /limb pain reproduced) Basic conception on SLR

INVESTIGATION:

No need to do- CBC, ESR, urine RME, CRP, X-Ray of lumber spine…if non specific ALBP (<3months) or absence of risk factors. Risk factors includes: trauma, chronic steroid use, old age, postmenopausal, H/O increased night temperature for long time, iritis , urethral discharge etc. MRI (for soft tissue structure), CT Scan. EMG –assess the functional integrity of PNS Nerve conduction study INVESTIGATION

WHEN DO MRI:

Painful spinal deformity Severe / symmetrical spinal deformity Saddle anesthesia Progressive neurological signs, foot drop/ muscle wasting Multiple level of root sign Major trauma Past medical history-Ca, TB, steroid use, HIV WHEN DO MRI

WHEN NOT TO DO MRI:

Pacemaker or metallic clip plate screw other than titanium No neurological deficit Presence of features of simple back pain Patient’s requirement Personal interest WHEN NOT TO DO MRI

DIFFERENTIAL DIAGNOSIS:

Epidural abscess Hematoma Tumor or SOL Tuberculosis/ Pott’s disease AVM DIFFERENTIAL DIAGNOSIS

TREATMENT:

For sciatica/ simple LBP: analgesia, early mobilization; bed rest does not help recovery. Instruction of back-strengthening exercises and advised to avoid physical manoeuver . Steroid injection, if symptoms due to ligamentous or joint dysfunction. Surgery: if conservative measurement is failed or progreesive neurologicval deficit develop.CES need urgent surgical decompression. TREATMENT