1. LOW BACK
PAIN

3. Vertebral column
The spine has four natural
curves. Two are lordotic
and two are kyphotic.
The cervical and lumbar
curves are lordotic.
The thoracic and sacral
curves are kyphotic.
The curves help to
distribute mechanical
stress as the body moves.

6. The lumbar vertebrae
• Lumbar spine. Most people
have five lumbar vertebrae
although it is not unusual to
have six.
• The lumbar vertebrae are
larger than the cervical or
thoracic as this spinal
region carries most of the
body's weight.
• Can be distinguished by
other vertebrae by their
greater size and the
absence of costal facets on
the sides of their bodies.

7. Spinal Segment

8. The Lumbar Vertebræ
the largest segments
can be distinguished by
the absence of a foramen in the transverse
process
and by the absence of facets on the sides of the
body

10. Ligaments
• 1.The anterior longitudinal
ligament (ALL)
• 2.The posterior
longitudinal ligament (PLL)
• 3.The ligamentum flavum
(LF)
• 4.The intertransverse
ligaments (ITL)
• 5.interspinous ligaments
(ISL)
• 6.The supraspinous
ligament (SSL)
• 7.The capsular ligaments
(CL)

12. • The sacroiliac joint is
the joint between the
sacrum, at the base of
the spine, and the ilium of
the pelvis, which are
joined by ligaments.
• It is a strong, weight
bearing synovial joint with
irregular elevations and
depressions that produce
interlocking of the bones.

13. • Inflammation of this joint may be caused by
sacroiliitis, one cause of disabling low back
pain. With sacroiliitis, the individual may
experience pain in the low back, buttocks and
thighs, and may also have other symptoms of a
rheumatic condition such as inflammation in the
eyes or psoriasis.

14. • Another condition of the sacroiliac joint is
called sacroiliac joint dysfunction.
• While SI joint dysfunction also causes low
back and leg pain, and results from
inflammation of the sacroiliac joint, it
differs from sacroiliitis in that its origin is a
disruption in the normal movement of the
joint (too much or too little movement in
the joint).

15. Intervertebral Disc
flat, round "cushions
act as shock absorbers
Each disc has a
strong outer ring of fibers called the
annulus, and a soft, jelly-like center called
the nucleus pulposus

16. Biomechanics of low back

17. Spine joint motion
• Determined by
• Extensibility of long ligment
• Elasticity of artic capsule
• Fluidity of disc
• Elasticity of ms

18. • TENSION
• COMPRESSION
• SHEAR
• TORTIONAL(rotational)
• BENDING(flex)

19. THE FACETS
•The shape & the articulation on each other
permit specific direction of motion.
IN the lumber region their sagittal vertical
plane permit fle. &extention but restrict lat.
Flex. &rot.
They are not weight baring .they support
only 10% to 12% of body w.
•Except in hyperlordosis and disc
degeneration

20. PHISIOLOGICAL CURVES
• CERVICAL,LUMBER LORDOSIS
DORSAL ,SACRAL KYPHOSIS. All curves
are dependent upon the lumbosacral angle to
retain its balance to the center of gravity

21. Lumbosacral angle
•It is formed of a line parallel to the top of
the sacrum & a line drawn horizontal.
AS the angle inc. the lordosis incr.
The changes in the angle occur dueto
faulty habits,lig.laxity,muscular tone

22. Low back pain
Low back pain defined as pain and
discomfort,localized below the costal
margin and above the inferior gluteal folds,
with or without referred leg pain while
chronic low back pain is defined as low
back pain persisting
for at least 12 weeks.

23. Risk factors
• Risk factors.The most
frequently reported are heavy physical
work,frequent bending ,twisting,lifting ,pulling
and pushing ,repetitive work ,static postures and
vibrations.(2)Psychosocial risk factors include
stress ,distress ,anxiety ,depression , ,,,and
mental stress Other risk factors may be
associated with low back pain as heavy lifting
,driving motor vehicles ,jogging ,weaker trunk
strength ,obesity ,pregnancy ,psychosocial
factors ,and cigarette smoking)

24. • Acute low back pain is usually self-limiting
(recovery rate 90% within 6 weeks)but 2-
7% of people develop chronic pain.
Recurrent and chronic pain account for 75
to 85% of total workers, absenteeism.

25. Causes of low back pain
• may be either mechanical (apophyseal
osteoarthritis ,degenerative disc spinal
disc herniation ,spinal stenosis ,spondylo
listhesis and other congenital
abnormalities,fracture,ligamentous strains
or sprains),

26. • inflammatory(rheumatoid arthritis,seronegative
spondylo arthropathy e.g ankylosing spondylitis),
neoplastic, metabolic (osteoprotic fracture
osteomalacia, paget`s disease)
))infectious(osteomyelitis,epidural abcess,septic
discitis
• Psychosomatic disorders,referred pain(ovarian
cyst,chronic prostatitis,colonic neoplasm)

27. Mechanical
• 95% of causes LBP
• Dt an anatomical or functional
abnormalities
• E.g lumber spondylosis ,disk prolapse
sponylolisthesis spinal stenosis
,DISH,strain and sprain

28. Lumbar spondylosis
• Most common cause of LBP common in
heavy work
• Pathology:affect central i.v joint (body to
body and post i.v j)
• The central j. affected frist, degeneration
with narrowing of i.v.d. and hyper trophy of
bone at joint margine lead to osteophytes
formation

29. • Thining tf articular cartilage lead to
decrease stability and predispose to
spondylolithesis

30. C.P
• Aching pain worse by activity, prolonged
standing or setting
• The pain often worse in the
morning,feeling of stiffness when rising
from asetting position
• Girdle pain
• Sciatica according to compression of n.
route(s.n L4,5 S1,2,3)

31. X-RAY
• NARROWING OF I.V.D SPACE
• Osteophytes formation
• Mangment
• Orthotic brace
• Exercise
• Patient education to avoid any strain for
back as heavy lifiting

32. Disc rolaps
• 95% at L4-5 or L5-S1->L5 OR S1 nerv
route comp.
• C.P , agonising pain in the lower back
radiate to buttok and back of the thigh and
calf and foot

33. Prolapsed lumbar IVD
• Herniation of part of a lumbar IVD is a common
cause of combined back pain & sciatica.
• Cause: ppt. by an injury or spontaneous age-
degeneration of disc
• L4-L5 & L5-S1 are mostly affected.
• Part of gelatinous nucleus pulposus protrudes
thro’ a rent in annulus fibrosus at its weakest
part( i.e postero-lateral) or sometimes torn
annulus itself protrudes backwards

34. Manifestation of n.r. comp.
S1L5 COMPRESSION
Weak p.f of foot absent
ankle jerk
Weak d.f of great toe
Numbness on dorsal
foot

35. Investigation
•M.R.I show disc substance and nerve
roots

36. • Imaging:
1. X-ray:is done to exclude other causes of back
pain & sciatica. very late after many months or
yrs., appreciable disc space narrowing &
spurring of j. margins( 2ndry oa)
2. MRI: will show IVD substance & n. roots
• Treatment:
I. conservative; bed rest , moulded plastic jacket
or well fitted brace for 6-12 wks.
.

37. treatment
• Conserv
Rest of spine (bed rest or brace )
Continoues or intermittent traction
Surgical (if pain not relived by conservative)

38. II. Surgical: (discectomy)
• With severe persistant sciatica preventing
sleep & deteriorating general health
• If sciatica is unrelieved by conservative t.
for at least 8 wks.
• Massive prolapse with compression of
cauda( cauda equina syn.) leading to
severe neurological disturbance

41. DISH
• Diffuse idiopathic skeletal hyper osteosis
• Marginal bone proliferation lead to formation
osseous ridges
• Ossification of paraspinal ligement(ant,post lig)
• Thoracic spine most common
sffected, cervical, lumbar also affected
• i.v.d space and s.i.j normal and this diffrentiate
dish from spondylosis and
spondyloarthoropatheis

42. • Seen in midle age and elder
• Pain minimal or absent
• Stiffness common complaint

43. spondylolysis
• Defect in neural arch of 5th ( rarely 4th) lumbar vertebrae
• Loss of bony continuity bw sup. & inf. Articular
pr., deficiency being bridged by fibrous tissue; if this is
stretched or gives way, spondylolisthesis results.
• Defect(congintal,stress #)
• U symptomless, but may cause deep lumbar back pain
• Radiography: defect is best shown in oblique projections
• treatment: unnecessary
corset or belt
close defect by bone graft
local fusion of spine

46. spondylolisthesis
• Spontaneous displacement of lumbar vert. upon the
segment next below it.
• Forward >backward
• Causes:
1. Congenital malformation of articular pr.( more common
at lumbo sacral j., u ass. With severe neurological
upset & cauda equina trapping)
2. Spondylolysis( body & sup. Articular pr. Slipping
forward leaving spinous pr. &inf. Art. Pr. In normal
relationship with sacrum)
3. OA of post. J.( commonest, wearing out of cart. Of
post. IVJ , backward rather than forward, never severe
Or neurologic disturbance)

47. • o/e: symptomless ,back ache ,step above
sacral crest( v. severe), slight restricted
spinal movements
• Treatment:
-conservative; corset
-surgical; (disability) decompression of
affected nerves followed by fusion of
affected segments

50. SPINAL STENOSIS
• LUMBAR SPINAL STENOSIS is defined
as anarrowing of the spinal canal , its
lateral recesses , and neural foramina that
may result in a compression of
lumbosacral nerve roots

51. CAUSES
• CONGENITAL
• Idiopathic
• ACQUIRED
• Degenerative
• Hypertrophy of facet joints
• Hypertrophy of ligamentum flavum
• Disc herniation
• Spondylosthesis
• Scoliosis
• IATROGENIC
• Postlaminectomy
• MISCELLANEOUS
• Paget disease
• DISH

52. C*P
• Elder man above 60
• Pain in standing and walking (heavy
aching sensation in one or both L.L)
associated with sever pain in gluteal
region
• (this pseudoclaudication resemble to
intermittinte claudication of vascular
disease , to difrentiate in between

53. • Claudication of SP stenosis induced by
walking and standing and releaved by
setting and flexing the spine(increase
canal diameter)
• Vascular system show no
abnormality, preservation of pedal pulse
• The maximal discomfort to the thighs
rather than calves

54. • Diagnosis best confirmed by MRI
• Treatment
• Modification of activities(avoid prolonged
standing)
• surgical :decompression of spinal
canal(removal of osteophytes)

57. infection
• Back pain not relived by rest or
recumbency
• Spinal tenderness over aff segm
• Elevated ESR
• Fever
• Abcess form
• WBC normal

58. • MRI most sensitive and specific for spinal
infection
• Earliest sign in spine infec loss disc height

59. Tuberculous spondylitis/ pott’s
disease
• Affection begins at ant. Margin of vertebral body
near IVD, disc itself is u affected at an earlier
stage, leading to massive & complete
destruction of one or more IVD. ant. collapse of
affected v. may lead to angular kyphosis.
• An abscess or mass of GT encroaching upon
spinal canal may interfere with spinal cord /
nerve.

60. • c/p :
1. Back pain
2. Back stiffness
3. Deformity( kyphosis)
4. Localised swelling (abscess)
5. Weakness of legs or visceral dysfunction d.t cord
affection
• o/e:
1. Pt. looks ill
2. Palpable angular kphosis
3. Restricted all spinal movements
4. Abscess
5. Spinal cord/ nerve root compression (pott’s paraplegia)

62. Pyogenic spondylitis/ spine
osteomyelitis
•Uncommon
•Similar to TB but runs a more acute
course

64. RA of spinal joints
•It’s common to affect cx. Spines , but also
thx. & lumbar spines may be likely affected
•c/p is diffuse aching pain with impaired
spinal movements

66. inflamatory
•Seen spondyloarth ,worsen by rest
, improve by activity and morning stiff

67. Ankylosing spondylitis
• Chr. Inflammation progressing slowly to bony ankylosis
of j. of spinal column & occasionally of proximal limb j.
• It begins at sacroiliac j. extending up to involve lumbar,
thx.,& often cx.spines. In worst cases hip & shoulder
affection.
• Men> women, age 15-25
• c/p : diffuse aching low bp & increasing back stiffness
with limitation of all spinal movements (poker back) & if
thx. Is affected, chest expansion is markedly reduced.
• 90% of pts. It’s HLA-B27 Ag +ve
• Treatment : unsatisfactory( medical)
special ex. To preserve remaining fn.

70. SI joint involvement “Bamboo spine”

71. Referred pain
• pelvic infection
• ovarian cyst
• Dysmenorrhoea
• Cancer(ovary or uterus)
• Endometriosis
• Cronic prostatitis
• Pyelonephritis, hydronephrosis
• Ureter obstruction
• Renal stone

72. • Inflammatory bowel disorders
• Diverticulitis
• Colonic neoplasm
• Retro peritoneal hge
• Abdominal aortic
• Pancreatitis
• Cholecystitis