Low back pain is very common, affecting over 80% of people at some point in their lifetime. While the exact cause is often unclear, imaging is usually not needed and most cases resolve within a few weeks with conservative treatment. Serious underlying causes that may require imaging or surgery include infection, cancer, fractures, or progressive neurological deficits. Physical therapy, medications, and avoiding prolonged bed rest can help acute low back pain, while cognitive behavioral therapy may help chronic cases influenced by psychological factors. Surgery is usually only indicated for severe or progressive neurological problems or cases resistant to other treatments.
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Low back pain or Backache
1. Low Back Pain
Sciatica & Disc Prolapse:
Their Evaluation & Treatment
Dr Bhaskar Borgohain
MBBS(AMC), MS (Delhi), DNB, AO Fellow (Germany)
Professor and HoD
Department of Orthopaedics
NEIGRIHMS, Shillong
www.neigrihms.gov.in
Clinical Grand Round presentation March 23, 2018, NEIGRIHMS Shillong
5. Spinal biomechanics is study of the movements of the spine;
in health & disease
Movements are so essential but
at times so bizarre
6.
7. Epidemiology & Natural history
• Over 80% of population experience some back pain
in their lifetime
(Quebec task force study on spinal disorders)
• Overall Prevalence 18%, Annual incidence 15-
20%(USA)
• Exact cause can be diagnosed in only 12-15%
• Good news: 50% recover in 2 weeks; 90% in 6 wks
• Bad news: Only 1% chronically disabled- but 80%
Hospital resources drained by this 1%
10. Low back: Lumbo-sacral Spine
• Anatomically Multi-segmental column: Connects upper
torso to the pelvis
• Function: Maintains upright position ( Spinal stability)
• While stable must allow flexibility for actions: 5 IV Discs
• During all ROMs provide a protective conduit for
neurological structures within
• Practically No rotation possible: Facet Joints of spine
11. Functional components of lumbar spine
Each Lumbar vertebra has 3
Components
• Body : To bear weight
• Neural Arches: To
protect the neural
elements
• Bony Processes: To
increase efficacy of
spinal muscle actions
12. SPINAL STABILITY SYSTEM
3 Interrelated subsystem
• Active: Actively contracting muscles (Erectors / Abdominals)
• Passive: Bone, Joints, Ligaments, Passively elongated muscles
• Neural (Control): Neural elements within the active & passive
subsystem giving Dynamic stability
16. Risk factors of low back pain
Works requiring heavy lifting
Bending and twisting; or whole-body vibration, such as
truck driving
Physical inactivity & Obesity
Arthritic spine or Osteoporotic spine fractures
Pregnancy
Age >30 years
Bad posture: Computer work
Stress or depression
Smoking
17. Classification by duration of symptoms
• Acute: Lasts < 4 weeks
– Often cause can’t be determined
– May be related to trauma or musculo-ligamentous strain
– Usually resolves within 4 weeks with self care
• Subacute: Lasts 4–12 weeks
- Transition period between acute and chronic back pain
- Improvement is not as pronounced as in the acute phase
• Chronic: Lasts >12 weeks
- Patients at risk for long-term pain or functional disability
- Episodes of pain may recur (“acute-on-chronic” symptoms)
18.
19. Simple Mechanical Backache
Vs
Sinister Backache
Green flag
• Noninflammatory backache
• No constitutional symptoms
• No obvious spinal deformity
• No neurological deficits or
tension signs
• Not in Extremes of age
Red flag
• Inflammatory
• Constitutional symptoms
• Spinal deformity
• Neurological deficits or
tension signs
• Extremes of age
46. Provocative tests in Physical exam that suggest
lumbar disc herniation or prolapse.
“Slipped Disc”.
• Straight-leg–raising test
– Passive lifting of the affected leg by the examiner
to an angle <60 degrees reproduces pain radiating
distal to knee
• Crossed straight-leg–raising test
– Passive lifting of the unaffected leg by the
examiner reproduces pain in the affected
(opposite) leg
47. • Compression fracture: Osteoporosis
– Associated with older age, white race, trauma,
prolonged corticosteroid use
Serious underlying systemic Causes
• Cancer: Malignancies
- Hx cancer: strongest risk factor for cancer-
related back pain
- Also: unexplained weight loss, no relief with
bed rest, pain lasting >1 month, Older age
48. INFLAMMATORY TYPE
• Ankylosing spondylitis
≥ 4 of following: Morning stiffness, Less pain
with exercise, onset of back pain before age 40,
slow onset of symptoms, pain persisting >3
months
• Osteomyelitis
History of IV drug use, recent infection, fever
50. Discogenic back pain
• Axial low back pain
• Sinuvertebral nerve arise from dorsal root
ganglion: non-segmental innervations
• S.V.N. Innervates posterior annulus close to
PLL is irritated
• Disc bulges on axial compression
• Axial pain begins d/t signal carried by
paravertebral sympathetic trunk
51. When to suspect nerve root involvement?
If patient presents with back & leg pain
The more distal the pain radiation, the more specific
the symptom for nerve root involvement
Pain that radiates from the back through the buttocks
to the legs (sciatica) is common
Severe or progressive motor deficits warrant urgent
evaluation
Symptoms of claudication : leg pain with exertion,
rather than with changes in position
52. • Symptoms of disk herniation
– Weakness of the ankle and great toe dorsi-flexors
– Loss of ankle reflex or sensory loss in the feet
• Symptoms of nerve root compression
- Leg pain is worse than back pain
- Straight leg-raising test is positive
- Neurologic symptoms in the foot are unilateral
• Neurologic compromise at upper motor neuron
When to suspect nerve root involvement? (continued)
53. When to suspect nerve root involvement? (continued)
• Spinal cord compression above conus medullaris
– Weakness, decreased motor control, altered muscle tone,
spasticity or clonus
• Spinal cord compression below the conus medullaris
– Cauda equina syndrome: bowel or bladder dysfunction,
saddle anesthesia, hyporeflexia
– Requires immediate imaging and surgical evaluation
54. When should clinicians consider imaging?
• If history or physical suggests specific
underlying cause
– Neurologic deficits are severe or progressive
– Serious underlying conditions are suspected
– RED FLAGS
– Use MRI (preferred) or CT
– X-Ray is often the first screening test
55. CLINICAL BOTTOM LINE: Diagnosis…
Focus on identification of features that indicate:
Potential serious underlying condition
Radiculopathy
Psychosocial factors associated with chronicity
Classify pain as acute, subacute, or chronic
Treatment options can differ with duration
Reserve imaging for when history or physical suggests specific
underlying cause and for when surgery considered
56. Mangement
• Goal: Early return to work
• Tailored to each patient
• Interdisciplinary approach
• Modify activity in acute phase
• Confirm the etiological diagnosis
57. What are reasonable goals for clinicians and
patients for treatment of low back pain?
• Acute, nonspecific low back pain
– Control pain + maintain function
– Symptoms often diminish without treatment
– Most cases resolve within 4 to 6 weeks
• Chronic low back pain
– Maintain function, even if complete resolution not
possible
– Address psychosocial factors associated with chronicity
– Focus more on interventions that increase activity than on
medical treatments
• Most patients don’t need surgery, even with herniated disks
58. What advice should clinicians give to patients
regarding level of activity and exercise?
• Prolonged inactivity is associated with worse outcomes
– Minimize bed rest
– Maintain activity levels as near to normal as possible
– As long as warning signs of serious underlying pathologic
conditions are lacking (No Red Flags)
Most patients with nonspecific occupational low back pain can
return to work quickly within days
Avoid Back-specific exercises while patient is in acute pain
59. What other physical interventions are effective?
• Superficial heat
• Traction: Mostly avoid it
• Transcutaneous electrical nerve stimulation/ TENS
• Ultrasound Therapy/ UST
• Low-level LASER therapy
• Interferential therapy/ IFT
• Short-wave diathermy/ SWD
EBM: RCTs have found low level of evidence of the benefits of various
modalities of physical therapy
60. When should drug therapies be considered,
and which drugs are effective?
• First-line drug therapy: Acetaminophen or NSAIDs
• Muscle relaxant: Controversial
• Adjunctive: Short course muscle relaxants or opiates
- Use opioids with caution, assess risk before
prescribing in elder
- Tramadol “dual-action” opioid agonist: affects
neuro-transmitters as well as weak μ-opioid
receptor affinity
61. Drug therapies in LBA…
• Antidepressants that inhibit nor-epinephrine reuptake
– Tricyclic or tetracyclic antidepressants, serotonin-norepinephrine
reuptake inhibitors
– Depression is fairly common in chronic low back pain
– Antidepressants not appropriate for acute low back pain
• Anticonvulsants (Gabapentin, Pregabalin, Carbamazepine)
– Limited evidence of efficacy in treating radiculopathy
62. Bed rest: Contradictory to the goal
• Bed rest of > 2days has serious implications
• 3% of muscle bulk/ mass is lost daily
• 6% of bone demineralized in 2 weeks
• Restriction of social activity & inability to carry out
responsibilities PPT depression, illness behavior &
lack of motivation
• Adequate sleep: of course yes, endorphin/
melatonin
64. Medications
• NSAIDs: 1ST Line
• Narcotics: Not beyond 2
weeks
• Muscle relaxant: No
role
• Antidepressant :Only if
>3 months
• Trigger point injections:
No role
• Spinal manipualation:
Controversial OR
contraindicated if disc
herniation
65. Cure Vs Curiosity in Backache
• Can we cure backache :yes
• Can we cure spondylosis: no
• Does all disc prolapse need operation: no
• Is it possible to have a normal life after a disc
prolapse: yes
• Can physiotherapy improve spinal
biomechanics: yes
66. Physical therapy
• Exercises : once acute phase is over
• Heat/Infrared/ US Therapy
• Electric Stimulation
• IFT: only if acute phase is over
• TENS: only if acute phase is over
• C fibre & Gate theory
• Endorphin?
67. Thermal therapy
• Heat : Superficial
• Infrared: Deep
• US Therapy: Deep
• Increase circulation
• Wash off cytokines
• Promote healing
• Relieve spasm
• Counterirritant
• Touch
68. DISC PROLAPSE: SURGICAL INDICATIONS
• Acute neurological complications
• Gradual but progressive neurological
deterioration
• Persistent radiating pain despite strict bed rest
and medication for 3- 4 weeks
69. DISC: TYPES OF INTERVENTIONS
• Chymopapain Injection
(Europe): Anaphylaxis
• Microdiscectomy: Good
option
• Open discectomy:
Complete Neural
decompression
• Visibility: Safety
• Laser discectomy:
Contained disc
• Endoscopic discectomy:
• Intradiscal electrothermal
therapy: Thermally ablate
the sinuvertebral nerve
fibre of posterior annulus
70. When to do disk surgery
after 3 - 4 Wks: TNF,Cytokines
CONTAINED DISCS UNCONTAINED DISCS
BULGE PROTRUSION EXTRUTION SEQUESTRATION
76. Waddell signs
• Nonorganic / psychological component
– Non-dermatomal distribution of sensory loss
– Pain on axial loading; regional weakness / sensory change
– Non-reproducibility of pain when the patient is distracted
– Exaggerated and inconsistent painful responses
77. What psychological therapies are effective?
Cognitive behavioral therapy
Best evidence for use in sub-acute or chronic low back pain
Other psychological therapies
- Evidence less conclusive
- Most effective when targeted at those with psychosocial risk factors for
chronic disabling low back pain
- Intensive inter- / multidisciplinary therapy consisting of physical,
vocational, and behavioral interventions more effective than standard care
- Important treatment option
78. What are the indications for surgical
intervention?
Suspected cord or cauda equina compression
Spinal infection
- Less urgent surgical evaluation appropriate
- Worsening suspected spinal stenosis
- Neurologic deficits
- Intractable pain that resists conservative treatment
- Role of surgery for chronic back pain without neurologic
findings is less clear
79. • Signs urgent surgical intervention may be needed
– Bowel- or bladder-sphincter dysfunction
– Diminished perineal sensation, sciatica, or sensory motor
deficits
– Severe, progressive, bilateral or unilateral motor deficits
• Other signs surgical intervention may be needed
- Weakness of the ankle and great toe dorsiflexors
- Loss of ankle reflex
- Sensory loss in the feet
- Persistent leg pain in addition to and more severe than back
pain
80. How should clinicians follow patients with
low back pain?
• Follow-up needed after 3 to 4 weeks if no
improvement
• If recovery is delayed
– Address patient response to treatment, any complications
– Assess probability of transition to subacute / chronic pain
– Reevaluate for possible underlying causes of back pain
– Ensure that psychosocial factors are addressed
- Symptoms of neurologic dysfunction or systemic disease should
prompt additional evaluation
- Reinforce healthy lifestyle messages (staying active)
- Patient education helps prevent recurrence
81. CLINICAL BOTTOM LINE: Treatment…
Most acute nonspecific pain resolves w/o medical intervention
Maintain normal activities as much as possible
If symptoms persist, consider nondrug interventions
Exercise, spinal manipulation, acupuncture, massage
Psychological therapies
If analgesia needed
First-line therapy: acetaminophen or NSAIDs
Muscle relaxants / opiates: short course only, cautiously
Antidepressants: may be helpful for chronic symptoms
Urgent surgical referral indicated: if infection, cancer, acute nerve
compression, or cauda equina syndrome suspected
Nonurgent surgical referral: if back pain persists + symptoms suggest
nonacute nerve compression or spinal stenosis
82. Case
• 46/f complaining severe
LBP
• pt was conservatively m/m
for 6 months – no relieved
with neurological
detoriation
98. Future treatments may include stem
cell therapy
• Doctors Victor Y. L. Leung, Danny Chan and Kenneth M. C.
Cheung have reported in the European Spine Journal that
"substantial progress has been made in the field of stem cell
regeneration of the intervertebral disc.
• Autogenic mesenchymal stem cells in animal models can
arrest intervertebral disc degeneration or even partially
regenerate it and the effect is suggested to be dependent on the
severity of the degeneration.
99. Preventing low back pain
• Strategies to decrease risk for low back pain
– Maintain normal body weight
– Exercise Regularly
– Avoid Back abuse/activities that can injure the
back
• EBM: Insufficient evidence to recommend
routine preventive interventions in the
primary care setting
100. Are specific preventive measures
effective for prevention?
• Certain jobs increase the risk for low back pain
– Jobs that require heavy lifting and other physical
work
• Interventions that might help prevent it
– Educational interventions
– Mechanical supports- Spinal Corsett
– Post-treatment exercise program to prevent
recurrence
• Low back pain is a common cause of lost work
days and the need for workers’ compensation.
101. CLINICAL BOTTOM LINE: Prevention…
Prevention may include
Regular exercise and maintenance of fitness
Educational interventions
Worksite prevention programs
Mechanical supports.
But evidence is insufficient to support the use of specific preventive
interventions
