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Low Back Pain and Disorders of the Lumbar Spine

Low Back Pain and Disorders of the Lumbar Spine. Risk Factors. Occupational Factors (lifting-pulling-pushing-slipping Sitting-vibration-dissatisfying) Patient-Related Factors Age(55years old) Sex Anthropometric Factors Postural Factors Muscle Strength Smoking Psychosocial.

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Low Back Pain and Disorders of the Lumbar Spine

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  1. Low Back Pain and Disorders of the Lumbar Spine

  2. Risk Factors • Occupational Factors (lifting-pulling-pushing-slipping • Sitting-vibration-dissatisfying) Patient-Related Factors • Age(55years old) • Sex • Anthropometric Factors • Postural Factors • Muscle Strength • Smoking • Psychosocial

  3. EVALUATION OF THE PATIENT WITHLOW BACK PAIN Clinical Evaluation • History(mode of onset-provoking and relieving factors-effect of posture –inactivity- exertion- rest cough -sneeze –presenceat night and interference with sleep-course-ppn-weakness-urinary symptom-types of treatments implemented-PH) • MSK Examination • Neurological Examination • Straight-Leg Raising Test

  4. 15>AGE>55 • TRAUMA • PAIN AT NIGHT • HISTORY OF CANCER • WEIGHT LOSS • DRUG ABUSE • FECAL OR URIN INCONTINENCE • SADDLE ANESTHESIA • PROGRESSIVE MOTOR WEAKNESS • MARKED MORNING STIFNESS • PERIPHERAL JOINT INVOLVEMENT • SKIN RASH-COLITIS-URETHRAL DISCHARGE

  5. Mechanical Low Back Pain • A descriptive TERM • It does not point to a single or particular cause. • stress or strain to the back muscles, tendons, and ligaments • chronic, dull, aching pain of varying intensity that affects the lower spine and might spread to the buttocks. • worsens during the day. • no associated neurological symptoms or signs, • correction of static or dynamic postural abnormalities is helpful. • An exercise program consisting of abdominal and back strengthening exercise is necessary, and patients often improve quickly.

  6. Osteoarthritis • occurs with aging and can begin during the third decade of life. If the disease is symptomatic, the associated pain is centered in the lower back and is often increased with movement of the spine. • Range of motion of the spine may be limited. Pain is often relieved by rest. • Hypertrophic changes and spurs can compress nerve roots and cause additional radicular pain. • Radiographs, particularly after the early stages, are diagnostic. • When muscle support is poor, the application of an elastic support to control pain is advisable. The back support can be used for 6 weeks while attempts are made to improve the strength of the supporting muscles. • Exercises include abdominal and back muscle strengthening exercises (preferably isometric exercise

  7. Lumbar Disk Syndrome and Lumbosacral radiculopathies • Lumbar disk syndrome is a common cause of acute, chronic, or recurrent low back pain, particularly in young to middle-aged men, but it also occurs in women, older persons, and even adolescents, especially if they are involved in strenuous physical activity. • Overall, the mean age of the patient with lumbar disk herniation is the early 40s. • Disk herniation can occur in the midline, but it often occurs to one side. • Pain may be unilateral, bilateral, or bilateral but more prominent on one side. • Irritation or compression of an adjacent nerve root can occur, as is often the case with laterally extruded ("squeezed toothpaste") disk herniations (Figs. 40-10 and 40-11). • Different degrees and types of disk herniation can occur. • Bulging Disk. A bulge and convexity of the disk beyond the adjacent vertebral disk margins, but with an intact annulus fibrosus and Sharpey's fibers. • Prolapsed Disk. The disk herniates posteriorly through an incomplete defect in the annulus fibrosus.

  8. Extruded Disk. The disk herniates posteriorly through a complete defect in the annulus fibrosus • Sequestered Disk. Part of the nucleus pulposus is extruded through a complete defect in the annulus fibrosus and has lost continuity with the present nucleus pulposus. • The pain often radiates into the buttock. the posterior thigh,and lateral calf or to lateral or medial malleoli(in cases of L5 or S1 radiculopathies). • The pain radiates to the anterior thigh in L3or L4 radiculopathies. • When the disk is extruded, the low back pain is sometimes decreased or even relieved, but radicular limb symptoms become more prominent. • The most common levels of lumbar disk protrusion, herniation, or extrusion, in decreasing order of frequency, are L5-Sl, L4-L5, L3-L4, and L2-L3.

  9. Midline disk protrusion may cause low back pain but no significant radiculopathy. • Large midline disk herniations can cause bilateral radiculopathies or cauda equine syndrome severe enough to produce sphincter problems. • Upper lumbar radiculopathies are less commonly caused by disk disease. When upper lumbar radiculopathy is evaluated, other etiologic factors, particularly neoplastic disease, should be ruled out. • Examination of the back • paraspinal muscle spasm, loss of lumbar lordosis, • positive straight-leg-raising test, and, sometimes, crossed straight-leg-raising sign in cases of L5 or S1 radiculopathies. • The chin-chest maneuver might cause low back pain because of upward traction on the cord and lower nerve roots.

  10. Dorsiflexion of the foot can also cause stretching of the sciatic nerve and therefore stretching of the attached tendon nerve root, leading to pain. The same findings may be noted when the patient tries to perform heel-walkingor tries to bend forward. • Coughing, sneezing, or straining causes an increase in abdominal pressure leading to distention of epidural and intervertebral veins. • MRI has become a major diagnostic tool in the diagnosis of herniated lumbar disks • It is also very useful for demonstrating several nondiscogenic entities. However, some herniated disks may be missed by MRI. • Electromyography is very helpful for localizing the level of involvement, determining whether root involvement is single or multiple, and differentiating a multiple root from a plexus lesion.

  11. Most patients with discogenic low back pain respond to conservative management. • Operation is considered when definite radiculopathy and neurological deficits are present, especially when they are persistent or progressive. • However, in the spectrum of discogenic low back pain, patients in this group are a definite minority. • Large midline disk protrusions with cauda equina syndrome require urgent treatment and decompression. . • However, in many patients with lumbar disk syndrome, the major difficulty is low back pain with only mild, slight, or no evidence of radiculopathy. • The standard surgical procedure is open laminectomy and discectomy.

  12. Posttraumatic Compression Fracture • Posttraumatic compression fracture usually results from compressive flexion trauma. • It can also occur spontaneously in patients with osteoporosis, osteomalacia, multiple myeloma, hyperparathyroidism, and metastatic cancer. • The upper lumbar spine or the middle to lower thoracic spine is most commonly affected. • The pain usually is present immediately after the fracture and is often localized. • There may be accompanying paraspinal muscle spasm, and the range of motion of the related level of the spine is limited. • Plain radiography, CT, MRI, or bone scanning may be needed-to establish the diagnosis.

  13. Posttraumatic Compression Fracture • Sedative rehabilitative measures, especially in the acute phase, including application of cold for the first 24 to 48 hours, analgesics, and muscle relaxants, are often necessary. • The pain can be managed with use of a back support, such as a thoracolumbar support that functions on the basis of three-point contact. • For provision of extension in cases of thoracic compression fractures, the three points of contact are the base of the sternum, the symphysis pubis, and the lumbar spine, as in the Jewett brace • When therapeutic exercises are to be prescribed. extension rather than flexion exercises should be utilized. • Flexion exercises can increase the incidence of vertebral body wedging and compression fractures. Extension exercises are effective for strengthening back muscles at any age.

  14. Spondylolysis and Spondylolisthesis • Spondylolysis refers to a bony defect in the pars interarticularis. • Bilateral spondylolysis of the lumbar spine can lead to anterior slipping of the vertebral body on its adjacent vertebra and cause spondylolisthesis (in Greek, spondylo means "vertebra" and listhesis means "sliding on a slippery surface"). • Five types of spondylolisthesis: (1) dysplastic, (2) isthmic (3) degenerative, (4) traumatic, and (5) pathological. To these categories, a sixth category is sometimes added: postsurgical or iatrogenic spondylolisthesis.

  15. Spondylolysis or spondylolisthesis may cause back pain. • However, the presence of a pars defect (spondylolysis) or even spondylolisthesis in a patient with back pain does not necessarily indicate a cause-and-effect relationship. • Spondylolisthesis is two to four times more common in males. • The pars defect is at L5 in 67% of persons, at L4 in 15% to 30%, and at L3 in 2%. • It is rare in the cervical region.

  16. Spondylolisthesis can also cause compression of nerve roots and lead to radicular pain or neurological deficits in the lower extremities. • The lumbar lordosis is often exaggerated in patients with spondylolisthesis, and range of motion of the lumbar spine may be limited.

  17. For grades 1 and 2 spondylolisthesis and in older patients, nonsurgical treatment is recommended.“ • The physical therapeutic procedures consist of application of heat and massage for reduction of pain and stiffness. • Special attention can be given to reducing the tightness of the hip flexors, hamstrings, and Achilles tendons. • A program of stretching exercises is recommended. During stretching of the back and lower extremities, flexion of one hip (related knee) at a time helps reduce the strain on the lumbar spine.

  18. LUMBAR CANAL STENOSIS • DJD is the most common cause • Pseudo claudication is the most common manifestation and often is bilateral • Sensory symptoms(66%) • LBP(70%) • DTR AB.(50%) • Weakness(40%)

  19. Level of stenosis: • L4-5 L3-4 L2-3 L5-S1 T12-L1 • Treatment: strengthening the abdominal and lumbar flexors • Abdominal binder • NSAIDS • Surgical

  20. AS. • It mainly affects spine • Sacroiliitis is usually the first manifestation • Age 20-35 • Males>females • HLA-B27+(80-90%) • Morning stiffness & pain in the lower back improve with activity

  21. BACK EXT.EXC. • Deep breathing Exc. • Posture training • ROM of the proximal joints • Stretching EXC. • Flexed Posture to be avoided • HEAT & MASSAGE before EXC. • Evaluation of chest expantion(<5cm PFT) • NSAID

  22. NEOPLASTIC DISEASE HALLMARK:pain at rest particularly noctural painBony metastasis is the most common cause Sometimes spInal metastasis is the first manifestation of canser Lung-prostate-breast

  23. LBP in pregnancy • Prevalence at 49-76% • Risk factors: History of prior LBP Previous pregnancy related LBP • LBP during menses • Pregnant woman s age • The risk of IBP during pregnancydecreases with age • Pain has a peak at 36 weeks then decreases

  24. Sacroiliac pain • Nacturnal back pain • Mechanical pains

  25. LBP of pregnancy may not disappear with delivery • Other cause • Remission of RA

  26. PROPHYLAXIS • TREATMENT

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