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Common Low Back Problems

Common Low Back Problems. Daniel E. Gelb, MD Associate Professor and Vice Chair Department of Orthopaedics University of Maryland School of Medicine Baltimore, MD. Low Back Pain. Normal Experience. Disease Process. Disability. Epidemic. The Prevalence of LBP in the United States

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Common Low Back Problems

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  1. Common Low Back Problems • Daniel E. Gelb, MD • Associate Professor and Vice Chair • Department of Orthopaedics • University of Maryland School of Medicine • Baltimore, MD

  2. Low Back Pain Normal Experience Disease Process Disability Epidemic

  3. The Prevalence of LBP in the United States Annual prevalence 56% Lifetime prevalence 70% Annual prevalence frequent LBP 18% Annual prevalence LBP > 30 days 15% National Arthritis Data Workgroup 1998

  4. North American Spine Society algorithm for the treatmen of Low Back Pain Complex! Confusing!

  5. Conduit for neural elements Scaffolding for support of head and arms in space Two-Fold Function of the Spine

  6. Conduit for neural elements Intrinsic neurologic disease Extrinsic compression Scaffolding for support of head and arms in space Instability Deformity Degenerative change Two-Fold Function of the Spine

  7. Radiculopathy: nerve root disease Cervical, thoracic or lumbar Single, multilevel Myelopathy: cord disease Cervical, thoracic Myeloradiculopathy Cauda Equina Syndrome Extrinsic Compression

  8. Various Pathologies Interact in Clinical Practice Degenerative change Instability Deformity Extrinsiccompression

  9. Anatomy

  10. Anatomy and Biomechanics The functional unit of the spine is the spinal motion segment composed of 2 vertebra and the interposed 3 joint complex of disk, facets and intervertebral ligaments

  11. Anatomy and Biomechanics • Each portion of the motion segment may be subject to disease • disk • facet joint • bone • ligament

  12. The normal reciprocal spinal curvatures of cervical lordosis, thoracic kyphosis, and lumbar lordosis serve to allow efficient energy utilization to balance the torso over the lower extremities in stance Mechanically, the spine acts like a crane, with a load bearing boom in front and a tension cable (ligaments) behind

  13. Anatomy and Biomechanics Polygon of Sustentation - the imaginary“cone” in which minimal muscular activity is required to maintain upright position

  14. Loss of sagittal curvature leads to painful alteration in posture

  15. The spine is surrounded by important soft tissue structures • Vasculature • Nerves • Muscles

  16. The normal spinal cord is shorter than the spine itself. The cord ends at the thoracolumbar junction. Below this, nerve roots travel individually (caudaequina) to exit at each level to supply the muscles of the lower extremities

  17. Anatomy and Biomechanics • Pain may be due to: • destructive inability to bear load • inflammation related to arthritis • instabililty • nerve compression • spinal deformity

  18. Radiology Standing plain x-rays show anatomy and biomechanics

  19. Anatomic structures visible on plain x-ray spinous process disk superior facet pars interarticularis vertebral body inferior facet pedicle

  20. Anatomic structures visible on plain x-ray spinous process disk superior facet pars interarticularis vertebral body inferior facet pedicle

  21. Most patients do not require ANY imaging studies until pain has been present for 6-8 weeks Plain AP and lateral x-ray, CBC and ESR in combination can provide diagnosis for most patients Staiger, TO, et al, “Imaging Studies for Acute Low Back Pain” Postgraduate Medicine 105(4); 1999

  22. History of cancer Constitutional symptoms Recent infection IVDA Age over 50 Steroid use Imaging “Red Flags” • Neurologic deficit • Pain at rest

  23. All diagnostic testing only serves to substantiate or repudiate a diagnosis based on clinical history and physical examination. Non-specific changes are sufficiently common to make “diagnosis by X-ray” unreliable. Evaluation

  24. MRI CT/CT-myelogram Discography Bone scan EMG-NCVs Diagnostic Testing

  25. Non-radicular pain No red flags 4 wks; plain films Suspect infection or neoplasm MRI spondylolisthesis MRI/surgical consult Radicular pain Level clear MRI Unclear level EMG/MRI Trauma MVA Plain films Osteoporosis Plain films Suspect infection Tenderness/fever Plain films/MRI Suspect Malignancy Plain film/MRI Imaging Strategies

  26. Parasagittal MRI shows individual nerve roots exiting the neuroforamen

  27. T2 weighted MRI shows hydration status of the disks. Dark disks have lost internal architecture, hydration and are “degenerate”

  28. Annular tears 56% High Intensity Zones 47% Disk Protrusions 33% Disk Bulges 81% Disk Degeneration 72% Severe Disk Degeneration 55% Lumbar MRI Findings in Asymptomatic Population Stadnik, TW et al Radiology 206:49-55; 1998

  29. degeneration with no compression

  30. degeneration with no compression

  31. Anatomy and Biomechanics • Pain may be due to: • destructive inability to bear load • inflammation related to arthritis • instabililty • nerve compression • spinal deformity

  32. Most episodes of low back pain are benign and self-limited.

  33. Symptoms of acute low back pain resolve equally with a physician supplied booklet on back care, chiropractic or physical therapy.

  34. Acute non-specific low back pain 1) No suspicion infection/tumor 2) Maintain as close to normal activity level as possible 3) Non-narcotic pain relievers 4) Generalized Aerobic fitness 5) Tobacco cessation 6) Weight loss

  35. What does the Spine Surgeon do? • extrinsic compression - excellent • deformity - good • instability - good • degenerative change - good • intrinsic neural disease - bad • intradural pathology - neurosurgery

  36. Everyone had at least 6 weeks of symptoms High Crossover Rate No significant neurological decline in non-op group Surgical Care better than non-op care

  37. Lumbar Spinal Stenosis • Low back pain • Buttock and leg pain • Neurogenic claudication • Shopping Cart Sign

  38. Forward subluxation of one vertebra on subjacent neighbor Forward displacement of entire trunk Issues: Deformity Instability Disk degeneration Radiculopathy Spondylolisthesis

  39. Adolescent Spondylolisthesis • Rest until symptoms resolve • Bracing if symptoms persist • (adolescent > adult) • Exercise program concentrating on flexion • Gradual return to activity • radiographic f/u until maturity • Fusion • slip progression • persistent pain, hamstring tightness

  40. Questions Thank You

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