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Low Back Pain

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  • 1. Low Back Pain Dr.Kishore Nallapu
  • 2. Goals
    • To recognize red flags
    • To recognize yellow flags
    • To recognize disability from simple low back pain
    • To relieve pain
    • To improve ability to function and alleviate disability
    • To prevent recurrence and the development of chronicity
  • 3. How Common?
    • 4% of GP consultations.
    • £1632 million (1998).
    • 800,000 in-patient bed-days.
    • 52 million lost working days each year in Britain.
    • Lifetime prevalence is.
    • -- >80% in adults.
    • -- >40% in adolescents.
    • Men and women are equally affected.
    • Aged 30 to 50.
  • 4. How Common Are Serious Causes ?
    • <5% have true nerve root pain
    • <1% have serious disease such as spinal tumour or infection
    • <1% have inflammatory disease such as ankylosing spondylitis
  • 5. Anatomy
  • 6.  
  • 7. Anatomy
  • 8.  
  • 9.  
  • 10.  
  • 11. Risk factors
    • Heavy physical work
    • Lifting and handling of loads
    • Awkward postures and movements
    • Whole body vibration (truck driving)
    • Trauma
  • 12. Causes
    • Mostly unknown (simple low back pain)
    • Traumatic
    • Referred pain
    • Degenerative
    • Inflammatory
    • Infective
    • Neoplastic
    • Metabolic
    • etc
  • 13. Referred pain
    • Abdomen: aortic aneurysm
    • Kidney: pyelonephritis, hydronephrosis, calculi, tumour, perinephric abscess
    • Ovary: cysts, cancer
    • Pelvis: endometriosis, period pain, pelvic inflammatory disease
    • Bladder: infections
  • 14. Degenerative and Structural
    • Spondylosis
    • Spondylolisthesis
    • Gross scoliosis and/or kyphosis
  • 15. Inflammatory Conditions
    • Ankylosing spondylitis
    • Polymyalgia rheumatica
    • Rheumatoid arthritis (rarely)
    • Coccydynia
  • 16. Infections
    • Shingles
    • Discitis
    • Osteomyelitis
    • Epidural abscess
  • 17. Metabolic Bone Disease
    • Osteoporosis
    • Osteomalacia
    • Paget's disease
  • 18. Neoplasm
    • Secondaries
    • Myeloma , etc
  • 19. Red flags
    • Spine fracture
    • Cancer or Infection
    • Cauda equina syndrome
  • 20. Red flags for spine fracture
    • Major trauma
    • Minor trauma, or even just strenuous lifting, in people with osteoporosis
    • Suspicion of secondaries
  • 21. Rx –suspected spinal #
    • X-ray
    • Refer if #, if not follow up in 10 days
    • On follow-up
    • -if fracture still suspected, or
    • -multiple sites of pain,
    • consider bone scan and referral
  • 22. Red flags for cancer or infection
    • Age > 50 years and new back pain, or age <20 years
    • History of cancer
    • Constitutional symptoms (fever, unexplained wt. loss)
    • Recent bacterial infection (e.g. UTI)
    • IVDU
    • Immune suppression
    • Pain that worsens when supine; severe night-time pain; thoracic pain
    • Structural deformity
  • 23. Rx –suspected cancer or infection
    • Check FBC,ESR, Urine analysis
    • If still concerned, consider
    • -referral
    • - bone scan, X-ray, etc.
    • Note that a negative X-ray alone does not rule out disease.
  • 24. Red flags for cauda equina syn.
    • Perianal/perineal sensory loss (Saddle anaes.)
    • Bladder dysfunction (e.g. urine retention, increased frequency, overflow incontinence)
    • Faecal incontinence
    • Neurological deficit in the lower extremities
    • Unexpected laxity of the anal sphincter
  • 25. Rx-suspected Cauda equina syn.
    • Refer immediately
  • 26. Yellow Flags
    • Belief that pain and activity are harmful
    • Sickness behaviours (extended rest)
    • Social withdrawal
    • Emotional problems
    • Problems and/or dissatisfaction at work
    • Problems with claims or compensation or time off work
    • Overprotective family; Lack of support
    • Inappropriate expectations of treatment
  • 27. How do I know my patient has simple low back pain?
    • Thorough history + brief examination
    • Red & yellow flags
    • Distinguish referred pain from nerve root pain
    • Consider diagnostic imaging only if red flags
  • 28. Chronicity
    • Acute :< 6 weeks
    • Sub-acute : 6-12 weeks
    • Chronic >12 weeks
  • 29. Complications
    • Chronicity
    • Depression
    • Disability and loss of employment
    • Cauda equina syndrome
  • 30. Table 1 . Questions for disability assessment. Dress: help required with footwear Dressing? Sexual activity reduced or curtailed Sex life? Sleep disturbed by pain at least twice a week Sleeping? Miss or curtail social activities (excluding sport) Socializing? Travel less than 30 minutes Travelling ? Walk less than 30 minutes or 1-2 miles Walking? Stand in one place: less than 30 minutes Standing? Sit in an ordinary chair: less than 30 minutes Sitting? Lift 15-20 kg, heavy suitcase, 3- to 4-year-old Bending, lifting? Standard limits Does back pain limit you in:
  • 31. Rx of Simple Low Back Pain
    • Educational advice
    • Symptom control
    • Rapid return to usual activities (incl. work)
    • Consider referral to
    • -physiotherapists
    • -osteopaths
    • -chiropractors
    • Address any psycho-social risk factors.
    • Assess response to treatment after about 4 weeks.
  • 32. Drug treatment
    • Paracetamol – 1 st choice
    • If it is unsuitable/ineffective
      • -NSAID s’ if suitable
      • -Combination : e.g. paracetamol, an NSAID, or codeine
    • Muscle relaxant (diazepam-1 st choice)
  • 33.
    • Traction
    • Electrotherapy
    • Ultrasound
    • Interferential therapy
    • Laser treatments
    • TENS - not to be confused with PENS
    Not recommended Rx
  • 34. What do I do if it remains after 4-6 weeks?
    • Reassess
    • Address concerns
    • Adjust analgesia to control pain
    • -Pcm ,NSAIDs’ ,Diazepam ,
    • -Antidepressants, Gabapentin,
    • Amitriptyline, Opioids
  • 35. not responding to analgesia ?
    • Referral
    • Multi-disciplinary (bio-psycho-social) assessment
    • Cognitive behavioural therapy
    • Spinal manipulation therapy (SMT)
    • Exercise therapy
    • Back school
  • 36. Evidence based medicine
    • Routine physiotherapy was no more effective for chronic low back pain than one session of assessment and advice from a physiotherapist [Frost et al, ‘04]
  • 37. Evidence ….
    • Exercise and spinal manipulation therapy (SMT) provide at best only modest clinical benefits
    • acupuncture is more effective than no treatment
    • acupuncture compared with other active treatments is inconclusive.
  • 38. Summary
    • Red & Yellow flags
    • Analgesia
    • Disability
    • Support
  • 39. NICE Referral guidelines
    • Cauda equina - immediately
    • Serious spinal pathology – in 1 wk
    • Progressive neurological deficit –in 1 wk
    • Nerve root pain that is not resolving after 6 weeks –in 3 wks
    • Inflammatory disorder -soon
    • Yellow flags not resolved in 3 mon-soon
  • 40.