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Low back pain

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  • 1. LOW BACKPAIN
  • 2. Vertebral columnThe spine has four naturalcurves. Two are lordoticand two are kyphotic.The cervical and lumbarcurves are lordotic.The thoracic and sacralcurves are kyphotic.The curves help todistribute mechanicalstress as the body moves.
  • 3. The lumbar vertebrae• Lumbar spine. Most peoplehave five lumbar vertebraealthough it is not unusual tohave six.• The lumbar vertebrae arelarger than the cervical orthoracic as this spinalregion carries most of thebodys weight.• Can be distinguished byother vertebrae by theirgreater size and theabsence of costal facets onthe sides of their bodies.
  • 4. Spinal Segment
  • 5. The Lumbar Vertebræthe largest segmentscan be distinguished bythe absence of a foramen in the transverseprocessand by the absence of facets on the sides of thebody
  • 6. Ligaments• 1.The anterior longitudinalligament (ALL)• 2.The posteriorlongitudinal ligament (PLL)• 3.The ligamentum flavum(LF)• 4.The intertransverseligaments (ITL)• 5.interspinous ligaments(ISL)• 6.The supraspinousligament (SSL)• 7.The capsular ligaments(CL)
  • 7. • The sacroiliac joint isthe joint between thesacrum, at the base ofthe spine, and the ilium ofthe pelvis, which arejoined by ligaments.• It is a strong, weightbearing synovial joint withirregular elevations anddepressions that produceinterlocking of the bones.
  • 8. • Inflammation of this joint may be caused bysacroiliitis, one cause of disabling low backpain. With sacroiliitis, the individual mayexperience pain in the low back, buttocks andthighs, and may also have other symptoms of arheumatic condition such as inflammation in theeyes or psoriasis.
  • 9. • Another condition of the sacroiliac joint iscalled sacroiliac joint dysfunction.• While SI joint dysfunction also causes lowback and leg pain, and results frominflammation of the sacroiliac joint, itdiffers from sacroiliitis in that its origin is adisruption in the normal movement of thejoint (too much or too little movement inthe joint).
  • 10. Intervertebral Discflat, round "cushionsact as shock absorbersEach disc has astrong outer ring of fibers called theannulus, and a soft, jelly-like center calledthe nucleus pulposus
  • 11. Biomechanics of low back
  • 12. Spine joint motion• Determined by• Extensibility of long ligment• Elasticity of artic capsule• Fluidity of disc• Elasticity of ms
  • 13. • TENSION• COMPRESSION• SHEAR• TORTIONAL(rotational)• BENDING(flex)
  • 14. THE FACETS•The shape & the articulation on each otherpermit specific direction of motion.IN the lumber region their sagittal verticalplane permit fle. &extention but restrict lat.Flex. &rot.They are not weight baring .they supportonly 10% to 12% of body w.•Except in hyperlordosis and discdegeneration
  • 15. PHISIOLOGICAL CURVES• CERVICAL,LUMBER LORDOSISDORSAL ,SACRAL KYPHOSIS. All curvesare dependent upon the lumbosacral angle toretain its balance to the center of gravity
  • 16. Lumbosacral angle•It is formed of a line parallel to the top ofthe sacrum & a line drawn horizontal.AS the angle inc. the lordosis incr.The changes in the angle occur duetofaulty habits,lig.laxity,muscular tone
  • 17. Low back painLow back pain defined as pain anddiscomfort,localized below the costalmargin and above the inferior gluteal folds,with or without referred leg pain whilechronic low back pain is defined as lowback pain persistingfor at least 12 weeks.
  • 18. Risk factors• Risk factors.The mostfrequently reported are heavy physicalwork,frequent bending ,twisting,lifting ,pullingand pushing ,repetitive work ,static postures andvibrations.(2)Psychosocial risk factors includestress ,distress ,anxiety ,depression , ,,,andmental stress Other risk factors may beassociated with low back pain as heavy lifting,driving motor vehicles ,jogging ,weaker trunkstrength ,obesity ,pregnancy ,psychosocialfactors ,and cigarette smoking)
  • 19. • 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 75to 85% of total workers, absenteeism.
  • 20. Causes of low back pain• may be either mechanical (apophysealosteoarthritis ,degenerative disc spinaldisc herniation ,spinal stenosis ,spondylolisthesis and other congenitalabnormalities,fracture,ligamentous strainsor sprains),
  • 21. • inflammatory(rheumatoid arthritis,seronegativespondylo arthropathy e.g ankylosing spondylitis),neoplastic, metabolic (osteoprotic fractureosteomalacia, paget`s disease)))infectious(osteomyelitis,epidural abcess,septicdiscitis• Psychosomatic disorders,referred pain(ovariancyst,chronic prostatitis,colonic neoplasm)
  • 22. Mechanical• 95% of causes LBP• Dt an anatomical or functionalabnormalities• E.g lumber spondylosis ,disk prolapsesponylolisthesis spinal stenosis,DISH,strain and sprain
  • 23. Lumbar spondylosis• Most common cause of LBP common inheavy work• Pathology:affect central i.v joint (body tobody and post i.v j)• The central j. affected frist, degenerationwith narrowing of i.v.d. and hyper trophy ofbone at joint margine lead to osteophytesformation
  • 24. • Thining tf articular cartilage lead todecrease stability and predispose tospondylolithesis
  • 25. C.P• Aching pain worse by activity, prolongedstanding or setting• The pain often worse in themorning,feeling of stiffness when risingfrom asetting position• Girdle pain• Sciatica according to compression of n.route(s.n L4,5 S1,2,3)
  • 26. X-RAY• NARROWING OF I.V.D SPACE• Osteophytes formation• Mangment• Orthotic brace• Exercise• Patient education to avoid any strain forback as heavy lifiting
  • 27. Disc rolaps• 95% at L4-5 or L5-S1->L5 OR S1 nervroute comp.• C.P , agonising pain in the lower backradiate to buttok and back of the thigh andcalf and foot
  • 28. Prolapsed lumbar IVD• Herniation of part of a lumbar IVD is a commoncause 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 protrudesthro’ a rent in annulus fibrosus at its weakestpart( i.e postero-lateral) or sometimes tornannulus itself protrudes backwards
  • 29. Manifestation of n.r. comp.S1L5 COMPRESSIONWeak p.f of foot absentankle jerkWeak d.f of great toeNumbness on dorsalfoot
  • 30. Investigation•M.R.I show disc substance and nerveroots
  • 31. • Imaging:1. X-ray:is done to exclude other causes of backpain & sciatica. very late after many months oryrs., 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 jacketor well fitted brace for 6-12 wks..
  • 32. treatment• ConservRest of spine (bed rest or brace )Continoues or intermittent tractionSurgical (if pain not relived by conservative)
  • 33. II. Surgical: (discectomy)• With severe persistant sciatica preventingsleep & deteriorating general health• If sciatica is unrelieved by conservative t.for at least 8 wks.• Massive prolapse with compression ofcauda( cauda equina syn.) leading tosevere neurological disturbance
  • 34. DISH• Diffuse idiopathic skeletal hyper osteosis• Marginal bone proliferation lead to formationosseous ridges• Ossification of paraspinal ligement(ant,post lig)• Thoracic spine most commonsffected, cervical, lumbar also affected• i.v.d space and s.i.j normal and this diffrentiatedish from spondylosis andspondyloarthoropatheis
  • 35. • Seen in midle age and elder• Pain minimal or absent• Stiffness common complaint
  • 36. spondylolysis• Defect in neural arch of 5th ( rarely 4th) lumbar vertebrae• Loss of bony continuity bw sup. & inf. Articularpr., deficiency being bridged by fibrous tissue; if this isstretched 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: unnecessarycorset or beltclose defect by bone graftlocal fusion of spine
  • 37. spondylolisthesis• Spontaneous displacement of lumbar vert. upon thesegment next below it.• Forward >backward• Causes:1. Congenital malformation of articular pr.( more commonat lumbo sacral j., u ass. With severe neurologicalupset & cauda equina trapping)2. Spondylolysis( body & sup. Articular pr. Slippingforward leaving spinous pr. &inf. Art. Pr. In normalrelationship with sacrum)3. OA of post. J.( commonest, wearing out of cart. Ofpost. IVJ , backward rather than forward, never severeOr neurologic disturbance)
  • 38. • o/e: symptomless ,back ache ,step abovesacral crest( v. severe), slight restrictedspinal movements• Treatment:-conservative; corset-surgical; (disability) decompression ofaffected nerves followed by fusion ofaffected segments
  • 39. SPINAL STENOSIS• LUMBAR SPINAL STENOSIS is definedas anarrowing of the spinal canal , itslateral recesses , and neural foramina thatmay result in a compression oflumbosacral nerve roots
  • 40. CAUSES• CONGENITAL• Idiopathic• ACQUIRED• Degenerative• Hypertrophy of facet joints• Hypertrophy of ligamentum flavum• Disc herniation• Spondylosthesis• Scoliosis• IATROGENIC• Postlaminectomy• MISCELLANEOUS• Paget disease• DISH
  • 41. C*P• Elder man above 60• Pain in standing and walking (heavyaching sensation in one or both L.L)associated with sever pain in glutealregion• (this pseudoclaudication resemble tointermittinte claudication of vasculardisease , to difrentiate in between
  • 42. • Claudication of SP stenosis induced bywalking and standing and releaved bysetting and flexing the spine(increasecanal diameter)• Vascular system show noabnormality, preservation of pedal pulse• The maximal discomfort to the thighsrather than calves
  • 43. • Diagnosis best confirmed by MRI• Treatment• Modification of activities(avoid prolongedstanding)• surgical :decompression of spinalcanal(removal of osteophytes)
  • 44. infection• Back pain not relived by rest orrecumbency• Spinal tenderness over aff segm• Elevated ESR• Fever• Abcess form• WBC normal
  • 45. • MRI most sensitive and specific for spinalinfection• Earliest sign in spine infec loss disc height
  • 46. Tuberculous spondylitis/ pott’sdisease• Affection begins at ant. Margin of vertebral bodynear IVD, disc itself is u affected at an earlierstage, leading to massive & completedestruction of one or more IVD. ant. collapse ofaffected v. may lead to angular kyphosis.• An abscess or mass of GT encroaching uponspinal canal may interfere with spinal cord /nerve.
  • 47. • c/p :1. Back pain2. Back stiffness3. Deformity( kyphosis)4. Localised swelling (abscess)5. Weakness of legs or visceral dysfunction d.t cordaffection• o/e:1. Pt. looks ill2. Palpable angular kphosis3. Restricted all spinal movements4. Abscess5. Spinal cord/ nerve root compression (pott’s paraplegia)
  • 48. Pyogenic spondylitis/ spineosteomyelitis•Uncommon•Similar to TB but runs a more acutecourse
  • 49. RA of spinal joints•It’s common to affect cx. Spines , but alsothx. & lumbar spines may be likely affected•c/p is diffuse aching pain with impairedspinal movements
  • 50. inflamatory•Seen spondyloarth ,worsen by rest, improve by activity and morning stiff
  • 51. Ankylosing spondylitis• Chr. Inflammation progressing slowly to bony ankylosisof 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 & shoulderaffection.• Men> women, age 15-25• c/p : diffuse aching low bp & increasing back stiffnesswith limitation of all spinal movements (poker back) & ifthx. 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.
  • 52. SI joint involvement “Bamboo spine”
  • 53. Referred pain• pelvic infection• ovarian cyst• Dysmenorrhoea• Cancer(ovary or uterus)• Endometriosis• Cronic prostatitis• Pyelonephritis, hydronephrosis• Ureter obstruction• Renal stone
  • 54. • Inflammatory bowel disorders• Diverticulitis• Colonic neoplasm• Retro peritoneal hge• Abdominal aortic• Pancreatitis• Cholecystitis