Low Back Pain

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Low Back Pain

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

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