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Approach to Low Back Pain

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Practically approaching Low Back Pain

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Approach to Low Back Pain

  1. 1. Dr. Ramkrishna Dahal (Clinical Fellow Spinal Reconstructive Surgery) Department of Spine Services Grande International Hospital 2018
  2. 2.  A 25 yrs stunt motorcyclist presented to ER with severe back pain. He had history of RTA with multiple ribs fracture with no external injuries. His GCS was 15/15 on presentation and was falling gradually. ◦ BP 80/60, Pulse 130  How will you approach this patient???
  3. 3.  A 42yrs old banker presented to clinic with complaints of LBP for 6 months, no significant medical and surgical history, intact neurology non radiating, pain worsens with activity.  How will you approach this patient???
  4. 4.  A 22 yrs old student presented to clinic with complaints of back pain for 6 months, morning stiffness, intact neurology, managed with analgesics and physical therapy with no significant pain relieve.  How will you approach this patient???
  5. 5.  A 50 yrs old farmer presented in clinic with complaints of LBP for 6 months, occasional fever and night pain, pain worsens with spine flexion, managed with analgesics and physical therapy with no pain relieve.  How will you approach this patient???
  6. 6.  A 75 yrs old patient with complaints of LBP for 6 months, incresed in severity for past few days, with no constitutional symptoms, but gives history of difficulty in micturition for past 10 yrs seen by urologist and gave some medication for his urinary symptoms.  How will you approach this patient???
  7. 7.  The patient was just seen by the pain management specialist and had an epidural steroid injection yesterday. He is here again with back pain, and he cannot walk.
  8. 8.  He seems weak in his legs, but that’s just pain.” Patients who are status post procedure are at increased risk for developing complications that include epidural hematoma and spinal infection. These patients need imaging if they have new neurologic findings.
  9. 9.  You got a call from ER in the midnight with your patient presented with generalised tonic clonic seizure. You had seen that patient yesterday for LBP and you had prescribed some medicine for it.  How will you approach this patient???
  10. 10.  87% of the population will have back pain at any time of life.  Second most common condition after common cold.  Most common cause of disability for people less than 45 years of age
  11. 11.  Inflammatory LBP common in 18–40 years  Degenerative conditions, malignancy and osteoporosis are common causes above 40 years  Infective causes can occur in all age groups
  12. 12. • Sphincter disturbance: bowel or bladder • History of cancer • Unexplained weight loss • Immunosuppression • Intravenous drug use • Recent onset of structural deformity • Recent or on-going infection • Fever
  13. 13. • Night sweats • Non-mechanical pattern of pain • Constant pain • Wide spread neurological signs or symptoms • Disproportionate night pain • Lack of treatment response • Thoracic dominant pain • Under 20 and over 55
  14. 14.  Rupture of aortic aneurysm  Epidural hemorrhage  Anterior spinal artery thrombosis  Epidural abscess  Spinal cord tumors  Cauda equina syndrome
  15. 15. Stress Anxiety Depression
  16. 16.  Upto 72% of pregnant females can complain of LBP during the course of pregnancy.  Chronic backache ◦ who are depressed ◦ who have chronic medical disorders ◦ adjustment problems at workplace or at home ◦ inability to cope up with stress can present as LBP.
  17. 17. Pain Stress Anxiety Pain Stress
  18. 18.  Any evidence of systemic disease? ◦ Age (especially >50), hx of cancer, unexplained weight loss, IVDU, chronic infection ◦ Duration ◦ Presence of nocturnal pain ◦ Response to therapy ◦ Many patients with infection or malignancy will not have relief when lying down  Note for arthritis patients – young age, nocturnal pain and worsening with rest are common in AS
  19. 19.  Ageing  Genetics  Occupational hazards  Sedentary life style  Obesity  Poor posture  Pregnancy  Smoking
  20. 20. Investigate
  21. 21.  Clinical examination ◦ SLRT ◦ FABER test ◦ Motor and sensory neurological ◦ Schober’s test and pelvic rock test (in selected cases)
  22. 22.  W- With Distraction  O- Over Reaction  R- Regional  S- Stimulation  T- Tenderness
  23. 23.  Potential sources of pain ◦ nerve roots ◦ intervertebral disc ◦ facet joints ◦ vertebral bodies ◦ ligaments or soft tissues
  24. 24.  Zygapophyseal (z-joint)  Poor correlation with history and exam  Commonly pain with extension & rotation  Referral patterns 1. Schwarzer AC, et al. Spine 1994;19:1132-7. 2. Slipman, C. Arch PM&R 81:334-338, 2000.
  25. 25. Buttocks 94% Thigh 48% Lower leg 28% Dreyfuss D, J Am Acad Ortho Surg 2004, 12.
  26. 26.  Most recover rapidly ◦ 90% of patients seen within 3 days of symptom onset recovered within 2 weeks  Recurrences are common ◦ Most have chronic disease with intermittent exacerbations  Spinal stenosis is the exception  usually gets progressively worse with time
  27. 27.  Oswestry Disability Score Vs  Rolland Morris Questionnare
  28. 28.  Xray  Biochemistry  CT scan  MRI
  29. 29.  CT and MRI ◦ detection of infection and cancer ◦ Also able to image herniated discs and spinal stenosis, which cannot be appreciated on plain films ◦ Beware: herniated/bulging discs often found in asymptomatic volunteers  may lead to overdiagnosis/overtreatment ◦ MRI better than CT for detection of infection, metastases, rare neural tumours
  30. 30.  Most of the backaches may be self-limiting hence require good counseling and reassurance
  31. 31.  With all our technology we can identify the specific patho-anatomic source of pain in only 20% of back pain patients.  Everything else is labeled “non-specific” back pain. It is treated “non-specifically”,
  32. 32.  NSAIDs first line drugs as pain medication for acute low back pain unless contraindicated.  No evidence of one superior to another.  Prescribe regularly for short period of time rather than PRN basis  All have cardiovascular risk except Naproxen.  COX-2 have increased cardiovascular risk so avoid in elderly. European guidelines for management of CLBP
  33. 33.  Muscle relaxants work better if added with NSAIDs.  Tramadol inferior to NSAIDs for pain management  TCA are good for chronic low back pain except ◦ Renal failure ◦ Cardiac failure ◦ Glaucoma ◦ Pregnancy ◦ COPD  NSAIDs not recommended in radicular LBP  Herbal pain medications can be beneficial for chronic low back pain for long tern use. European guidelines for management of CLBP
  34. 34.  Exercise therapy- recommended (Gr. A evidence) for treating pain and disability due to CLBP.  Short course of Manual therapy (Gr. C evidence)  IPRP-Holistic approach European guidelines for management of CLBP
  35. 35.  Pain physician  Psychologists (for counselling)  Physiotherapist  Occupational therapists Grade B evidence European guidelines for management of CLBP
  36. 36.  Bed rest  Lumbar spinal support  TENS  Lumbar traction  Massage therapy  Systemic/local use of steroids European guidelines for management of CLBP
  37. 37.  Leading cause of disability  Rule out red flag signs  Do not investigate in all cases with LBP  Conservative therapy is the mainstay  Proper counseling  Interdisciplinary pain rehabilitation program (IPRP)
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Practically approaching Low Back Pain

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