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Low back pain
1.
Low Back Pain Dr
Herman Gofara, SpOT (K) Spine
2.
Incidence Very common
among working group 90% in pt >45years old 80% resolves with conservative treatment (in <3 months) Only 5-10% may require operation
3.
Implication Work &
productivity loss
4.
Anatomical consideration Commonly
at lumbosacral junction (L4/L5, L5/S1) Why?
5.
Most mobile
region of the spine Therefore prone to degeneration (wear & tear)
6.
Causes of pain
Degenerative (most common) Instability(fracture, spondylolisthesis) Organic (Tumour,infection) Nerve compression/irritation(PID, root compression) Rule out psychogenic cause (insurance claim, problem with employer etc)
7.
Referred pain 1. Abdominal
cavity gastritis/peptic ulcer pancreatitis cholecystitis 2. Urinary system renal calculi UTI 3. Pelvic cavity ovarian cyst dysmenorrhea 4. Aorta Aortic aneurysm
8.
Nature of pain
MECHANICAL VS NON-MECHANICAL REFERRED VS RADICULAR CLAUDICATION – VASCULAR VS SPINAL
9.
MECHANICAL PAIN 1. Muscle
strain 2. Ligament sprain 3. Facet joint arthritis 4. Disc-Discogenic 5. Instability - Spondylolysis/spondylolisthesis
10.
NON-MECHANICAL PAIN Infection
– PYOGENIC VS TB Tumour – PRIMARY VS SECONDARY Primary - BENIGN VS MALIGNANT
11.
Common causes of
low back pain Pathology Age Pain nature Assoc pain Assoc sx DEGENERA TIVE Spondylosis >40y mechanical Distance claudication Active pt Spondylolisth esis <20y >40y mechanical extension Hyperextensi on activity Trauma Any age mechanical - Trauma Infection Any age non- mechanical Rest pain Fever Mets >50y Non- mechanical Rest pain Primary + LOW LOA Osteoporosis >60y mechanical - Trivial trauma
12.
RED FLAGS Constitutional
symptoms LOW, LOA, fever AGE(>50) IMMUNOCOMPROMISED, TB CONTACT KNOWN CANCER NEUROLOGICAL DEFICIT (CAUDA EQUINA SYN)
13.
Physical findings General
examination Age Ill looking Local examination – DO NOT MISS A GIBBUS
14.
Deformity Scoliosis/kyphosis
Step deformity Local tenderness/paraspinal spasm Limited ROM
15.
Full neurological
examination ANAL TONE / PERIANAL SENSATION DERMATOME & MYOTOME
16.
Investigations
17.
Plain radiograph AP -loss
of lumbar lordosis -reduced disc space -osteophytes -deformity -fracture (increase interpedicular distance) -osteoporosis -pedicle disruption
18.
19.
20.
21.
22.
23.
24.
25.
Lateral -fracture/wedging -kyphosis -spondylolisthesis Oblique -spondylolysis
(SCOTTIE DOG)
26.
27.
28.
Plain x-rays
29.
30.
Blood investigations FBC
Anemia, TWC ESR Liver function test ALP Renal function test Calcium level
31.
CT Scan better
visualization of bone pathology (eg. cortical destruction) fracture tumor
32.
33.
34.
35.
MRI -better soft
tissue visualization -disc -ligaments (ALL,PLL) -nerves (spinal cord, roots) -bone marrow -pus collection
36.
MRI
37.
38.
CT myelogram role
replaced by MRI for delineation of neural structures where MRI is not available/contraindicated
39.
CT Myelogram
40.
Bone scan Suspicious
of multiple bone mets Eg. with history of untreated/treated CA Negative in Multiple myeloma
41.
Treatment Mainly conservative -Bed
rest/pelvic traction -physiotherapy -back exercise -modification of daily activities -SWD/ultrasound -NSAIDs/COX-2 inhibitor -local injection (epidural steroids, facet joint)
42.
Pelvic traction
43.
Surgery
44.
Indications for surgery -PAIN
- failed conservative treatment (>6 months) -Evidence of neurological deficit (motor) -Cauda equina syndrome -Spinal instability (excessive spinal motion) -Unacceptable deformity (eg degenerative scoliosis)
45.
Surgery 1. DECOMPRESSION of
spinal nerves (BURST FRACTURE, Spinal stenosis, PID) 2. Fusion & Stabilization (Instrumentation) 3. Correction of deformity
46.
Non Surgery Treatment
47.
48.
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50.
THANK YOU