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Lumbar pain - Mrinal Joshi

Lumbar Pain
PMR Refresher Course

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Lumbar pain - Mrinal Joshi

  1. 1. LUMBAR PAIN Mrinal Joshi MBBS MD DNB MNAMS GCMskMed Professor & Head, Dept. of PMR Rehabilitation Research Center SMS Medical College & Hospital Jaipur
  2. 2. Low Back Pain • Most expensive and common cause of disability • Maximum number of physician office visit • Even more at quacks and alternate practitioners • Rates of surgery is on rise • Recurrent symptom but benign prognosis 2
  3. 3. 3
  4. 4. 4
  5. 5. Back Problem • Extremely common medical issue • Most expensive industrial injury ?? • 25% to 45% have symptom radiating below gluteal fold • 5% neurological changes during physical examination • 2% indicative of good surgical outcome by decompression • Half of the above recovery sufficiently to lose interest in surgery 9
  6. 6. Irrational Aspects • Bleeding legs • Screening x-rays • Ageing changes as indication of pathology, CT/MRI • Passive treatments • Huge Owen Thomas 10
  7. 7. Elements of Pain • Sinuvertebral nerves are primary innervation of disc • Travel rostrally 2 levels and caudally 3 levels • Posterior rami circumflex extends to facet joints • Potential autonomic input responsible for burning skin, shocks etc., • Sciatica results from both chemical and mechanical irritation • Muscular protection reduces with age e.g. leg in cast • Activity beyond the capacity can result in symptoms 12
  8. 8. Caveats • Difficult to predict the outcome of back problems • Difficult to pain in those who are extremely inactive • Convince that there is nothing dangerous • Using the back is beneficial and safe • Managing back pain is like training for marathon 14
  9. 9. Precis of Assessment • History (sitting) • Observation (standing) • Examination • Active movements (standing) • Forward flexion • Extension • Side flexion (L/R) • Rotation (L/R) • Quick test • Trendelenburg’s and S1 root test 15
  10. 10. • Passive movements (with care and caution) • Peripheral joints scan (standing) • Sacroiliac joints • Special tests (standing) • One leg standing lumbar extension test • H & I test • Resisted isometric movements (sitting) • Forward flexion • Extension • Side flexion (L/R) • Rotation (L/R)
  11. 11. • Special tests (sitting) • Slump test • Sitting root test • Resisted isometric movements (supine lying) • Dynamic abdominal endurance • Double straight leg lowering • Internal/external abdominal oblique test
  12. 12. • Peripheral joint scan (supine lying) • Hip joint (F/E/Ab/Ad/MR/LR) • Knee joint (F/E) • Ankle joint (Df/Pf) • Foot joints (Sup/Pro) • Toe joints (F/E) • Myotomes • Hip flexion (L2) • Hip extension (S1) • Knee extension (L3) • Knee flexion (S1-S2) • Ankle dorsiflexion (L4) • Toe extension (L5) • Ankle eversion or plantar flexion (S1)
  13. 13. • Special tests (supine lying) • SLR and its variants • Buttock signs • Reflexes & cutaneous distribution • Palpation (supine lying) • Resisted isometric movements (side lying) • Horizontal side support • Special tests (side lying) • Femoral nerve traction test • Special torsion tests • Peripheral joint scan (prone lying) • Hip joint (Ex/MR/LR) • Resisted dynamic extension test • Special test (prone lying) • Prone knee bending test
  14. 14. • Joint play (prone lying) • Posteroanterior central vertebral pressure (PACVP) • Posteroanterior unilateral vertebral pressure (PAUVP) • Transverse vertebral pressure (TVP) • Palpation • Multifidus test
  15. 15. Waddell Embellishment Tests • Tenderness: subcutaneous (or less) pressure to reproduce symptoms • Simulation • Simulation of loading spine with weight of your hand to reproduce pain • Simulation of twisting trunk when rotating the hips and shoulder in unison to reproduce pain • Distraction: sitting knee extension and SLR test • Non-anatomic distribution of pain on pain drawing or giving away on muscle testing • Overreaction: grimacing, complaints or suffering displays inappropriate for situation or manoeuvre21
  16. 16. Red Flags 22
  17. 17. Non-Physical Interference • Threats to patient’s self-esteem, livelihood, future, or other loss can significantly influence patient’s response to caregivers • Try not to be too judgemental • Survival behaviour is a common human response • Zero to two Waddell’s are normal 23
  18. 18. Treatment • Assure that there is nothing to fear • Comfortable activity tolerance can be achieved only by overcoming or avoiding the debilitation of inactivity • Conditioning • 3-4 weeks of general conditioning • Speed walk, stationary cycle, jogging • Specific muscle training at least 4-5 times/week • Next phase of other core and neck muscles • Work hardening • Patient benefit more from our honest help than judgement of legitimacy 24
  19. 19. Diagnostic Considerations In Delayed Recovery • If back symptoms persist and continue to limit activity for more than 4 weeks, SEEK CAUSE • A picture of tissue/bone abutting the dura does not indicate it to be the cause • Physiological evidence will tell us whether the nerve root is compromised 25
  20. 20. Diagnostic Considerations 26 Technique Physiological Evidence Anatomic Evidence History + + Circumference measurement + + Reflexes ++ ++ Straight-leg raise ++ ++ Crossed SLR ++ + Motor ++ ++ Sensory ++ ++ Lab test (ESR,CBC,UA) ++ 0 Bone Scan +++ +++ EMG +++ +++ X-Ray 0 + CT 0 ++++ MRI 0 ++++ Myelography 0 ++++ Myelo-CT 0 ++++
  21. 21. Disc Findings
  22. 22. Reasonable Approach to MRI • Start with MRI T1 weighted parasagittal lateral view • For evaluating fat in foramina canal • Vanishes before root is compressed • Lateral views are usually left to right • T2 weighted parasagittal lateral view • Water content is white like in myelogram • Contour of canal & indentations • T2 weighted cross sectional images • Evaluate convex or flat dural sac 29
  23. 23. Wheel of Fortune 30
  24. 24. Epidural Steroid Injection & Inflammatory Theory • Have been used for more than 40 years • Use of caudal epidural was reported in 1961 with 66% improvement • Near level advocacy started in 1972 • Most back pains are due to muscular and ligamentous strain & spasm • Mechanical back pain is primarily somatic • Most studies are anecdotal, retrospective and not RBCT 33
  25. 25. Result of well controlled Lumbar Epidural Steroid Injections for Acute Herniated Disc
  26. 26. Current Role • Efficacy of ESI has not been conclusively demonstrated • Very good short to intermediated-term success in selected patients • Presence of nerve root irritation is required to justify use of ESI • Less efficacious in patients with neurologic deficits and a large disc herniations • Comprehensive management rather than being a needle jockey • Fundamentally a safe injection with good efficacy but should a part of multidisciplinary plan35
  27. 27. Surgery in Sciatica • Only when non-operative treatment fails except some emergencies • Nonsurgical management should be attempted for at 4-6 weeks to 6 months depending on condition • Back pain with leg symptoms of pain, numbness or weakness after a dermatomal distribution • Sinuvertebral nerve can get irritated with mechanical or chemical factors • Short term relief of symptoms is better with surgery but in most the long term outcomes are almost similar 37
  28. 28. Surgery for Herniated Disc • Tendon reflexes do not usually recover • One-third are left with some sensory deficit • Only absolute indication is caudal equina syndrome • Relative indication • Gross motor weakness • Loss of bowel bladder function • Recurrent incapacitating leg pain • Persisting leg pain • Best window 3-6 months • Not a life saving procedure but improves QOL • Exclude other causes • Most have 70% improvement 38
  29. 29. Herniated Disk • Back & leg pain with strong physiological evidence on physical examination or EMG and corresponding anatomic confirmation on Imaging are an indication to consider decompression • If able to function at less than 3+ EMG and deferred surgery will eventually recover with 60% recurrence • With surgery recurrence rate is down to 10% 39
  30. 30. Appropriate Treatment • No more than 2-3 days bed rest • Trial of NSAIDs for 3-4 weeks • Physical therapy/conditioning • Nerve root/epidural injection may be attempted • Lack of scientific data on effect • Decision usually case-by-case basis 40
  31. 31. Procedures • Chemonucleolysis • Percutaneous discectomy • Mechanical • Laser • Open Surgery • Posterior Surgery • Standard laminectomy and discectomy • Limited approach/microdiscectomy • Far lateral discectomy • Anterior approach • Arthroscopic discectomy 41

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