This document discusses low back ache and sciatica. It notes that spinal pain is influenced by structural, biomechanical, biochemical, medical, and psychosocial factors. Treatment is often difficult. Chronic low back ache is defined as lasting over 3 months. It is a common cause of disability in adults under 45 years old and is the most expensive benign condition in industrialized countries. Sciatica involves leg pain localized to one or more nerve roots from L4-S2, with or without neurological deficits. Risk factors, clinical evaluation, diagnostic strategies, non-operative treatments, interventional procedures, surgery, and physical therapy approaches are described.

1. LOW BACK
ACHE AND
SCIATICA

2. Spinal pain is multifaceted- involving
 Structural
 Biomechanical
 Biochemical
 Medical
 Psychosocial influences
 Treatment is often difficult/ineffective

3.  LBA is defined as chronic (cLBA) after 3
months because most connective tissues
heal within 6-12 weeks, unless
pathoanatomic instability persists.
 cLBA is the most common cause of
disability in adults younger than 45 years.
 LBA is the most expensive benign
condition in industrialized countries.

4.  SCIATICA- leg pain that is localised in the
distribution of one or more lumbosacral
nerve roots, typically L4-S2, with or without
neurological deficit.
 Non specific radicular pattern- when
dermatomal distribution is unclear

5. RISK FACTORS
 Men=women
(>60 years: women> men)
 Sciatica –fourth and fifth decades of life
 Extreme height
 Cigarette smoking
 Morbid obesity
 Weakness of trunk extensor muscles compared with
flexor strength– sciatica
 Occupational risk factors- heavy physical work,
lifting, prolonged static work postures, simultaneous
bending and twisting, exposure to vibration

6. CLINICAL EVALUATION
 HISTORY
-characterization of pain as mechanical-
most often aggravated by static loading of
the spine, long- lever activities and levered
postures. Pain relieved by rest.
Non mechanical pain- r/o serious causes like
infection and cancer.

7. PHYSICAL EXAMINATION
 Complete inspection- limb length
discrepancy and pelvic obliquity,scoliosis,
postural dysfunction with forward leaning
head and shoulders, accentuated kyphosis.
 Any soft tissue abnormalities and tenderness
to palpation should be noted.
 palpation of lumbar paraspinal, buttock and
other regional muscles- note areas with
superficial and deep muscle spasms.

8.  SLRT with patient supine-ipsilateral leg pain
between 10 and 60 degrees- positive
SLRT that produces pain in the opposite leg
carries a high probability of disc herniation-
investigate
 Reverse SLRT
 Neurological evaluation is performed to
determine the presence or absence of and
levels(if present ) of radiculopathy or
myelopathy.

9. Mechanical/activity- related
causes of LBP
 Discal and segmental degeneration- may include
facet arthropathy from osteoarthritis
 Myofascial, muscle spasm or other soft tissue
injuries and/or disorders
 Radiographic spinal instability with possible
fracture or spondylolisthesis- may be due to
trauma or degeneration
 Fracture of bony vertebral body or trijoint
complex- may not reveal overt radiographic
instability
 Spinal canal or lateral recess stenosis
 Arachnoiditis, including postoperative scarring

10. Disorders associated with non
mechanical LBA
 Neurological syndromes
 myelopathy from intrinsic or extrinsic
processes
 Lumbosacral plexopathy esp from diabetes
 Neuropathy including the inflammatory,
demyelinating type- eg. Guillan Barre
syndrome
 Myopathy
 Dystonia

11.  Systemic disorders
 Neoplasms
 Infections
 Metabolic bone diseases
 Vascular disorders
 Referred pain
 Gastro intestinal disorders
 Genitourinary disorders
 Gynaecological disorders

12. DIAGNOSTIC STRATEGIES
 PLAIN XRAYS(AP/LATERAL) OF LUMBAR SPINE-
indicated for patients older than 50 years
 CT SCANNING- effective when the spinal and
neurological levels are clear and bony
pathology is suspected.
 MRI- useful when the spinal and neurological
levels are unclear and a pathological
condition of disc or spinal cord is suspected.
 MYELOGRAPHY –useful in elucidating nerve
root pathology
 EMG/SSEP

13. NON OPERATIVE TREATMENT
 NSAIDS
 Muscle spasmolytics
 Neuropathic pain analgesics
 Antidepressants(TCA)
 Opiod analgesics

14.  3 phases depending upon the duration of
symptoms:
 PRIMARY
Passively applied physical therapy during the
acute phase of soft tissue healing(<6 week)
 SECONDARY
Spine care education
Active exercise programs during the subacute
phase between 6-12 weeks with physical
therapy-driven goals to achieve preinjury levels
of physical and psychological deconditioning
and disability.

15.  TERTIARY
When spinal pain persists into the chronic
phase, therapeutic interventions shift from
rest and applied therapies to active exercise
and physical restoration.
Therapeutic injections, manual therapy and
other externally applied therapies should be
used adjunctively to reduce pain so that
strength and flexibility can continue.

16.  Elimination of activity of positive
biomechanical loading can only be
achieved by BEDREST.
 Bedrest is usually considered an
appropriate treatment for acute
backpain.

17.  Topical treatment is drug delivery over or
onto the painful site.
 The medication is deivered through the
skin to a shallow depth <2cm and acts
locally without producing systemic side
effects.
 Bisphosponates (palmidronate) have
recently attracted attention as a
potential new treatment for mechanical
spinal pain involving discal and radicular
structures.

18. SPINAL INTERVENTIONAL
PROCEDURES
Local anaesthetics, corticosteroids or other
substances may be directly injected into
painful soft tissuess, facet joints or epidural
spaces.
Local injections into paravertebral soft
tissues, specifically into myofascial trigger
points are widely advocated.
Intra-articular facet blocks are also
advocated.
Medial branch blocks have been used for
both diagnostic and therapeutic purposes.

19.  Epidural injections, epidural adhesiolysis are
also other methods
 Intradiscal ElectroThermal Therapy (IDET)
Is a minimally invasive technique in which the
annulus is subjected to thermo-modulation,
thereby reducing the nociception reduced by
mechanical loading of a painful disc.

20. SURGERY
 The benefit of lumbar spine surgery is not
controversial in many clinical circumstances
like major trauma, chronic or complicated
spinal infection etc
 Moden suregery for LDD and sciatica are
characterised by small incisions, minimal
blood loss and early hospital discharge with
post- operative convalescence lasting only a
few weeks.

21.  PHYSICAL THERAPY FOR THE SPINE CAN BE
DIVIDED INTO PASSIVE AND ACTIVE THERAPIES:
 Passive therapy includes ultrasound, electric
muscle stimulation, traction, heat and ice and
manual therapy, were appropriate for short
term treatment for acute backpain or acute
exacerbation of a chronic backpain,
 Corsets and braces are long used adjuncts for
treatment.

22.  Traction is a long endured medical
prescription for LBP and is incorporated
into a variety of methods to treat
conditions of the spine.
 Education/ cognitive behavioural
therapy.
 Exercise

23. THANK YOU!