Low Back Pain Anatomy - Pathophysiology - Management Pain Management

1. Low Back Pain
E-Mail: ali_saad_ali@hotmail.com - Website: www.alisaadali.com

2. What is low back pain?
• Any pain in the back. It is usually
characterized by dull, continuous
pain and tenderness in the lower
lumbar, lumbosacral or sacroiliac
regions. Sometimes referred to
the leg, following the
disturbution of the sciatica nerve.
- 70% of the world adults will experience at least one
disabling episode in their lives due to back pain.
By: Dr. Ali Saad Ali - E-Mail: ali_saad_ali@hotmail.com - Website: www.alisaadali.com

3. Anatomy of the Low Back
Lumbar Vertebrae
Sacrum
Sacro-iliac Joint
Coccyx
Ilium
By: Dr. Ali Saad Ali - E-Mail: ali_saad_ali@hotmail.com - Website: www.alisaadali.com

4. Anatomy of the Low Back
Intervertebral Discs
Vertebrae
- Nucleus Pulposus
- Annulus Fibrosus
- Transverse process
- Spinous process
- Superior articular facet
- Spinal Cord
By: Dr. Ali Saad Ali - E-Mail: ali_saad_ali@hotmail.com - Website: www.alisaadali.com

5. Classification of the
low back pain
Acute RecurrentChronic
< 6 weeks > 6 weeks
In Only 10-15% of patients

6. Causes of
low back pain
Systemic
Psychogenic
Referred
ComplicatedUncomplicated
By: Dr. Ali Saad Ali - E-Mail: ali_saad_ali@hotmail.com - Website: www.alisaadali.com

7. Causes of low back pain
Uncomplicated Back pain
when performing day-to-day activities, or from direct trauma
Injury to muscles & ligament
Strain
Sprain
Contusion
Degenerative Joint Disease (Osteoarthritis)
most common cause of chronic low back pain in the elderly
- Loss of articular cartilage
- Osteophyte formation
- Articular surface irregularity
impair joint function and at times
can lead to inflammation and pain

8. Degenerative Disc Disease
The discs most commonly involved are L3-L4, L4-L5, L5-S1
Weakening of the fibrous
outer ring of an
intervertebral disc (the
annulus fibrosus)
Bulge or herniation of the gelatinous
center of the disc into the spinal
canal
Motion restriction of spinal structures
- facet joints
- The sacroiliac joint
- Vertebral bodies

9. Spondylolysis & Spondylolisthesis
Spondylolysis
break in the integrity of the neural
arch caused by aquired defect in pars
interarticularis due to fracture
Spondylolisthesis
defect causes slippage of vertebra on
the one below

10. Fractures
Compression fracture of the
vertebral body, often caused by
minor trauma in older people with
Osteoarthritis
Other Causes
Type of occupations workers in occupation requiring
lifting heavy objects
Smoking
Obesity
By: Dr. Ali Saad Ali - E-Mail: ali_saad_ali@hotmail.com - Website: www.alisaadali.com

11. Complicated Back Pain
Structural with nerve root compromise (sciatica).
It is a condition in which pain, numbness, parasthesia
&/or muscle weakness reflect injury to the spinal root.
The most common cause is herniation of intervertebral disc.
Spinal Stenosis
Back & leg symptoms associated with
narrowing of the lumbar spinal canal
seen on CT or MRI scanning.
- Bony pressure on multiple nerve roots
- Congenital

12. Systemic Causes
- Infections
- Cancer
- Inflammatory arthritis
- Paget’s disaese.
Less than 1% of all cases
Referred Pain
From abdominal or
pelvic structures
- Acute pancreatitis
- Pyelonephritis, pelvic
inflammatory disease
- Dysmenorrhea
- Posterior peptic ulcer
- Abdominal aneurysm
- Cholecystitis

13. Management of low back pain
Non-Interventional:
- Conservative
- Medications
Interventional:
- Minimal invasive
- Surgical treatment

14. Non-Interventional Management
Conservative:
Exercise can be very beneficial for mild to moderate back pain, but if you
have severe back pain be very careful, and don't do too much.
- Aerobic exercise
- Swimming
- Cycling
- Yoga and Pilates
- Physiotherapy
- Osteopathy and Chiropractic
Medications:
- NSAIDs: Ibuprofin and Diclofinac (SE: GI bleeding and fluid retension).
- COX-2 inhibitors: Arcoxia and Celebrex (better tolerated than NSAIDs).
- Mild Opioids: Codeine, Dihydrocodeine, and Tramadol.
- Strong Opioids: Buprenorphine, morphine, and fentanyl.
- Anti-Neuropathic treatments: Amitriptyline, Carbemazepine, Gabapentin, or
Pregabalin.

15. Interventional Management
Minimal invasive:
Surgical treatment:
- Acupuncture
- Facet Radio Frequency (Rhizotomy)
- Facet joint injections
- Facet joint denervation
- Pulsed Radio Frequency
- Epidural injections
- Transforaminal epidural injections
- SIJ injections
- Sellective nerve root block
- Lumbar Sympathetic block
- Stellate ganglion block
- Dekompressor discectomy
- Percutaneous disc nucleoplasty
- Vertebroplasty
- Kyphoplasty
- Discectomy
- Laminectomy
- Fusion
- Microdiscectomy

16. Minimal Invasive
Radio-Frequency:
- Lumbo-Sacral facets
- Cervical facets
- Coccyx
- Sacro-Iliac Joint (SIJ)
Minimally invasive procedure under fluoroscope
by a local anesthesia and by a radiofrequency
electrode through a cannula that reduces or
eliminates the pain from damaged facet or
sacroiliac joints by disrupting the medial branch
nerves that carry pain signals.
Pain may increase for the 1st week after procedure,
patient may have full relief after a month, successful
RF can last longer

17. Transforaminal injection:
Injection of a steroid (anti-inflammatory
agent) and lidocain (numbing agent) into the
opening at the side of the spine where a
nerve roots exits.
By: Dr. Ali Saad Ali - E-Mail: ali_saad_ali@hotmail.com - Website: www.alisaadali.com

18. Epidural injection:
Injection of a steroid (anti-inflammatory
agent) and lidocain (numbing agent) into
the epidural space.
By: Dr. Ali Saad Ali - E-Mail: ali_saad_ali@hotmail.com - Website: www.alisaadali.com

19. SIJ Block:
Injection of a steroid (anti-inflammatory agent)
and lidocain (numbing agent) by inserting a
needle in the sacro-iliac joint.
An SI joint block injection may be
repeated up to three times per year. For
the treatment to be successful, the
injection should be followed by physical
therapy and/or chiropractic adjustments
to provide mobilization and range of
motion exercises.

20. A special device the size of a needle is inserted into the
affected disc. This then rotates like a drill removing some
of the nucleus of the damaged disc, thus decompressing
it and allowing the bulge to reduce. This in turn reduces
the pain from both the disc and the nerve root.
Dekompressor Discectomy:
A special device the size of a needle is inserted into the
affected disc. This probe has radiofrequency electrodes
at its tip and is slightly angled. It is moved around inside
the disc vapourising a very controlled amount of disc
nucleus, typically 1 - 2 ml.
Percutaneous nucleoplasty:

21. Intra-discal Ozone Injection:
Intradiscal  Causes pressure drop  pull the disc
herniation inward
Ozone!
- Prevents and reverses degenerative diseases
- Reduces inflammation
- Stop bleeding
- Normalizes hormone and enzyme production
- Supports and enhances the healing process
- Stimulates the immune system
- Destroy cancer cells

22. Low Back Pain
E-Mail: ali_saad_ali@hotmail.com - Website: www.alisaadali.com