Low back pain
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Low back pain is very common, especially among those over age 45. Most cases resolve with conservative treatment within 3 months, while 5-10% may require surgery. The lumbar spine is most prone to degeneration and pain due to its mobility. Common causes of low back pain include degeneration, instability, infection, nerve compression, and psychological factors. Pain can be mechanical, non-mechanical, referred, or radicular in nature. Conservative treatments include rest, physiotherapy, medication, and injections while surgery is indicated for cases of neurological deficit, instability, or unacceptable deformity.
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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
- 28. Plain x-rays
- 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
- 35. MRI -better soft tissue visualization -disc -ligaments (ALL,PLL) -nerves (spinal cord, roots) -bone marrow -pus collection
- 36. MRI
- 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
- 50. THANK YOU