Low back pain

1. BY:- ANKIT KUMAR

2. LOW BACK REGION
Low back pain is defined as “pain and
discomfort, localized below the costal
margin and above the inferior gluteal
folds, with or without leg pain [4]
This area consists of the 5 lumbar
vertebrae (L1-L5), the joints between
them (intervertebral discs and facet
joints), ligaments (longitudinal and
segmental), muscles (originating from
the lumbar region), nerves L1-L5 and
the skin covering this region.[4]

3. ANATOMY[6]
The main anatomical components of a
lumbar vertebra are:
• Vertebral body
• Vertebral arch
• Spinous process
• Pedicles and laminae
• Vertebral foramen
• Superior and inferior articular
processes/facets
• Transverse processes

5. The joints of the lumbar vertebrae are supported by several ligaments. They
can be divided into two groups; those present throughout the vertebral
column, and those unique to the lumbar spine.[9]
Present throughout Vertebral Column
 Anterior and posterior longitudinal ligaments: Long ligaments that run
the length of the vertebral column, covering the vertebral bodies and
intervertebral discs.[9]
 Ligamentum flavum: Connects the laminae of adjacent vertebrae.[9]
 Interspinous ligament: Connects the spinous processes of adjacent
vertebrae.[9]
 Supraspinous ligament: Connects the tips of adjacent spinous processes.

6. o Superficial Group Muscles: Among all the superficial back
muscles there is only one muscles that originates in the
lumbar region.

7. o Deep Group Muscles:
o Erector spinae muscles: Iliocostalis, Longissimus and Spinalis. The
help in the extension of the back and also maintain and erect posture.
o Multifidus : Well developed in the lumbar region. Their function is
similar to that of erector spinae when they contract bilaterally.
“However, when muscles on only one side contract, they pull the
spinous processes toward the transverse processes on that side,
causing the trunk to turn or rotate in the opposite direction.”[6]
o The Thoracolumbar fascia covers the deep muscles of back and trunk.
 Nerves: There are five spinal nerves that arise in the
lumbar region which are named as L1-L5 and the
posterior branch of spinal nerve innervates the intrinsic
muscles and adjacent skin.

9.  “Low back pain affects people of all ages, from children to the
elderly, and is a very frequent reason for medical consultations.” [2]
 “The 2010 Global Burden of Disease Study estimated that low back
pain is among the top 10 diseases and injuries that account for the
highest number of Disability-Adjusted Life Year (DALYs)
worldwide.” [2]
 “It is difficult to estimate the incidence of low back pain as the
incidence of first-ever episodes of low back pain is already high by
early adulthood and symptoms tend to recur over time.” [2]
 “The lifetime prevalence of non-specific (common) low back pain is
estimated at 60% to 70% in industrialized countries.” [2]
 “The prevalence rate for children and adolescents is lower than that
seen in adults but is rising.” [2]
 “Prevalence increases and peaks between the ages of 35 and 55.” [2]

10.  Age.
 Lack of exercise.
 Excess weight(obesity).
 Diseases like arthritis, osteoporosis and cancer
can contribute to back pain.
 Occupational hazardous.
 Improper lifting.
 Psychological conditions.
 Smoking.
 Poor Posture.

11.  Muscle or ligament strain.
 Bulging or ruptured disks.
 Arthritis.
 Skeletal irregularities like scoliosis
 Trauma
 Vertebral fractures can cause spondylolysis and
spondylolisthesis
 Osteoporosis.

12.  Patient history: It should include questions regarding the
present illness which include location, onset, duration,
radiation, associated symptoms, character, and exacerbating
or alleviating factors. Followed by Past Medical history, social
history, family history, etc. The review of system should focus
on systemic signs like fever, weight loss, morning stiffness,
etc. Activity level, sleep habits, injury, posture.[1]
 Physical exam: palpation, range of motion, neurologic exam,
reflex test, and special tests like abdominal muscle strength
because it stabilizes the spine, Passive Intervertebral Motion
Testing and Prone Instability Test.[4]
 Laboratory investigations like CBC, ESR, C-reactive protein if
there are signs of systemic diseases or presence of red flags.[4]
 Imaging Tests CT scan, MRI is helpful to diagnose the cause
of pain if there is a disk fracture or disk herniation.[4]

13.  The goal of initial evaluation is to categorize the
cause of pain in the following categories:
“(1) non-specific low back pain;
(2) back pain associated with radiculopathy or spinal stenosis;
(3) back pain referred from a nonspinal source;
(4) back pain associated with another specific spinal cause” [1]
 Psychosocial factors are important as some of them
are associated with increased risk of developing
chronic back pain and disability and these common
factors are termed “yellow flags” which should be
carefully looked for during evaluation of low back
pain

14.  Age older than 50 years
 Fever; chills; recent
urinary tract or skin
infection; penetrating
wound near spine
 Significant trauma
 Unrelenting night pain or
pain at rest
 Progressive motor or
sensory deficit
 Saddle anaesthesia;
bilateral sciatica or leg
weakness; difficulty
urinating; faecal
incontinence
 Unexplained weight loss
 History of cancer or
strong suspicion for
current cancer
 History of osteoporosis
 Immunosuppression
 Chronic oral steroid use
 Intravenous drug use
 Substance abuse
 Failure to improve after
six weeks of conservative
therapy

15.  Presence of catastrophic thinking: there is no way the
patient can control the pain, that disaster will occur if
the pain continues, etc.
 Expectations that the pain will only worsen with work
or activity
 Behaviours such as avoidance of normal activity, and
extended rest
 Poor sleep
 Compensation issues
 Emotions such as stress and anxiety
 Work issues, such as poor job satisfaction and poor
relationship with supervisors
 Extended time off work

17.  The objective of treatment is "transient help with
discomfort, an improved capacity to accomplish self-
sedation, stomach and lumbar muscle reinforcing,
expanded hip and lumbar spine versatility, improved
lumbar and pelvic proprioceptive reasonableness,
intervertebral joint adjustment, lumbar stance alteration
and improved general wellness" [5]
 Treatment can incorporate conservatives choices like
exercise, needle therapy, chiropractic treatment, massage,
orthotic uphold (supports), pharmacological treatment
and non-moderate choice is medical procedure which
can be utilized in instances of injury, disc herniation and
vertebral compression fracture causing neurologic side
effects or not reacting to conservative treatment.

18.  "Patients normally use non-pharmacologic treatment choices, with or
without talking with a doctor. 45 percent of patients with low back agony
see a chiropractor, 24 percent use massage, 11 percent get acupuncture,
and 7 percent attempt meditations." [1]
Exercise Therapy:
 The goal of exercise therapy is to focus on strengthening and stabilizing
the core muscles of abdomen and back as they provide support to the back
and help maintain the alignment of the spine and a good posture. [1]
 "Numerous excellent examinations have found, notwithstanding, that
activity brings about certain results in the therapy of constant low back
pain. This will help with discomfort (in spite of the fact that this alleviation
is unobtrusive, with an ongoing meta-analysis of 43 preliminaries
demonstrating a mean distinction of 10 focuses on a 100-point scale),
improvement in functions, and slightly reduced sick leave." [4]
 Activities can be stabilizing, strengthening, and stretching.

23.  Manual Therapy: It is manual mobilisation of the joint or
muscles provided by the therapist. The techniques include Traction,
Massage, Trigger Point Therapy, Assisted Active Range of Motion
(AAROM), Passive Range of Motion, Stretches (muscle, neural
tissue, joints, fascia), Instrument Assisted Soft Tissue
Mobilization.[8]
 Other options for treatment include Acupuncture, Back Schools,
Yoga, Kinesio tapes and Transcutaneous Electrical Nerve
stimulation can be used. [1]

24. PHARMACOLOGICAL OTHER OPTIONS
 NSAIDS are the most commonly
used drugs for the treatment of
low back pain.
◦ Tricyclic Antidepressants can be
used for chronic pain. [4]
◦ Tramadol is an analgesic that has
weak opioid and serotonin-
norepinephrine reuptake inhibitor
(SNRI) activity. Studies demonstrate
short-term improvements in pain
and function. [4]
 Surgery: It is useful in cases
of when in cases of vertebral
disc herniation causing
neurologic symptoms,
vertebral fractures not
responding to conservative
treatment.
◦ “Good evidence supports the
use of spinal fusion for treating
back pain caused by fractures,
infections, progressive
deformity, or instability with
spondylolisthesis.[4]

25. 1. ALLEN R. LAST, MD, MPH, and KAREN HULBERT, MD. (n.d.). Chronic Low Back
Pain: Evaluation and Management. Retrieved from
https://www.aafp.org/afp/2009/0615/p1067.html
2. Low Back Pain. (n.d.). Retrieved from
https://www.who.int/medicines/areas/priority_medicines/Ch6_24LBP.pdf
3. MayoClinic. (n.d.). Low Back pain. Retrieved from
https://www.mayoclinic.org/diseases-conditions/back-pain/symptoms-
causes/syc-20369906
4. RANDALL L. BRADDOM MD, MS. (n.d.). Physical Medicine and Rehabiliation.
5. Revel, M. (n.d.). Rehabilitation of low back pain patients. A review. Retrieved from
https://pubmed.ncbi.nlm.nih.gov/7788322/#:~:text=Goals%20include%20short%2Dterm%20
pain,modification%20and%20improved%20general%20fitness.
6. Richard L. Drake, A. Wayne Vogl, Adam W. M. Mitchell. (n.d.). Gray's Anatomy For Students.
7. Richard L. Drake, A. Wayne Vogl, Adam W. M. Mitchell,. (n.d.). Gray's Atlas of Anatomy.
8. https://www.physio-pedia.com/Manual_Therapy
9. https://teachmeanatomy.info/abdomen/bones/lumbar-spine/#:~:text=Joints-
,There%20are%20two%20types%20of%20joint%20in%20the%20lumbar%20spine,int
ervertebral%20discs%2C%20made%20of%20fibrocartilage.

26. THANK YOU