Sciatic conditions you treat conditions you refereed

Bahaa Ali Kornah-Al-Azhar Un. Cairo. EGYPT

Sciatica:
conditions you treat ,
conditions you refereed
Dr. Bahaa Ali Kromah
Prof... Of Orthopedic
Al-Azhar University
Cairo -Egypt

Sciatica
l Sciatica is pain in the lower extremity resulting
from irritation of the sciatic nerve.

SCIATICA
It Is a symptoms of low back pain that spreads (radiates)
through the hip, to the back of the thigh, and down the
inside of back the leg via the sciatic nerve, characterized
by pain, tingling, numbness, or weakness.
Sciatica (radiculopathy) is a description of symptoms of
inflammation or compression of the sciatic nerve , not
a diagnosis.
A herniated disc, spinal stenosis, degenerative disc
disease, and spondylolisthesis can all cause sciatica.

SCIATICA part of Low Back Pain (LBP)
Topics covered:
What is back pain (SCIATICA) ?
Who gets back pain ?
How to diagnose?
How can you stay Pain-Free ?
Treatment approaches
**

LOW BACK PAIN
DEFINITION:
l It is usually defined as pain, muscle
tension, or stiffness localised below the costal
margin and above the inferior gluteal folds, with or
without leg pain (sciatica).
Type
 Acute
 Chronic
 Acute on tope of chronic

Types Of Pain
1. Acute Versus Chronic
2. Somatic Versus Visceral
3. Somatogenic Versus Psychogenic
4. Referred Versus Radicular
5. Nociceptive Versus Neuropathic

Acute V Chronic
Sudden onset
Temporal (disappears once stimulus is
removed)
Can be somatic, visceral, referred
Associated anxiety
Physiological responses:
↑ RR, HR, BP and
↓ Gastric Motility
Persistent –usually ≥3 Ms
Cause unknown –may be due to
neural stimulation or
↓endorphins
Physiological responses are less
obvious especially with
adaptation.
Psychological responses may
include depression

Somatic V Visceral
 Superficial:
Stimulation Of
Receptors In
Skin
 Deep:
Stimulation Of
Receptors In
Muscles, Joints
& Tendons
 Stimulation Of
Receptors In
Internal Organs,
 Often Poorly
Localized as Fewer
receptors located In
Viscera.
 Can be referred.

Somatogenic V Psychogenic
 Is A Pain
Originating From
An Actual Physical
Cause e.g.
Trauma, Ischemia
 Is Pain For Which
There Is No
Physical Cause.
 It Is Not Imaginary
Pain and Can be as
Intense as Somatic
Pain.

Differentiating Remote Pain:
Referred OR Radicular?
l Referred Pain Is A Nociceptive Pain ,It is pain perceived at a location
other than the site of the painful stimulus/ origin
l (Gall bladder → shoulder pain, kidney stones → Groin pain,
l Radicular Pain Is A Neuropathic .felt in the distribution of the
dermatome associated with the nerve root.
l pain described by patients as shooting, electric shock-like or burning,
often with tingling or numbness
Baron R, Binder A. 2004 Orthopade. 2004;33(5):568-75

Nociceptive V Neuropathic
 Nociceptive
Pains Result
From
Activation Of
Nociceptors
(Noci =
Harmful)
 Neuropathic Pains
Result From Direct
Injury To Nerves In
The Peripheral
Nervous System

Causes of low back pain
l So, what are the causes?
_ Bone
_ Spinal Column
• Vertebrae
• Discs
_ Spinal Cord
• Nerves
_ Blood Vessels
_ Facets Joints
_ Soft Tissue
• Ligaments*Muscles*Tendons*
• Connective Tissue*Joint Capsule

Causes of back pain

Common Sources of sciatica
Disc
1. posteriorly - sinu vertebral n.
2. laterally - gray rami communicantes
a. branches of ventral rami
3. various types of nerve endings up to
½ annulus depth
Targets for dorsal primary ramus
1. facet joints
2. interspinous ligaments
3. back muscles
VPR
DPR
GRC
SVN

What is Back Pain ?
A “herniated” disc ?

Common Sources of LBP
Somatic dysfunction
Muscle in “spasm”
Nerve root
In somatic dysfunction, some muscles become overactive (“spasm”)
and other muscles become inactive.

Any dysfunction
involving the thoracic or
lumbar
spine, the sacroiliac joint
or the hip can create low
back pain.

L2
L3
L4
L5
S1
S2

Long dorsal si ligament
Sacro tuberous ligament
sacrospinous ligament
sciatic nerve
piriformis

Differential –
three broad categories:
1. Mechanical (97%)
2. Nonmechanical (~1%)
3. Visceral (~2%)

Mechanical Low Back Pain
l Mechanical Low Back Pain (LBP) generally
results from an acute traumatic event, but it may
also be caused by cumulative trauma. [1]
Heuch et al 2010

Mechanical Causes of LBP
l Facet
l Disc
l Paraspinal Muscles
l Instability
l Ligaments
l Sacroiliac Joint
l Spondylolysis / spondylolisthesis
l Spinal stenosis

Mechanical LBP
 Lumbar Strain or Sprain (70%)
 Degenerative processes of disc and facets (10%)
 Herniated disc (4%)
 Osteoporotic Compression Fracture (4%)
 Spinal Stenosis (3%)
 Spondylolisthesis (2%)
 Traumatic Fractures (<1%)
 Congenital disease (<1%)
 Severe Kyphosis or Scoliosis
 Transitional Vertebrae
 Spondylolysis
 Internal Disc Disruption/Discogenic Back Pain
 Presumed Instability

Non mechanical LBP (~1%) :Neoplasia (0.7%)
Multiple Myeloma
Metastatic Carcinoma
Lymphoma and Leukemia
Spinal Cord Tumors
Retroperitoneal Tumors
Primary Vertebral Tumors
Inflammatory Arthritis
(0.3%) – note HLA-B27
association.
• Ankylosing Spondylitis
• Reiter Syndrome
• Inflammatory Bowel Disease
Paget Disease
Scheuermann
Disease
(osteochondrosis)
Infection (0.01%)
• Osteomyelitis
• Septic Diskitis
• Paraspinous Abscess
• Epidural Abscess
• Shingles

Visceral Disease:
l Pelvic organ involvement:
_ Prostatitis
_ Endometriosis
_ Chronic Pelvic Inflammatory Disease
l Renal involvement
_ Nephrolithiasis
_ Pyelonephritis
_ Perinephric Abscess
l Aortic Aneurysm
l Gastrointestinal involvement
_ Pancreatitis
_ Cholecystitis
_ Penetrating Ulcer

Types of Pain
• Local
• Referred
• Radicular

Types of Pain
Local
• Irritation of bone, muscle, joints
• Steady, sharp or dull
• Worse with movement

Types of Pain
Referred
 Non-spinal referred to back
- Abdominal aortic aneurysm
 Originate in spine but felt elsewhere
- Upper lumbar pain felt in upper thighs
- Rarely extends below the knee

Types of Pain
Radicular
Irritation of the nerve root
Can radiate to the calf and feet
Worse with movement that
increases CSF pressure

Nerve Root Diagnosis
L4
• Pain = lateral aspect of the leg,
below the knee.
• Numbness = anterior leg
• Motor= quadriceps
• Reflex= Diminished knee jerk
• Can not a squat or get out of a
chair

L5
• Pain = hip, groin, postero-lateral
thigh, lateral calf and dorsum of
foot and big toe.
• Numbness = lateral calf
• Motor = Extensor Hallusis
Longus muscle or the muscles
that dorsi-flex the foot
• Heel walking

S1
• Pain = mid-gluteal region, posterior
thigh, posterior calf to heel & sole
• Numbness = posterior calf
• Motor =weakness and/or atrophy in
the Gastrocnemius muscle , the
peroneal muscles (foot evertors),
plantar flex great toe
• Reflex =Diminished ankle jerk
• Walk on toes - ve

l Posterior sciatica
Pain which radiates along the posterior thigh
and the posterolateral aspect of the leg ( S1 or L5
radiculopathy).
l S1 irritation it may proceed to the lateral aspect of the
foot;
l L5 radiculopathy may radiate to the dorsum of the
foot and to big toe.
Anterior sciatica
Pain which radiates along the anterior aspect
of the thigh into the anterior leg is due to L4 or
L3 radiculopathy. L2 pain is antero-medial in the
thigh.
Pain in the groin usually arises from an L1
lesion.

inflammation
Pain mechanism of spine disorders
Degenerative
disease/injury
instability
Nerve lesion PAIN
Muscle spasm
Per joint
periosteal
decompression
medication
Stabilization

Local back pain can be neuropathic ?
Nucleous pulposus Human diseased discs
Sprouting of nerve fibers
(C-fibers) around the disc
High levels of cytokinesNerve growth inducer
Chronic pain

Lumbar
Vertebra
Disc Herniation
Activation of peripheral nociceptors –cause of
Nociceptive Pain component
Compression and inflammation of nerve root – cause of
Neuropathic Pain component
1. International Association for the Study of Pain. IASP Pain Terminology.
2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57
Baron R, Binder A. 2004 Orthopade. 2004;33(5):568-75

The Co-presentation Of Nociceptive And
Neuropathic Pain
Both Types Of
Pain Co-Exist In
Many Conditions
Neuropathic painNociceptive pain
1. Baron and Binder. 2004 Orthopade. 2004;33(5):568-75
2. Cherny et al. Neurology. 1994;44(5):857-61
3. Grond et al. Pain. 1999;79(1):15-20
LBP Associated With
Radiculopathy,
Effective Management Requires A Broader Therapeutic Approach To
Relieve Both The Nociceptive And Neuropathic Pain Components

Nociceptive And Neuropathic Pain May
Co-exist In LBP Conditions
Neuropathic pain componentNociceptive pain component
1. International Association for the Study of Pain. IASP Pain Terminology.
2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57 Baron R, Binder A. 2004 Orthopade. 2004;33(5):568-75

Low Back Pain
(LBP)
Topics covered:
What is back pain ?
How to diagnose?
**

l Almost Everybody
_ Estimates run as high
as 80% of the
population.
_ Frequently associated
with pregnancy.
_ Peak occurrence is
between age 40 and
60.

Risk Factors of LBP
l Repetitive lifting
l Vibration
l Smoking and Alcohol abuse
l Multiple pregnancies
l Inactivity
l Osteoporosis
l Familial Trend
l Anxiety associated with depression

Prevalence of LBP
l Increases with age
l Reaches 50% in persons > 60 yrs.
l 5% of population yearly (900,000 people)
l 80% of population in lifetime
l 10% LBP lasts > 6 weeks
l Chronic LBP
_ occurs in only 5%
_ Incurs 87% of cost

A. Epidemiology:
 Incidence of LBP:
60-90 % lifetime incidence
5 % annual incidence
 90 % of cases of LBP resolve without treatment
within 6-12 weeks
 75 % of cases with nerve root involvement can
resolve in 6 months

B. Disability:
 Patient who is functionally disabled beyond a period of 3 months
 Disability
 Physical (disease)
 Emotional (psy.soc)
 Situation (claim)
 Prevalence rate:
Increased 140 % from 1970 to 1981 with only
125 % population growth
Nearly 5 million people in the U.S. are on
disability for LBP

C. Occupational Risk
Factors:
l Low job satisfaction
l Monotonous or repetitious work
l Educational level
l Adverse employer-employee relations
l Recent employment
l Frequent lifting

The aims of back pain assessment
are
 To recognize serious pathology.
 To relieve pain.
 To improve function.
 To recognize and assess level of disability.
 To identify barriers to recovery.
 To prevent recurrence or persistence of
symptoms.

Diagnosis is difficult
Why!!!!

Diagnosis is difficult (1)
Anatomical complexity –
vertebrae/discs/ligaments/ muscles/SI joints
“The mobile segment” - discs
- facet joints
- muscles and ligaments
at each level = indissoluble mechanical entity

l Nociceptors >>> in all tissues except disc +
synovial membrane
l Stimulation of any of these may cause muscle
spasm which may or may not be painful
l Referred pain >>> 2 or more sources may refer
to the same site
l Tenderness - may be produced by local
sensitization nociceptors but may exist in
normal tissue e.g. at site of referred pain

Psychological
factors
Social
factors

Acute low back pain - Triage
Aims to differentiate between :-
Simple backache (non specific LBP)
Nerve root pain
Possible serious spinal pathology

I. History:

• Mechanism of injury
• Associated symptoms:
– Bladder / bowel function
– Fevers / chills
– Sleep disturbance
– Numbness / tingling
• Prior injuries, treatment and outcomes
• Medications
• Family history
• Social history:
– Vocational
– Education
– Tobacco / ETOH / Illicit drugs
– Function: ADLs & Mobility
• Litigation

Pain Specifics:
l Onset:
• Gradual: DDD
• Acute: Disc abnormality, strain, compression fractures
l Location / Distribution:
• Radicular: Dermatome distribution, dysesthesias
• Radiating: Nondermatomal
l Quality: sharp, dull, shooting, burning, etc.
l Severity / Intensity
l Frequency: Constant vs. Intermittent
l Duration
l Exacerbating and Alleviating Factors
l Time of Day: If nocturnal, consider malign

Red Flags:
 Significant trauma history, or minor in older adults
 Nocturnal pain in supine position with history of cancer
 Bladder or bowel incontinence or dysfunction
 Constitutional symptoms:
 Fever / chills
 Weight loss
 Lymph node enlargement
 Risk factors for spinal infection
 Recent infection
 IV drug use
 Immunosuppression
 Major motor weakness

‘Yellow flag’ signs
l Factors associated with chronicity
l “doc, you are the 5th specialist”
l “my back is going to kill me”
l “I must rest when there’s pain”
l “nothing is interesting anymore”
l “HEY, HEY, THAT HURTTTTTTTT”

‘Blue flag’ signs
l Work related predisposing factors
l Fear of being lay-off
l Monotony
l Lack of job satisfaction
l Unsatisfactory rating by supervisor
l Poor relationship with peers
l Law suits against employer (s)

B. Symptom Magnification
Examination:
l Waddell signs: Presence of nonorganic signs
suggesting symptom magnification and
psychological distress
Superficial or nonanatomic distribution of tenderness
Nonanatomic or regional disturbance of motor or
sensory impairment
Inconsistency on positional SLR
Inappropriate/excessive verbalization of pain or
gesturing
Pain with axial loading or rotation of spine

B. Symptom Magnification
Examination:
l Give-away weakness: Inconsistent effort on manual
motor testing with “ratcheting” rather than smooth
resistance

II. Examination:

Outline of Spine Physical Exam
• Some don’t know where to look!
l Inspection
l Palpation
l Range of motion
l Special tests
l Neurological exam (motor,
sensory, reflexes, tone)

A. Physical:
• Posture:
– Splinting
– Body language
• Gait:
– Antalgia
– Heel / Toe pattern
– Trendelenberg
• Musculoskeletal:
– ROM
– Leg length
– Vascular
– Atrophy

• Abdomen:
– Presence of masses
• Back:
– Inspection
– Palpation
– ROM
– Scoliosis
• Neurological:
– Sensation
– Motor
– DTRs
• Rectal if indicated:
– Evaluation of sphincter tone

Straight Leg Raising (SLR)
•Test causes
stretching
of nerve root of
sciatic nerve
•With slight
relaxation, DF foot
to reproduce pain
(Differentiating from
back pain cause)

Well (crossed) Leg Raising
•Test causes
stretching of
ipsilateral and
contralateral nerve
root » pulls laterally
on dural sac
•Indication of a
space occupying
lesion

Bowstring Sign
• SLR » pain »
bend knee » relief
of pain » pressure
in popliteal area »
pain
•Usually indicates a
sciatic nerve
problem

Femoral Stretch (L3) Test
 Pain with lifting of
leg in flexed
position causes
Pain / reproduction
of symptoms
 – due to stretch of
femoral nerve (L2-
L4 roots)

Special Tests -Valsalva
Maneuver (History !!)
l Increased
intrathecal pressure
l Leads to pain when
there is a space
occupying lesion
l Ex) tumour,
herniated disc

C. Pathological
Examination:
Patrick’s
maneuver: Crossed
leg with unilateral pain
indicative of sacro-iliac (SI)
joint dysfunction

LABORATORY AND
RADIOGRAPHIC TESTING –
WHEN TO ORDER?
l Symptoms less than 1 month
duration generally do not warrant any
testing.

F. Diagnostic Tools:
l 1. Laboratory:
• Performed primarily to screen for other disease
etiologies
• Infection
• Cancer
• Spondyloarthropathies
• No evidence to support value in first 7 weeks unless with red
flags
• Specifics:
• WBC
• ESR or CRP
• HLA-B27
• Tumor markers: Kidney Breast Lung Thyroid Prostate

l 2. Radiographs:
• Indications:
– History of trauma with continued pain
– Less than 20 years or greater than 55 years with severe
or persistent pain
– Noted spinal deformity on exam.
– Signs / symptoms suggestive of spondyloarthropathy.
– Suspicion for infection or tumor.

l 3. Myelogram:
• Procedure of injecting contrast material into the spinal canal
with imaging via plain radiographs versus CT

l 4. CT with myelogram:
• Can demonstrate much better anatomical detail than
myelogram alone
• Utilized for:
– Demonstrating anatomical detail in multi-level
disease in pre-operative state
– Determining nerve root compression etiology of disc
versus osteophyte
– Surgical screening tool if equivocal MRI or CT

l 5. CT:
• Best for bony changes of spinal or foraminal stenosis
• Also best for bony detail to determine:
– Fracture
– DJD
– Malignancy
• SW Wiesel study 1984 Spine:
– 36 % of asymptomatic subjects had “HNP” at L4-L5
and L5-S1 levels

Spinal Tumors
 Osteoid Osteoma
or Osteoblastoma
 Night Pain
relieved by
NSAIDs.
 Get a fine cut CT
scan.

Imaging (contd)
l CT scan

l 6. Discography (Diagnostic disc injection):
• Less utilized as initial diagnostic tool due to high
incidence of false positives as well as advent of MRI
• Utilizations:
– Diagnose internal disc derangement with normal MRI /
myelo
– Determine symptomatic level in multi-level disease

Diskography
l The only test that can assess pain for the disk.
l Nociceptive nerve fibers have been found in the outer
annulus and granulation of tissue growing into disk
fissures.
Figure 19-3
E. Normal L5-S1 nucleogram in the lateral projection.
F. L5-S1 nucleogram in anteroposterior projection.
There is a slight lateral annular fissure (arrows), which
was asymptomatic, to the mid-annulus on the right.

l 9. MRI:
• Best diagnostic tool for:
• Soft tissue abnormalities:
• Infection
• Bone marrow changes
• Spinal canal and neural foraminal contents
• Emergent screening:
• Cauda equina syndrome
• Spinal cored injury
• Vascular occlusion
• Radiculopathy
• Benign vs. malignant compression fractures
• Osteomyelitis evaluation
• Evaluation with prior spinal surgery

l MRI with Gadolinium contrast:
• Gadolinium is contrast material allowing enhancement of
intrathecal nerve roots
• Utilization:
– Assessment of post-operative spine---most frequent
use
– Identifying tumors / infection within / surrounding
spinal cord
– Diagnosis of radiculitis
• Post-operatively can take 2-6 months for reduction of mass
effect on posterior disc and anterior epidural soft
tissues which can resemble pre-operative studies
• Only indications in immediate post-operative period:
– Hemorrhage
– Disc infection

l 10. Bone scan:
• Very sensitive but nonspecific
• Useful for:
– Malignancy screening
– Detection for early infection
– Detection for early or occult
fracture

l 11. EMG / NCV ( Electrodiagnostics):
• Can demonstrate radiculopathy or peripheral nerve
entrapment, but may not be positive in the
extremities for the first 3-6 weeks and paraspinals for
the first 2 weeks

l 12. Psychological tools:
• Utilized in case scenarios where psychological or emotional
overlay of pain is suspected
• Symptom magnification
• Grossly abnormal pain drawing
• Non-responsive to conservative interventions but with
essentially normal diagnostic studies
• Includes:
• Pain Assessment Report, which combines:
– McGill Pain Questionnaire
– Mooney Pain Drawing Test
• MMPI
• Middlesex Hospital Questionnaire
• Cornell Medical Index
• Eysenck Personality Inventory

Low Back Pain & Sciatica Treatment Guide | 23
The next question is what do you
do if you have low back pain?

How Can You Stay Pain-free ?
Have good genes – studies of identical twins show a
reasonably strong genetic component to disabling low back
pain.
Avoid sudden unintended movements.
Maintain good posture.
Exercise regularly and moderately.
Have regular check-ups

Avoid sudden unintended movements.
This is the presumed cause of most cases of
somatic dysfunction.
A sudden movement:
1) creates a quick stretch on muscles and joints
2) increases pressure on discs
3) increases sensory stimulus to the spinal cord

Maintain good posture. A spine that is too flat or too
curved increases stress on all the joints and the discs.
A normal lumbar lordosis helps to
distribute stress evenly and absorbs
shock when you walk or jump.
Sitting with a small towel roll in
your low back can help to maintain
this position.
During sitting , change position at
least every 20-30 minutes.

Exercise regularly and
moderately.
Begin slowly.
Don’t try to do too much at
once.
Pick a good time.
Watch what you eat.
During the first hour after waking,
the spine is 3 times as stiff because
discs have swelled overnight
(Adams et al., 1987).You should
delay exercise for an hour or two
after you wake up.

Have regular check-ups
Why is your spine any different ?
Regular spine health check-ups can prevent little problems from
turning into big problems later.

Low Back Pain
Topics covered:
What is back pain ?
**

Adequate
treatment starts with
a good evaluation.
A good evaluation
must include a good
examination
Treatment Approaches

T H E R A P Y
l CONSERVATIVE
l INTERVENTIONAL
l SURGICAL

Decrease
inflammatory
response. NSAIDS,
local anesthetics,
steroids
Rest
Activity
PT
Psychotherapy
BracingSpinal injection
Mechanistic Approach To Therapy

Back Pain Management Tools
Care Manager
Physical
Therapy
Chiropractic
Clinic
SurgeryPain
Management
Neurology
EMG
Medicine

G. Treatment
l Medications
• NSAIDS :
• Membrane stabilizers
– TCA / Pregabalin
– re-establish sleep pain
– reduce radicular dysesthesias
• Muscle relaxers:
– re-establish sleep patterns
– more useful in
myofascial/muscular pain
• Narcotics: rarely indicated
• Steroids: more useful for radiculitis
• Non-narcotic analgesics: Ultram

l Physical therapy
• Modalities
• Electrical stimulation/TENS
• Postural education / body mechanics
• Massage / mobilization / myofascial
release
• Stretching / body work
• Exercise / strengthening
• Traction
• Pre-conditioning / work-conditioning

What Type of Activity is Best?
MODE OF EXERCISE
• Walking
• Stationary Bicycle
• Aquacise
•Weight Training

l Injections
•Epidural blocks
•Facet blocks
•Trigger point
•SNRB
•SI joint
•etc

Laminectomy

Percutaneous Lumbar Discectomy
_ Success rate variable 50 -85 %
_ Low rate of complications:
– Infection
– Peripheral nerve injury
_ Benefits:
– Outpatient procedure
– Minimal to no epidural scarring
– No general anesthesia
– Spine stability preservation
– Decreased cost

Spinal fusion

Lumbar Fusion
l Fusion procedure used to treat:
_ Spondylolisthesis
_ Spondylolysis
_ DDD
l Multiple approaches
_ Posterior, anterior, transforaminal, combined
anterior/posterior

Posterior Lumbar Fusion
l Posterolateral fusion
(PLF)
_ Spondylolisthesis and
spondylolysis
without disc involvement
_ Usually includes the use
of screws/rods for
stabilization until the
fusion occurs

l Posterior lumbar interbody fusion (PLIF)
_ Used with disc involvement in conjunction with PLF
_ Usually includes the use of screws/rods for stabilization until
the fusion occurs
_ Bone graft
_ Cages

l Transforaminal lumbar interbody fusion (TLIF)
_ Used with disc involvement with or without PLF
_ Usually includes the use of screws/rods
for stabilization until the fusion occurs
_ Bone graft/cages
_ Less soft-tissue and bone trauma

Anterior Lumbar Fusion
l Anterior lumbar interbody fusion (ALIF)
_ Used with disc involvement primarily with, but sometimes
without, PLF
_ Bone graft/cages

l Total Disc Replacement
l Nucleus Replacement
l Interspinous Spacer Devices
l Pedicle Screw Based Stabilization Devices
l Total Facet Replacement System
Non Fusion
Spinal Motion Preservation

Lumbar Arthroplasty
l Total disc replacement (TDR)
_ DDD
_ Contraindicated for spondylolisthesis and
spondylolysis
The CHARITÉ Artificial Disc is indicated
for spinal arthroplasty in skeletally
mature patients with DDD at one level
from L4-S1.

Pedicle Screw Based Stabilization Devices

RECOMMENDATIONS
For acute LBP
Re-assure patients
Advise patients to stay active
Prescribe medication (at fixed time intervals)
- NSAID´s
- Muscle relaxants or weak opioids
- Paracetamol
Discourage bed rest
Consider spinal manipulations
Do not advise back specific exercises

E. Final Thoughts:
l It is the patient, not the
diagnostic test, that is treated
l 80 % of patients will recover from
acute low back pain within 3
days to 3 weeks, with or without
treatment, with up to 90 %
resolved in 6-12 weeks

T H A N K Y O U !
‫قرنة‬ ‫بهاء‬

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