LOW BACK PAIN

Dr. SUHERMAN,SP.S

ACCORDING TO ITS DURATION, LBP IS DIVIDED INTO :

ACUTE : < 2-8 WEEKSSUBACUTE : 2-8 WEEKS – 12 WEEKS

CHRONIC : > 12 WEEKS

CLASSIFICATION

EPIDEMIOLOGY

•Life time prevalence 59%•10% leads to consultation to GP

• 90% improved in 1 month• up to 70% patient tend to recur

Non-specific mechanical back pain Facet joint syndrome Lumbar disc degeneration (lumbar spondylosis) Lumbar disc prolapse Spondylolisthesis Spinal stenosis Osteoporosis Sero-negative spondyl arthritis (including ankylosing

spondylitis) Vertebral infection Disc space infection Malignancy – secondary myeloma and primary Paget’s disease, referred-visceral, pancreatic/pelvic, etc

etiology

RED FLAGS – POSSIBLE SERIOUS SPINAL PATHOLOGY

Age of onset : < 20 or 55 yearsViolent trauma, eg fall from a height, traffic

accidentConstant, progressive, non-mechanical pain

Thoracic painHistory of carcinoma

Systemic steroidsDrug abuse, HIV infection

Systemically unwellWeight loss

Persistent severe restriction of lumbar flexionWidespread neurological deficit

Structural deformity

1. Mechanical (deformity, trauma)2. Inflammation3. Neoplasm4. Degenerative5. Psychological

COMMON ETIOLOGY

•Ligamentous Strain• Muscle strain or spasm• Facet join disruption or degeneration• Intervertebral disc degeneration or herniation• Vertebral compression fracture• Vertebral end-plate microfractures• Spondylolisthesis• Spinal stenosis• Diffuse idiopathic skeletal hyperostosis

PRIMARY MECHANICAL DEARRANGEMENT

THE DISTINCTION AMONG SPONDYLOSIS, SPONDYLOLISIS AND SPONDYLOLISTHESIS

SPONDYLOSIS :refers to osteoarthritis involving the articular surfaces (joints and discs) of the spine, often with osteophyte formation and cord or root compression

SPONDYLOLISIS :refers to a separation at the pars articularis, which permits the vertebrae to slip.

Maybe uni or bilateral

THE DISTINCTION AMONG SPONDYLOSIS, SPONDYLOLISIS AND SPONDYLOLISTHESIS

SPONDYLOLISTHESIS :May result from bilateral pars defects or degenerative disc disease.Defined as the anterior subluxation of the suprajacent vertebrae, often producing central canal stenosis : it is the slipping forward of one vertebrae on the vertebrae below.

Epidural abcess Vertebral osteomyelitis Septic discitis Pott’s disease (tuberculosis) Nonspecific manifestation of systemic

illness

INFECTION

• Epidural or vertebral carcinomatous metastases

• Multiple myeloma • Lymphoma

NEOPLASM

1. Osteoarthritis2. Rheumatoid arthritis3. Thoracic Outlet Syndrome4. Cervical Spondylosis 5. Marie-Strumpell disease6. Lumbar disc prolaps (Hernia Nukleus Pulposus (HNP)7. Spinal Stenosis

DEGENERATIVE

The disc

Herniated disc

Distribution

Lumbar disc prolaps (most commo)L5-S1 (45-50%), L4-5 (40-45%)

Cervical disc prolapsC6-7 (69%), C5-6 (19%)

Thoracal disc prolaps (infrequent, < 1%)

Grade

Protruded disk : penonjolan nukleus pulposus tanpa kerusakan annulus fibrosus

Prolapsed disk : nukleus berpindah tetapi tetap dalam lingkaran annulus fibrosus.

Extruded disk : nukleus keluar dari annulus fibrosus dan berada di bawah ligamentum longitudinalis posterior.

Sequestrated disk : nukleus telah menembus ligamentum longitudinalis posterior.

Grade of herniated disc

Clinical symptoms

Lumbar HNP :* radicular pain* abnormal vertebral posture* paresthesia, parese, diminished tendon reflexes

Cervical HNP :* radicular pain, aggravated by neck extension, and reduced by abducting the arm and put it behing

the head* paresthesia, parese, diminished tendon reflexes

Ischialgia (sciatic)

Diagnosis

Neurological examinationLumbar HNP :* Lasegue (straight leg raising) test* Crossed Laseque (crossed SLR) test* Femoral stretch (reverse SLR) test

Cervical HNP :* Lhermitte test* Spurling’s sign* Shoulder abduction test

Diagnosis

RADIOLOGICAL EXAMINATION : Plain vertebral x-rays :

* limited information* disc narrowing, scoliosis, lordosis lumbal

Myelography CT or CT-myelography MRI

EMG/NCV : 90% abnormal after 1-2 weeks

Therapy

CONSERVATIVE* bed rest* orthopaedic mattress* analgetic* pelvic traction (controversial)

OPERATIVEIndication :1. Fail conservative treatment2. Progressive motor dysfunction3. Recurrence4. Compression of cauda equina

LUMBAR SPINAL STENOSIS

CLINICAL SYMPTOMS : neurogenic intermittent claudiation or pseudoclaudication

(most frequent) usually bilateral, but maybe unilateral a dull, aching pain the whole lower extremity is generally affected pain provoked by walking and standing, quickly relieved by

sitting or leaning forward LBP presents in 65% patients with lumbar spinal stenosis radicular pain is the least common manifestation

MOST FREQUENT CAUSES OF SPINAL STENOSIS

> 25 causes are identified The most common :

1. Idiopathic : the result of shorter than normal pedicles, thickened convergent lamina, and a convex

posterior vertebral body. 2. Degenerative (50% of cases) : degenerative changes

affect the facets posteriorly allowing instability and subluxation, osteophytes form and narrow the nerve root and the central canal ; and the disc anteriorly allowing the disc to bulge into the nerve root and central canal.

MOST FREQUENT CAUSES OF SPINAL STENOSIS

3. Degenerative spondylolisthesis : occurs when the facets degenerate, allowing slippage

of the upper vertebrae forward over the lower vertebrae. 4. Postoperative : occurs after laminectomy or spinal fusion. Stenosis is produced by bone formation and scar tissue

INDICATION FOR SURGICAL TREATMENT OF LUMBAR SPINAL STENOSIS

1. Persistent intolerable pain2. Limitation of walking distance or standing

endurance to a degree that compromises necessary activities

3. Severe or progressive muscle weakness or disturbed bladder of sexual function.