Low Back Pain

Dr Liau Kai Ming

Dept. of Orthopaedic

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

Implication

Work & productivity loss

Anatomical consideration

Commonly at lumbosacral junction (L4/L5, L5/S1)

Why?

Most mobile region of the spine

Therefore prone to degeneration (wear & tear)

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)

Referred pain

1. Abdominal cavitygastritis/peptic ulcerpancreatitischolecystitis

2. Urinary systemrenal calculiUTI

3. Pelvic cavityovarian cystdysmenorrhea

4. AortaAortic aneurysm

Nature of pain

MECHANICAL VS NON-MECHANICAL

REFERRED VS RADICULAR

CLAUDICATION – VASCULAR VS SPINAL

MECHANICAL PAIN

1. Muscle strain

2. Ligament sprain

3. Facet joint arthritis

4. Disc-Discogenic

5. Instability - Spondylolysis/spondylolisthesis

NON-MECHANICAL PAIN

Infection – PYOGENIC VS TB

Tumour – PRIMARY VS SECONDARY

Primary - BENIGN VS MALIGNANT

Common causes of low back painPathology Age Pain nature Assoc pain Assoc sx

DEGENERATIVE

Spondylosis

>40y mechanical Distance

claudication

Active pt

Spondylolisthesis

<20y

>40y

mechanical extension Hyperextension 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

RED FLAGS Constitutional symptoms

LOW, LOA, fever

AGE(>50)

IMMUNOCOMPROMISED,

TB CONTACT

KNOWN CANCER

NEUROLOGICAL DEFICIT (CAUDA EQUINA SYN)

Physical findings

General examination Age Ill looking

Local examination – DO NOT MISS A GIBBUS

Deformity Scoliosis/kyphosis Step deformity Local tenderness/paraspinal spasm

Limited ROM

Full neurological examination

ANAL TONE / PERIANAL SENSATION

DERMATOME & MYOTOME

Investigations

Plain radiograph AP

-loss of lumbar lordosis

-reduced disc space

-osteophytes

-deformity

-fracture (increase interpedicular distance)

-osteoporosis

-pedicle disruption

Lateral

-fracture/wedging

-kyphosis

-spondylolisthesis

Oblique

-spondylolysis (SCOTTIE DOG)

Plain x-rays

Blood investigations

FBC Anemia, TWC

ESR Liver function test

ALP Renal function test

Calcium level

CT Scan

better visualization of bone pathology (eg. cortical destruction)

fracture tumor

MRI

-better soft tissue visualization -disc -ligaments (ALL,PLL) -nerves (spinal cord, roots) -bone marrow -pus collection

MRI

CT myelogram

role replaced by MRI for delineation of neural structures where MRI

is not available/contraindicated

CT Myelogram

Bone scan

Suspicious of multiple bone mets Eg. with history of untreated/treated CA Negative in Multiple myeloma

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)

Pelvic traction

Surgery

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)

Surgery

1. DECOMPRESSION of spinal nerves (BURST FRACTURE, Spinal stenosis, PID)

2. Fusion & Stabilization (Instrumentation)

3. Correction of deformity

DECOMPRESSION Surgery

FUSION Surgery

THANK YOU