Lower Back Pain

Objectives

• At the end of the session the student will be enabled to:• Discuss with understanding risk factors for lower

back injury• Demonstrate theoretical knowledge of nursing

and collaborative care management – diagnosis and treatment.• Describe patient teaching requirements in

managing and preventing further injury

Etiology & Pathophysiology

• Common b/c lumbar region• Bears most of the weight of body• Is the most flexible region of spinal column• Contains nerve roots that are vulnerable to

injury or disease• Has an inherently poor biomechanical

structure

Risk factors

• Lack of muscle tone• Excess body weight•Poor posture•Cigarette smoking• Stress•Prolonged periods of seating•Repetitive heavy lifting•Vibration

Causes of musculoskeletal problems

•Acute lumbosacral strain• Instability of lumbosacral bony

mechanism•Osteoarthritis of lumbosacral

vertebrae•Degenerative Disk Disease (DDD)•Herniation of intervertebral disk

Acute Lower Back Pain

• Lasts 4 weeks or less• Symptoms do not appear at time of

injury but develop later b/c of gradual ↑ pressure on the nerve by an intervertebral disk• Straight-Leg Raise Test• (+) Disk herniation when radicular pain

occurs while lifting the leg in supine position

Outpatient Treatment

• Analgesics (e.g. NSAIDs)•Muscle relaxants (e.g. Flexeril)•Massage & back manipulation• Alternating use of heat & cold compresses• Opioid analgesics for severe pain• Brief period of rest (1-2 days) but avoid

prolonged bed rest• Refrain from activities that aggravate the

pain

Outpatient management

• Analgesics (e.g. NSAIDs)•Muscle relaxants (e.g. Flexeril)•Massage & back manipulation• Alternating use of heat & cold compresses• Opioid analgesics for severe pain• Brief period of rest (1-2 days) but avoid

prolonged bed rest• Refrain from anything that aggravates the

pain

Subjective data • Previous health history • Pain – anything which aggrevates it or relieves it • Sleep rest pattern• Exercise • Elimination• Occupation • Change in role within family

Objective Data

• Guarded movement• Depressed or absent Achilles tendon reflex• Patellar tendon reflex• (+) Straight-Leg Raise Test•↓ ROM of spine• Tense, tight paravertebral muscles on

palpation

Teaching advice -DOs• Prevent lower back from straining forward by placing

a foot on a step or stool during prolonged standing• Sleep in a side-lying position with knees & hips bent• Sleep on back with a lift under knees & legs or on

back with 10-inch-high pillow under knees to flex hips & knees• Exercise 15 minutes in the morning & evening

regularly• Carry light items close to body• Maintain appropriate body weight• Use local heat & cold application• Use a lumbar roll or pillow for sitting

Teaching Advice – Do nots

• Lean forward without bending knees• Lift anything above level of elbows• Stand in one position for prolonged time• Sleep on abdomen or on back or side with legs

out straight• Exercise without consulting health care provider

if having severe pain

Chronic Back Pain

• Lasts more than 3 months or is a repeated incapacitating episode • Causes• Degenerative Disk Disease (DDD)• Lack of physical exercise• Prior injury• Obesity• Structural abnormalities• Systemic disease

Spinal Stenosis

• Narrowing of vertebral canal or nerve root canals caused by movement of bone into the space• Compression of nerve roots result w/

subsequent disk herniation• Pain starts in low back & radiates to

buttock/leg•Worsens w/ walking or standing

Treatment

• Formal back pain program• Rest & local heat application when cold, damp

weather aggravates back pain• Mild analgesics to ↓ pain & stiffness• Weight reduction• Sufficient rest periods• Local heat & cold application• Exercise & activity throughout day• Antidepressants – Pain relief & sleep problems• Epidural corticosteroid injections

Surgical intervention indicated If: •Not responding to conservative

treatment•Patient is in consistent pain•Persistent neurologic deficit•Acute intervertebral disc protrusion

which requires immediate removal

Clinical manifestation• Low back pain• Radicular pain that radiates down buttock & below knee,

along distribution of sciatic nerve• Positive Straight-Leg Raising Test• Depressed/Absent Reflexes• Paraesthesia or muscle weakness• Multiple nerve root (Cauda Equina) compression may be

manifested as bowel & bladder incontinence or impotence (medical emergency)

• Cervical Disk Damage -Radicular pain radiating into the arms & hands, ↓Reflexes & weakness in hand grips

Subjective Pain Affective reflex

Motor function Sensation

L3-L4 Back to buttocks to posterior thigh and inner calf

Patella Quadriceps Anterior tibialis

Inner aspect of lower leg anterior part of thigh

L4 –L5 Back to buttocks to dorsum of foot and big toe

None Anterior tibialis extensor hallucis longus, gluteus medius

Dorsum of foot and big toe

L5 –S1 Back to buttocks to sole of foot and heel

Achilles Gastrocnemius, hamstring, gluteus maximus

Heel and lateral foot

Surgical Treatments

Laminectomy

Spinal Fusion

Intradiscal Electrothermoplasty (IDET)

Radiofrequency Discal Nucleoplasty (Coblation Nucleoplasty)

Interspinous Process Decompression System (X Stop)

Diskectomy

Percutaneous Laser Diskectomy

Nursing Management Post Operative • Maintain proper alignment of spine • Pillows under thighs of each leg when supine & between legs

when side-lying• Fears of any movement that increases pain• Sufficient staff should be available to move patient• Opioids for 24 to 48 hours w/ patient-controlled analgesia

(PCA) pumps• Once fluids are being taken, switch to oral drugs & possible

muscle relaxant (e.g. Valium)

Post Operative • Check for cerebrospinal fluid (CSF) leakage• Severe headaches• Monitor peripheral neurologic signs of extremities • Extremity circulation should be assessed by

temperature, capillary refill, & pulses• Repeat assessments q2-4 hours during first 48 hours

post surgery• Paresthesias may not be immediately relieved after

surgery• Note new muscle weakness or paresthesias & report

to surgeon• Paralytic Ileus

Post operative Care

• Altered bladder emptying• Use commode or ambulate to bathroom when

allowed• Ensure patient privacy

• Intermittent catheterization or indwelling catheter may be necessary• Patient usually ambulates as early in

postoperative period• Before discharge home will be assessed on the

stairs and will need to pass urine normally

Spinal fusion & bone graft

• Longer recovery time• Rigid Orthosis (thoracic-lumbar-sacral brace)

used• Teach patient preferred way to put on & take off

brace• Logrolling• Sitting or standing and mobility• Posterior iliac crest most common donor site

Class question • A 42 year old man with a large herniated disc at L4/5 has

been admitted to your ward he is diaphoretic, pale and clammy and in severe pain. On questioning it appears he has not passed urine in the last 24 hours. You have t prepare him to go for surgery in the morning

• What are your nursing priorities? • What is the nursing diagnosis?• Planning/ Goal setting • Implementation