LOW BACK PAINLOW BACK PAIN

Ald S R bAldy S. RambeDepartment of NeurologyUniversity of SumateraUniversity of Sumatera Utara, School of Medicine

What is LBPWhat is LBP

Low back pain is a common disorder affecting millions of individualsLow back pain is a common disorder affecting millions of individuals annually. Back pain is the single most common cause for lost workdays in the United States and one of the most common reasons for patients to visit ptheir primary care physician. It is estimated that approximately 50 to 80% of the adult population suffers from a memorable episode of low back pain each year. In the vast majority of cases no specific diagnosis is made and the symptoms resolve spontaneously. Only a minority of patients present with symptoms specific to an irritated nerve root or have identifiable pathology on radiographic studiespathology on radiographic studies. The overall prognosis of low back pain is good, with improvement occurring in the majority of cases without aggressive medical intervention.

ANATOMYANATOMY

ANATOMYANATOMY

CLASSIFICATION

ACCORDING TO ITS DURATION, LBP IS ,DIVIDED INTO :

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

CHRONIC : > 12 WEEKS

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Non-specific mechanical back pain

etiology

Non-specific mechanical back painFacet joint syndrome Lumbar disc degeneration (lumbar spondylosis)L b di lLumbar disc prolapseSpondylolisthesisSpinal stenosisOsteoporosisSero-negative spondyl arthritis (including ankylosing spondylitis)p y )Vertebral infectionDisc space infectionMalignancy secondary myeloma and primaryMalignancy – secondary myeloma and primaryPaget’s disease, referred-visceral, pancreatic/pelvic, etc

RED FLAGS – POSSIBLE SERIOUS SPINAL PATHOLOGY

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

accidentaccidentConstant, progressive, non-mechanical pain

Thoracic painHistory of carcinomaHistory of carcinoma

Systemic steroidsDrug abuse, HIV infection

Systemically unwelly yWeight loss

Persistent severe restriction of lumbar flexionWidespread neurological deficit

Structural deformity

COMMON ETIOLOGY

1 Mechanical (deformit tra ma)1. Mechanical (deformity, trauma)2. Inflammation3 Neoplasm3. Neoplasm4. Degenerative5 Psychological5. Psychological

LBP in pregnancyLBP in pregnancy

PRIMARY MECHANICALPRIMARY MECHANICAL DEARRANGEMENT

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

THE DISTINCTION AMONG SPONDYLOSIS, SPONDYLOLISIS AND SPONDYLOLISTHESIS

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

SPONDYLOLISIS :refers to a separation at the pars articularis, which permits the vertebrae to slippermits the vertebrae to slip.Maybe uni or bilateral

THE DISTINCTION AMONG SPONDYLOSIS, SPONDYLOLISIS AND SPONDYLOLISTHESIS

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 th li i f d f t b th t bthe slipping forward of one vertebrae on the vertebrae below.

INFECTION

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INFECTION

Epidural abcessVertebral osteomyelitisSeptic discitisPott’s disease (tuberculosis)Pott s disease (tuberculosis)Nonspecific manifestation of systemic illnessillness

NEOPLASM

• Epidural or vertebral carcinomatousEp u m umetastases

• Multiple myeloma

• Lymphoma• Lymphoma

DEGENERATIVE

1. Osteoarthritis2 Rh t id th iti2. Rheumatoid arthritis3. Thoracic Outlet Syndrome4 Cervical Spondylosis4. Cervical Spondylosis 5. Marie-Strumpell disease6. Lumbar disc prolaps p p

(Hernia Nukleus Pulposus (HNP)7. Spinal Stenosis

RADICULOPATHYRADICULOPATHY

ESSENTIALS f DIAGNOSISESSENTIALS of DIAGNOSIS :Pain in a dermatomal distribution, sensory symptoms alongthe same dermatome, weakness in a correspondingthe same dermatome, weakness in a correspondingmyotomal distribution, and absent or depressed reflexes.Frequency of incidence in order of occurrence :

lumbar > cervical > thoracicUsually caused by a herniated disk or by spondylosis;other causes are infection neoplasm granuloma cyst andother causes are infection, neoplasm, granuloma, cyst, andhematoma

Lumbar disc prolapsLumbar disc prolaps

The earliest change in the NP and AF are probably biochemical andThe earliest change in the NP and AF are probably biochemical and may be part of agingSuperimposed trauma accelerates these degenerative changesTh l t f th AF t d f i f ti l t l d tThe laters of the AF separate and form circumferential tear, leads to radial tears.NP may extrude producing disc herniation or prolapsMultiple tears produce weakening and circumferential bulging of the AF with loss of disc height

Further disc narrowing results from aging of the NP, which changes from gelatinous consistency int the childhood to a fibrotic consistency in adulthood

The diskThe disk

Herniated discHerniated disc

DistributionDistribution

L b di l ( t )Lumbar disc prolaps (most common)L5-S1 (45-50%), L4-5 (40-45%)

Cervical disc prolapsC6-7 (69%), C5-6 (19%)C6 7 (69%), C5 6 (19%)

Thoracal disc prolaps (infrequent, < 1%)

Lumbar Disc Prolaps : GradeLumbar Disc Prolaps : Grade

P t d d di k j l kl lProtruded disk : penonjolan nukleus pulposus tanpa kerusakan annulus fibrosusProlapsed disk : nukleus berpindah tetapi tetapProlapsed disk : nukleus berpindah tetapi tetap dalam lingkaran annulus fibrosus.Extruded disk : nukleus keluar dari annulusExtruded disk : nukleus keluar dari annulus fibrosus dan berada di bawah ligamentum longitudinalis posterior.g pSequestrated disk : nukleus telah menembus ligamentum longitudinalis posterior. g g p

Grade of herniated discGrade of herniated disc

Clinical symptomsClinical symptoms

Lumbar HNP :Lumbar HNP :* severe LBP and lumbar paraspinal spasms,

with pain radiating to the buttocks, legs, and feet ( di l i )(radicular pain)

* abnormal vertebral posture* paresthesia, parese, diminished tendonparesthesia, parese, diminished tendon

reflexes* pain, sensory loss and weakness typically occur in

a radicular patterna radicular pattern.* urinary symptoms, if present, reqquire immediate

attention

Ischialgia (sciatic)Ischialgia (sciatic)

Clinical symptomsClinical symptoms

Cervical HNP :Cervical HNP :* pain present in the posterior neck, with spasm of

the cervical paraspinal musculature and near or p pover the shoulder blades on the affected side.

* radicular pain, aggravated by neck extension,hi t i i l hi b di t icoughing, straining, laughing, bending, or turning

the neck to the side; and reduced by abducting thearm and put it behing the head

* paresthesia, parese, diminished tendon reflexes

Diagnosis : Neurological examinationDiagnosis : Neurological examination

Lumbar HNP :Lumbar HNP :* Lasegue (straight leg raising) test.

A positive SLR test is a sensitive indicator of nerveA positive SLR test is a sensitive indicator of nerveroot irritation (sensitivity 95%).,May be positive with disc protrussion, intraspinaltumor or inflammatory radiculopathytumor or inflammatory radiculopathy

* Crossed Laseque (crossed SLR) test.Less sensitive but highly specific.g y p

* Femoral stretch (reverse SLR) test.May detect an L2-4 root or femoral nerve irritation.

Diagnosis : Neurological examinationDiagnosis : Neurological examination

Cervical HNP :Cervical HNP :

* Lhermitte’s signA painless but unpleasant tingling or electric shock- likeA painless but unpleasant tingling or electric shock likesensation in the back and spreading instantaneously down thearms and legs following neck flexion (active or passive)

* Spurling’s sign Spurling s signIncrease in arm pain (brachialgia) associated with compressive cervical radiculopathy following neck rotation and flexion to the side of painside of pain.

* Shoulder abduction test

DiagnosisDiagnosis

RADIOLOGICAL EXAMINATIONRADIOLOGICAL EXAMINATION :Plain vertebral x-rays :* limited information* limited information* disc narrowing, scoliosis, lordosis lumbal Myelographyy g p yCT or CT-myelographyMRI : the best imaging study

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

MRI scan shows L4-5 herniated discMRI scan shows L4 5 herniated disc

Therapy : ConservativeTherapy : Conservative

* bed rest : max 2 days recommended* bed rest : max 2 days recommended* Pharmacotherapy :

- NSAIDh t f ti t id f t h i t d- short course of corticosteroid for acute herniated disc (controversial)

- muscle relaxantf hi i b i 5% lid i- for neuropathic pain : gabapentin, 5% lidocaine patch, tramadol, TCA.

* Nonpharmacologic therapy :- heat, ice, massage, stress reduction, activity limitation,

postural modification, physical therapy program- soft cervical collar or lumbar corset

Therapy :OperativeTherapy :Operative

Th f b l t i di tiThe few absolute indications :1. Marked muscular weakness pertaining to a nerve

root or roots.2. Progressive neurologic deficits.3. Cauda equina syndrome with urinary symptoms4. Pain that has existed for more than 4 months, has

d d i dnot responded to conservative treatment, andinterferes with normal function.

LUMBAR SPINAL STENOSISLUMBAR SPINAL STENOSIS

CLINICAL SYMPTOMSCLINICAL SYMPTOMS :neurogenic intermittent claudiation or pseudoclaudication (most frequent)pseudoclaudication (most frequent)usually bilateral, but maybe unilaterala dull, aching painthe whole lower extremity is generally affectedpain provoked by walking and standing, quickly

li d b itti l i f drelieved by sitting or leaning forwardLBP presents in 65% patients with lumbar spinal stenosisstenosis radicular pain is the least common manifestation

MOST FREQUENT CAUSES OF SPINAL STENOSIS

> 25 causes are identified> 25 causes are identifiedThe most common :1. Idiopathic : the result of shorter than normal1. 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 ll i th di t b l i t th t dallowing 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

f th t b f d th lof the upper vertebrae forward over the lower vertebrae.

4 Postoperative :4. Postoperative : occurs after laminectomy or spinal fusion. Stenosis is produced by bone formation and scar tissuep y

INDICATION FOR SURGICAL TREATMENT OF LUMBAR SPINAL STENOSIS

1. Severe and disabling pain (persistent intolerable pain)2. Limitation of walking distance or standing endurance g g

to a degree that compromises necessary activities3. Severe or progressive muscle weakness or disturbed

bl dd d b l l f tibladder and bowel, or sexual function.4. Poor response to at least 4 weeks of conservative

treatment

THANK YOUTHANK YOU