Low Back Pain
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Low Back Pain Anatomy - Pathophysiology - Management Pain Management
Transcript of Low Back Pain
What is low back pain?
• Any pain in the back. It is usually characterized by dull, continuous pain and tenderness in the lower lumbar, lumbosacral or sacroiliac regions. Sometimes referred to the leg, following the disturbution of the sciatica nerve.
- 70% of the world adults will experience at least one disabling episode in their lives due to back pain.
By: Dr. Ali Saad Ali - E-Mail: [email protected] - Website: www.alisaadali.com
Anatomy of the Low Back
Lumbar VertebraeSacrum
Sacro-iliac Joint
CoccyxIlium
By: Dr. Ali Saad Ali - E-Mail: [email protected] - Website: www.alisaadali.com
Anatomy of the Low Back
Intervertebral Discs
Vertebrae
- Nucleus Pulposus- Annulus Fibrosus
- Transverse process- Spinous process- Superior articular facet- Spinal Cord
By: Dr. Ali Saad Ali - E-Mail: [email protected] - Website: www.alisaadali.com
Classification of thelow back pain
Acute RecurrentChronic
< 6 weeks > 6 weeksIn Only 10-15% of patients
Causes oflow back pain
SystemicPsychogenic
Referred
ComplicatedUncomplicated
By: Dr. Ali Saad Ali - E-Mail: [email protected] - Website: www.alisaadali.com
Causes of low back painUncomplicated Back pain
when performing day-to-day activities, or from direct trauma
Injury to muscles & ligamentStrain SprainContusion
Degenerative Joint Disease (Osteoarthritis)
most common cause of chronic low back pain in the elderly
- Loss of articular cartilage- Osteophyte formation- Articular surface irregularity
impair joint function and at times can lead to inflammation and pain
Degenerative Disc Disease
The discs most commonly involved are L3-L4, L4-L5, L5-S1
Weakening of the fibrous outer ring of an intervertebral disc (the annulus fibrosus)
Bulge or herniation of the gelatinous center of the disc into the spinal canal
Motion restriction of spinal structures
- facet joints- The sacroiliac joint- Vertebral bodies
Spondylolysis & Spondylolisthesis
Spondylolysisbreak in the integrity of the neural arch caused by aquired defect in pars interarticularis due to fracture
Spondylolisthesis defect causes slippage of vertebra on the one below
FracturesCompression fracture of the vertebral body, often caused by minor trauma in older people with Osteoarthritis
Other Causes
Type of occupations workers in occupation requiring lifting heavy objects
Smoking
Obesity
By: Dr. Ali Saad Ali - E-Mail: [email protected] - Website: www.alisaadali.com
Complicated Back Pain
Structural with nerve root compromise (sciatica). It is a condition in which pain, numbness, parasthesia &/or muscle weakness reflect injury to the spinal root.
The most common cause is herniation of intervertebral disc.
Spinal Stenosis Back & leg symptoms associated with narrowing of the lumbar spinal canal seen on CT or MRI scanning.
- Bony pressure on multiple nerve roots- Congenital
Systemic Causes- Infections- Cancer- Inflammatory arthritis - Paget’s disaese.
Less than 1% of all cases
Referred Pain
From abdominal orpelvic structures
- Acute pancreatitis- Pyelonephritis, pelvic
inflammatory disease- Dysmenorrhea- Posterior peptic ulcer- Abdominal aneurysm- Cholecystitis
Management of low back painNon-Interventional:- Conservative- Medications
Interventional:- Minimal invasive- Surgical treatment
Non-Interventional ManagementConservative:Exercise can be very beneficial for mild to moderate back pain, but if you have severe back pain be very careful, and don't do too much.
- Aerobic exercise- Swimming- Cycling- Yoga and Pilates- Physiotherapy- Osteopathy and Chiropractic
Medications:- NSAIDs: Ibuprofin and Diclofinac (SE: GI bleeding and fluid retension). - COX-2 inhibitors: Arcoxia and Celebrex (better tolerated than NSAIDs).- Mild Opioids: Codeine, Dihydrocodeine, and Tramadol.- Strong Opioids: Buprenorphine, morphine, and fentanyl.- Anti-Neuropathic treatments: Amitriptyline, Carbemazepine, Gabapentin, or
Pregabalin.
Interventional ManagementMinimal invasive:
Surgical treatment:
- Acupuncture - Facet Radio Frequency (Rhizotomy)- Facet joint injections- Facet joint denervation- Pulsed Radio Frequency- Epidural injections- Transforaminal epidural injections- SIJ injections- Sellective nerve root block- Lumbar Sympathetic block- Stellate ganglion block- Dekompressor discectomy- Percutaneous disc nucleoplasty- Vertebroplasty- Kyphoplasty
- Discectomy- Laminectomy- Fusion- Microdiscectomy
Minimal Invasive
Radio-Frequency:- Lumbo-Sacral facets- Cervical facets- Coccyx- Sacro-Iliac Joint (SIJ)
Minimally invasive procedure under fluoroscope by a local anesthesia and by a radiofrequency electrode through a cannula that reduces or eliminates the pain from damaged facet or sacroiliac joints by disrupting the medial branch nerves that carry pain signals.
Pain may increase for the 1st week after procedure, patient may have full relief after a month, successful RF can last longer
Transforaminal injection:Injection of a steroid (anti-inflammatory agent) and lidocain (numbing agent) into the opening at the side of the spine where a nerve roots exits.
By: Dr. Ali Saad Ali - E-Mail: [email protected] - Website: www.alisaadali.com
Epidural injection:
Injection of a steroid (anti-inflammatory agent) and lidocain (numbing agent) into the epidural space.
By: Dr. Ali Saad Ali - E-Mail: [email protected] - Website: www.alisaadali.com
SIJ Block:Injection of a steroid (anti-inflammatory agent) and lidocain (numbing agent) by inserting a needle in the sacro-iliac joint.
An SI joint block injection may be repeated up to three times per year. For the treatment to be successful, the injection should be followed by physical therapy and/or chiropractic adjustments to provide mobilization and range of motion exercises.
A special device the size of a needle is inserted into the affected disc. This then rotates like a drill removing some of the nucleus of the damaged disc, thus decompressing it and allowing the bulge to reduce. This in turn reduces the pain from both the disc and the nerve root.
Dekompressor Discectomy:
A special device the size of a needle is inserted into the affected disc. This probe has radiofrequency electrodes at its tip and is slightly angled. It is moved around inside the disc vapourising a very controlled amount of disc nucleus, typically 1 - 2 ml.
Percutaneous nucleoplasty:
Intra-discal Ozone Injection:
Intradiscal Causes pressure drop pull the disc herniation inward
Ozone!
- Prevents and reverses degenerative diseases- Reduces inflammation- Stop bleeding- Normalizes hormone and enzyme production- Supports and enhances the healing process - Stimulates the immune system- Destroy cancer cells
