Understanding Low Backache

& its basis of treatment

Bhaskar Borgohain
MS ortho, DNB ortho, Fellow (Arthroplasty)
Asst Professor, Department of Orthopaedics.

NEIGRIHMS
MOVEMENT IS LIFE

LIFE IS MOVEMENT
 PAINLESS MOVEMENT
MEANS
ENJOYING A QUALITY OF LIFE

PAINFUL MOVEMENTS
MEANS
JUST HAVING A LIFE
OR EVEN WORSE
Biomechanics is nothing but the scientific
study of the movements of the spine;
in health & disease
Movements are so essential or at times so
bizarre
 Low back: Lumbo-sacral Spine
 Anatomically Multisegmental column:
Connects upper torso to the pelvis
 Function: Maintains upright position (stability)
 Yet allow great flexibility for actions: 5 Discs
 During all ROMs provide a protective conduit
for neurological structures within
 Practically No rotation possible: Facets
 Functional components of lumbar
spine
Each Lumbar vertebra
has 3 Components
 Body : To bear weight
 The Neural Arches:
To protect the neural
elements
 Bony Processes: To
increase efficacy of
spinal muscle actions
 SPINAL STABILITY SYSTEM
3 Interrelated subsystem
 Active: Actively contracting muscles
(Erectors / Abdominals)
 Passive: Bone, Joints, Ligaments,
Passively elongated muscles
 Neural (Control): Neural elements within
the active & passive subsystem giving
Dynamic stability
 LIMITATIONS
 Cadaveric:
 Muscle contarctions
 Neural control
 Dynamic balancing
 Translating lab finding to real time
situations
 Clinical implications
Components of Lumbar Spine
 Normal biomechanics of spine
 Photo of a gymnast
 Endless potential
 Elastic limits: Young’s modulus
 Pathobiomechanics: LBA
 Pain sensitive structures of the
spine
 Ligaments: PLL
 Nerves: sinuvertebral nerve
 Facet joint capsule
 Periosteum
 Meningeal coverings
 Muscles
 LBA: The grey zone
 Biological enigma
 Exact cause: 12-15%
 Evolutional paradox
 Proud spine in Health
 Terrible back in Disease
 Back Abuse/ Overuse
Epidemiology & Natural history
 Over 80% of population experience some back pain
in their lifetime
(Quebec task force study on spinal disorders)
 Overall Prevalence 18%, Annual incidence 15-20%
(USA)
 Good news: 50% recover in 2 weeks; 90% in 6 wks
 Bad news: Only 1% chronically disabled
 Ugly truth: 80% Hospital resources drained
 Simple Mechanical Backache
Vs
Sinister Backache
Green flag Red flag
 Noninflammatory  Inflammatory
backache  Constitutional symptoms
 No constitutional  Spinal deformity
symptoms  Neurological deficits or
 No obvious spinal tension signs
deformity  Extremes of age
 No neurological deficits or
tension signs
 Not in Extremes of age
 MECHANICAL BACKACHE
 Nothing is gravely  Dull backache
wrong except the aggravated by activity
backache itself  Physical signs often
 Non-inflammatory, non- slight
infective & non-  Neurological deficit nil
neoplastic pathology  Extensive radiating
 Lumbar Disc disease: pain to lower limbs
included absent
 IMPORTANCE OF
BIOMECHANICS OF SPINE
 Stability Vs Mobility
 Spinal motion
segments
 Disc & Facet joints
close to nerve roots
 Compressible gel
 Mobile Ball bearing
action
BIOMECHANICAL ANATOMY
 Hourglass connection
 Dynamic balance
 Abdominal muscle Vs
erector spinae group
of muscle
 Intrathoracic pressure
and intrabdominal
pressure
Dynamic balance
 INTRADISCAL PRESSURE
 IDP changes with
position
 Sitting worse,
Standing better ,lying
supine best
 After 6 hours
statistically significant
reduction of normal
disc height
DDD (Degenerative Disc disease)
Pathobiomechanics
 Loss of water content
 Abnormal stresses /
biomechanics
 Further degeneration
 Facet degeneration
 Disc prolapse: Weak
PLL
 Discogenic back pain
Poor blood supply: poor healing
WHOOP STRESS
DISC SPACE LOSS: SEQUEL
Sequel of Collapse of disc space:
Distorted attempt to stability
 Segmental spinal instability: Motion segment
abnormality- All column disturbances
 Facetopathy: Abnormal stress on facet joints
 Vertebral end plate sclerosis
 Ligamentum flavum hypertrophy
 Secondary canal stenosis
 LBA: Final common pathway
 DISC DESSICATION
Poor vascularity: Poor healing
 Discogenic back pain
 Axial low back pain
 Sinuvertebral nerve arise from dorsal root
ganglion: non-segmental innervations
 S.V.N. Innervates posterior annulus close
to PLL is irritated
 Disc bulges on axial compression
 Axial pain begins d/t signal carried by
paravertebral sympathetic trunk
Discogenic back pain
 Mangement
 Goal: Early return to work
 Tailored to each patient
 Interdisciplinary approach
 Modify activity in acute phase
 Confirming the diagnosis
Chronic Low Backache
 ABNORMAL POSTURE
 Lx lordosis
 Infancy Vs adulthood
 Muscle weakness
 Muscle fatigue
MODALITIES OF MANGEMENT
 Touching the back!
 Counseling: Back Schooling
 Posture care: Do & Don’t list
 Use of firm mattress
 Avoiding cumulative microtrauma to
spine
 Developing positive attitude: Depression
Bed rest: Contradictory to the goal
 Bed rest of > 2days has serious implications
 3% of muscle bulk/ mass is lost daily
 6% of bone demineralized in 2 weeks
 Restriction of social activity & inability to carry
out responsibilities PPT depression, illness
behavior & lack of motivation
 Adequate sleep: of course yes, endorphin/
melatonin
 MAN Vs SUPERMAN?
“Man is a social animal”
 Anatomically & Physiologically we are nothing
but Animals
 We are probably the only Animals that sit for 5
hours in the computer when the body is asking
for rest & sleep!
 Man cannot run faster than a cheetah but he can
drive at 100km/hour and stop in less than a
second
 Brunt is taken by the Spine,Discs and Ligaments
 BACK SCHOOL - I
 Don't try to be superman
 Anatomically & Physiologically we are
man
 Maintain good posture
 Take frequent break at work
 Use your back but don't abuse it
 BACK SCHOOL - II
 Smoke at your own peril
 Modify your activity to give rest to the tired
back
 Never flog a tired horse

“Single footstep of a man a giant leap for

the man’s back”
 Medications
 NSAIDs: 1ST Line
 Narcotics: Not beyond
 Trigger point
2 weeks injections: No role
 Muscle relaxant: No
 Spinal manipualation:
role Controversial OR
contraindicated if disc
 Antidepressant :Only
herniation
if >3 months
 SIMPLE BACKACHE IS NOT
SIMPLE
 Functional restoration program involv.
interdisciplinary approach if no narcotics or
surgery needed
 Psychological evaluation or Psychiatric
analysis whenever possible
 Treat co morbid condition that may aggravate
LBA
 SIMPLE BACKACHE IS NOT SIMPLE

Malingerers backache:
Compensation
 Hoover’s Test
 Simulation Rotation Test
 Pelvic Compression Test
 Sitting SLR Test
 Adams anterior bending test
 Sickness absenteeism
 SIMPLE BACKACHE IS NOT SIMPLE

Referred pain: High index of

suspicion
 Hips: Compensatory pain
 Pelvic organs
 S.I. Joints or pelvis
 Renal & Retroperitoneal tumor
 Vascular: aneurysm
 Cure Vs Curiosity in Backache
 Can we cure backache :yes
 Can we cure spondylosis: no
 Does all disc prolapse need operation: no
 Is it possible to have a normal life after a disc
prolapse: yes
 Can physiotherapy improve spinal
biomechanics: yes
 Physical therapy
 Exercises : once acute phase is over
 Heat/Infrared/ US Therapy
 Electric Stimulation
 IFT: only if acute phase is over
 TENS: only if acute phase is over
 C fibre & Gate theory
 Endorphin?
 Thermal therapy
 Heat : Superficial  Increase circulation
 Infrared: Deep  Wash off cytokines
 US Therapy: Deep  Promote healing
 Relieve spasm
 Counterirritant
 Touch
 Pregnancy
 Pregnancy aggravates LBA
 Weight Gain & Pull Of Abdomen
 Address LBA appropriately First
 Surgery if indicated: Do First
 Ligament Laxity
 Osteomalacia
 PhysioTh: Impractical (3rd Trimester)
 Facet injections
 Limited Indications: Not a common source
of pain
 Pain in spinal extension & radiation to
back of thigh that ends above knee level
 Multiple Joints and Peculiar nerve supply
 Doesn’t Change the Pathology: Adjunct
 Epidural steroids/block
 Controversial indications
 Decreases sciatic pain
 Unpredictability: Inoperable patient
 Undermines the actual disease
 Complications & Wrong diagnosis
 Surgery: Laminectomy:
 Cauda equina syndrome: Hemilaminectomy
 Single Laminectomy : 14% overall instability
 Cadaver study (Punjabi):

Unilat. Or B/L facetectomy increased

63% Flexion,
78% extension,
15% lateral bending &
126% axial rotation
 Surgery: Spinal fusion
 Rigid stabilization:  Posterior: Rods &
Spinal fusion + pedicular Screws
Facetal Fusion  Anterior: Rods &
 Halts abnormal Screws
biomechanics at  Address secondary
fused level causes:
 ALIF or PLIF  3600 Fusion
 Post. or Postlateral
 Intertransverse fusion
 Surgery: Spinal fusion
 Persistent disabling Discogenic axial low
back pain in absence of other organic or
psychological component: 70-80%
 Multilevel discectomy
 Documented instability
 DISC PROLAPSE: SURGICAL
INDICATIONS
 Acute neurological complications
 Gradual but progressive neurological
deterioration
 Persistent radiating pain despite strict bed
rest and medication for 3- 4 weeks
Why 3 - 4 Wks: TNF,Cytokines

BULGE PROTRUSION EXTRUTION SEQUESTRATION

CONTAINED DISCS UNCONTAINED DISCS

 DISC: TYPES OF INTERVENTIONS

 Chymopapain Injection  Laser discectomy:

(Europe): Anaphylaxis Contained disc
 Microdiscectomy: Good  Endoscopic discectomy:
option  Intradiscal electrothermal
 Open discectomy: therapy: Thermally ablate
Objectivity + Complete the sinuvertebral nerve
Neural decompression fibre of posterior annulus
 Endoscopic discectomy:
Transperitoneal video-assisted
 Technically  Retrograde
demanding: ejaculation: < 9.4%
 Complications  DVT
 Overall: 4.7% cf  Visceral injury,
2.3%  Paralytic ileus
 Vascular injury: 2.1%
to 25%
 Dynamic stabilization
 Fusion may fail to relieve  Don’t remove or disturb
pain normal anatomy
 Preserve movements of  Augmenting weak ligaments
motion segment and muscles without fusion
 Graf ligament recontruction:
 Instruments or artificial
mimic normal biomechanics
ligaments to control
 Interspinous Spacer (DIAM):
movements
no osteoporosis
 Load sharing during
movements
 Disc replacement
 Aim: Painless, Mobile and Stable Spine,
 Replaces anatomical structures
 Correct Soft tissue tensioning crucial for
maintaining spinal stability
 Pain causing structures are physically
removed at surgery
 Long term Safety: FDA ( MoM / MoP)
 Gene transfer
 Biochemical changes in nucleus
 Adenovirus as vector: rat model
 IRAP (interleukin receptor antagonist) or
Lac Z gene
 Increase synthesis of PG
 Immune privileged cells of nucleus
 Prophylactic injections?
 ALTERNATIVE THERAPY
 Too many options means too little known
 The exact cause found in only 12-15%
 Biofeedback: No role after 2 weeks of trial
 Acupuncture: No role after 2 weeks of trial
 Massage: breakdown adhesions
 Yoga
 Endorphin!
 Summary
 LBA In man is a biological
enigma
 Mobility leads to repetitive
cumulative microtrauma
 Microtrauma PPT
degenerative changes
 Microtauma progresses to
macrotrauma in
prolonged back abuse
 Degeneration reduces
mobility Decrease mobility
causes muscle atrophy
 Abnormal segmental
motion starts
 Abnormal biomechanics
evolves
 & encroaches neural
elements
 Secondarily encroaches
neural elements
 Low back Pain begins
 Thank
you