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LOW BACK PAIN

Ald S Aldy S. R Rambe b
Department of Neurology University of Sumatera Utara, School of Medicine

What is LBP
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Low back pain is a common disorder affecting millions of individuals annually. Back pain is the single most common cause for lost workdays in the patients to visit United States and one of the most common reasons for p their 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 studies. studies The overall prognosis of low back pain is good, with improvement occurring in the majority of cases without aggressive medical intervention.

ANATOMY

ANATOMY

. LBP IS DIVIDED INTO : ACUTE : < 2-8 WEEKS SUBACUTE : 2 2-8 8 WEEKS – 12 WEEKS CHRONIC : > 12 WEEKS .CLASSIFICATION ACCORDING TO ITS DURATION.

referred-visceral. pancreatic/pelvic. etc .etiology ti l „ „ „ „ „ „ „ „ „ „ „ „ Non-specific mechanical back pain Facet joint syndrome Lumbar disc degeneration (lumbar spondylosis) L b di Lumbar disc prolapse l Spondylolisthesis Spinal stenosis Osteoporosis Sero-negative spondyl arthritis (including ankylosing spondylitis) p y ) Vertebral infection Disc space infection Malignancy – secondary myeloma and primary Paget’s disease.

RED FLAGS – POSSIBLE SERIOUS SPINAL PATHOLOGY Age of onset : < 20 or 55 years Violent trauma. eg fall from a height. non-mechanical pain Thoracic pain History of carcinoma Systemic steroids Drug abuse. traffic accident Constant. HIV infection Systemically y y unwell Weight loss Persistent severe restriction of lumbar flexion Widespread neurological deficit Structural deformity . progressive.

3 3. 5 5.COMMON ETIOLOGY 1. (deformit trauma) tra ma) Inflammation Neoplasm Degenerative Psychological . 4. 1 2. Mechanical (deformity.

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LBP in pregnancy .

PRIMARY MECHANICAL DEARRANGEMENT •Ligamentous Strain • Muscle strain or spasm • Facet join disruption or degeneration • Intervertebral disc degeneration g or herniation • Vertebral compression fracture • Vertebral end-plate microfractures • Spondylolisthesis • Spinal stenosis • Diffuse idiopathic skeletal hyperostosis .

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which permits the vertebrae to slip slip. often with osteophyte p y formation and cord or root compression SPONDYLOLISIS : refers to a separation at the pars articularis. p .THE DISTINCTION AMONG SPONDYLOSIS. Maybe uni or bilateral „ . SPONDYLOLISIS AND SPONDYLOLISTHESIS „ SPONDYLOSIS : refers to osteoarthritis involving the articular surfaces (joints and discs) (j ) of the spine.

Defined as the anterior subluxation of the suprajacent vertebrae. . often producing central canal stenosis : it is th slipping the li i forward f d of f one vertebrae t b on the th vertebrae t b below. SPONDYLOLISIS AND SPONDYLOLISTHESIS „ SPONDYLOLISTHESIS : May result from bilateral pars defects or degenerative disc disease.THE DISTINCTION AMONG SPONDYLOSIS.

INFECTION Epidural E id l abcess b „ Vertebral osteomyelitis „ Septic discitis „ Pott Pott’s s disease (tuberculosis) „ Nonspecific manifestation of systemic illness „ .

NEOPLASM • Ep Epidural u or vertebral carcinomatous m u metastases • Multiple myeloma • Lymphoma .

Osteoarthritis 2 Rh 2. Lumbar disc prolaps p p (Hernia Nukleus Pulposus (HNP) 7. 5. Marie-Strumpell disease 6.DEGENERATIVE 1. Thoracic Outlet Syndrome 4 Cervical Spondylosis 4. Rheumatoid t id arthritis th iti 3. Spinal Stenosis .

sensory symptoms along the same dermatome. neoplasm granuloma. weakness in a corresponding myotomal distribution. Frequency of incidence in order of occurrence : lumbar > cervical > thoracic Usually caused by a herniated disk or by spondylosis. infection neoplasm. granuloma cyst. other causes are infection.RADICULOPATHY ESSENTIALS of f DIAGNOSIS : „ „ „ Pain in a dermatomal distribution. and absent or depressed reflexes. cyst and hematoma .

NP may extrude producing disc herniation or prolaps Multiple tears produce weakening and circumferential bulging of the AF with loss of disc height Further disc narrowing results from aging of the NP. t leads l d to t radial tears.Lumbar disc prolaps „ „ „ „ „ The earliest change in the NP and AF are probably biochemical and may be part of aging Superimposed trauma accelerates these degenerative changes Th laters The l t of f th the AF separate t and df form circumferential i f ti l tear. which changes from gelatinous consistency int the childhood to a fibrotic consistency in adulthood .

The disk .

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Herniated disc .

Distribution Lumbar L b disc di prolaps l (most ( t common) ) L5-S1 (45-50%). < 1%) „ . C5 C5-6 6 (19%) „ Thoracal disc prolaps (infrequent. L4-5 (40-45%) „ Cervical disc prolaps C6-7 C6 7 (69%).

Extruded disk : nukleus keluar dari annulus fibrosus dan berada di bawah ligamentum longitudinalis g posterior. p Sequestrated disk : nukleus telah menembus ligamentum g longitudinalis g p posterior.Lumbar Disc Prolaps : Grade „ „ „ „ Protruded P t d d disk di k : penonjolan j l nukleus kl pulposus l tanpa kerusakan annulus fibrosus Prolapsed disk : nukleus berpindah tetapi tetap dalam lingkaran annulus fibrosus. .

Grade of herniated disc .

reqquire immediate attention . diminished tendon reflexes * pain. parese. with pain radiating to the buttocks. legs.Clinical symptoms „ Lumbar HNP : * severe LBP and lumbar paraspinal spasms. and feet ( di l pain) (radicular i ) * abnormal vertebral posture * paresthesia. pattern * urinary symptoms. sensory loss and weakness typically occur in a radicular pattern. if present.

Ischialgia (sciatic) .

or turning t i the neck to the side. diminished tendon reflexes . aggravated by neck extension. coughing. hi b di bending. parese. * radicular pain. and reduced by abducting the arm and put it behing the head * paresthesia. t i i l laughing.Clinical symptoms „ Cervical HNP : * pain present in the posterior neck. with spasm of the cervical p paraspinal p musculature and near or over the shoulder blades on the affected side. hi straining.

May detect an L2-4 root or femoral nerve irritation. intraspinal tumor or inflammatory radiculopathy Crossed Laseque (crossed SLR) test. g y specific. p Less sensitive but highly Femoral stretch (reverse SLR) test. * * .. A positive SLR test is a sensitive indicator of nerve root irritation (sensitivity 95%).Diagnosis : Neurological examination Lumbar HNP : * Lasegue (straight leg raising) test. May be positive with disc protrussion.

Diagnosis : Neurological examination Cervical HNP : * Lhermitte’s sign A painless but unpleasant tingling or electric shock shock.like sensation in the back and spreading instantaneously down the arms and legs following neck flexion (active or passive) Spurling’s Spurling s sign Increase in arm pain (brachialgia) associated with compressive cervical radiculopathy following neck rotation and flexion to the side of pain. pain Shoulder abduction test * * .

lordosis lumbal Myelography y g p y CT or CT-myelography MRI : the best imaging study EMG/NCV : 90% abnormal after 1-2 weeks . scoliosis.Diagnosis RADIOLOGICAL EXAMINATION : „ „ „ „ Plain vertebral x-rays : * limited information * disc narrowing.

MRI scan shows L4-5 L4 5 herniated disc .

stress reduction. tramadol. ice.for f neuropathic hi pain i : gabapentin.short h t course of f corticosteroid ti t id for f acute t herniated h i t d disc (controversial) .NSAID . activity limitation. Nonpharmacologic therapy : . TCA.Therapy : Conservative * * bed rest : max 2 days recommended Pharmacotherapy : .soft cervical collar or lumbar corset * .heat.muscle relaxant . physical therapy program . postural modification. b i 5% lidocaine lid i patch. massage.

2. 3. Marked muscular weakness pertaining to a nerve root or roots.Therapy :Operative The few Th f absolute b l t indications i di ti : 1. Progressive neurologic deficits. . Pain that has existed for more than 4 months. and d interferes with normal function. has not responded d d to conservative i treatment. Cauda equina syndrome with urinary symptoms 4.

aching pain the whole lower extremity is generally affected pain provoked by walking and standing. but maybe unilateral a dull. quickly relieved li d by b sitting itti or leaning l i forward f d LBP presents in 65% patients with lumbar spinal stenosis radicular pain is the least common manifestation .LUMBAR SPINAL STENOSIS CLINICAL SYMPTOMS : „ „ „ „ „ „ „ neurogenic intermittent claudiation or pseudoclaudication (most frequent) usually bilateral.

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2. and the disc anteriorly allowing ll i the th disc di to t bulge b l into i t the th nerve root t and d central canal. osteophytes form and narrow the nerve root and the central canal . thickened convergent lamina. Idiopathic : the result of shorter than normal pedicles. and a convex posterior vertebral body.MOST FREQUENT CAUSES OF SPINAL STENOSIS „ „ > 25 causes are identified The most common : 1. Degenerative (50% of cases) : degenerative changes affect the facets posteriorly allowing instability and subluxation. .

4 Postoperative : 4. allowing slippage of f th the upper vertebrae t b f forward d over th the l lower vertebrae. Degenerative spondylolisthesis : occurs when the facets degenerate. Stenosis produced by y bone formation and scar tissue is p .MOST FREQUENT CAUSES OF SPINAL STENOSIS 3. occurs after laminectomy or spinal fusion.

Poor response to at least 4 weeks of conservative treatment . l or sexual lf function. Severe or progressive muscle weakness or disturbed bl dd and bladder db bowel. Severe and disabling pain (persistent intolerable pain) g distance or standing g endurance 2.INDICATION FOR SURGICAL TREATMENT OF LUMBAR SPINAL STENOSIS 1. Limitation of walking to a degree that compromises necessary activities 3. ti 4.

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