BACK PAIN

ACUTE LOW BACK PAIN…

5th most common reason for seeing a

Physician

2nd most common cause of lost work days and

disability claims, and single most costly
category
ANATOMY
Functional Units:
• Anterior Segment: 80% of the
load
• Posterior Segment: 20% of the
load

• Static stability: Bony elements

and intervertebral disk.
vs.
Dynamic stability: muscular and
ligamentous supports
Vertebra
Body: anteriorly
• support weight
Vertebral arch: posteriorly
• Formed by two pedicles and two
laminae
• Functions to protect neural
structures
Ligaments

Anterior longitudinal
ligament
ETIOLOGY…
•  Swelling and indentations of the ganglion
> reacts to both pressure and vibration
> DRG – capable of producing both
Sciatica and Back- dominant pain
•  Outer third of IVD and adjacent ligaments
à well innervated; potential sites of LBP
Linking facet joints à innervated by small
radicular nerves
Bone and priosteum à contain nociceptors
PATHOPHYSIOLOGY AND PATHOGENESIS
Probable origins of Pain: Spine structures
Ø  Annulus of the disk
Ø  post. Longitudinal ligament complex
Ø  zygopophyseal joints
Nerve Roots can be:

Compressed, Deformed
and stretched by the
disc, facet, ligaments or Ø Demyelination
the ligaments Ø Degeneration of
Nerve fibers
Ø Venous changes
Ø Atrophy of dorsal
ganglion
Mechanical Ø Compression
deformation
and Ischemia
***Wallerian Degeneration
•  Distortion of the anatomical structures in response to:

can stimulate
Load
nociceptors within
Position
Specific the disc, facet or
movement ligaments to induce
•  Cumulative trauma
vibration pain
CLASSIC FEATURES…
Mechanical Back pain- episodic; self –limiting.
resolves in 8- 12 weeks.

Direct involvement of dura à dominant pain;

involve gluteal fold

90% of pts with acute mechanical LBP à

recover within 6 weeks.

70- 80% of pts continue to experience LBP 1

year after the onset.
ASSESSMENT OF PATIENT WITH BACK PAIN:
Diagnostic Criteria:

Laboratory:
§ Localization
§ Onset § ESR
§ Constancy
§ Blood works
PATIENT HISTORY: “OPQRSTU”

§ Onset
§ Palliative/Provocative factors
§ Quality
§ Radiation
§ Severity/Setting in which it occurs
§ Timing of pain during day
§ Understanding - how it affects the
patient
IMAGING:
Plain Radiograph

Bone Scanning – Osteomyelitis,

Neoplasm or fracture

Bone Densitometry

MRI
TREATMENT:
Heat

Lumbar Extension exercises (McKenzie’s)

Maintaining (N) activity, limiting rest, minimal use of

medication, manipulation and reassurance
Surgery: decompress à restore neural
function
fusion à prevent presumably painful
motion

Education
MC KENZIE
Physical Modalities : TENS, Hydrotherapy,
acupuncture, manual traction and biofeedback
monitoring

Self treatment: liniment, massage, heating

pad or a bag of frozen vegetables

Back Support

Bed rest- up to 3 days only

Exercise : Mc Kenzie’s
MEDICATION:
Acute
1. Acetominophen – as effective pain reliever
2. Aspirin – inflammatory effect require upto 6 g/d in divided
doses
3. NSAIDs
4. COX- 2 inhibitors
5. Muscle Relaxant – CNS Anxiolytics, hypnotics and sedatives
6. Oral Corticosteroids – for acute Sciatica (to reduce nerve root
inflammation)
Chronic
1. Long Acting Opiods
2. Tricyclic Antidepressant and SSRIs
3. Ms relaxants, barbiturates, phenothiazines and
benzodiazepines – no role!
FAILED BACK SURGERY SYNDROME

Specific sources of continuing

pain:
• Unrecognized and uncorrected preexisting
lesions amenable to surgical correction
• Painful conditions arising directly from
operative intervention
• Pain associated with emotional conditions
or negative psychosocial factors.
Chronic Pain Behavior: largest and most complex group of pts with failed
back surgery

blaming
others

negative
sleep family,
distur 5 key workplace
& social
bance predictors of situations
AbN illness
behavior:
financial
Litigation compen
sation