Musculosceletal System 1

LOW BACK PAIN

dr. Fitriah Handayani, M.Kes, Sp.N

Medical Faculty
Tadulako University
2019
 Low Back Pain (LBP)
is pain, muscle tension, or stiffness localized
below the costal margin and above the
DEFINITION inferior gluteal folds, with or without
sciatica, and is defined as chronic when it
persists for 12 weeks or more

• More than 70 percent of persons in developed countries will experience low back pain at
some time in their lives.
• Each year, between 15 and 45 percent of adults have low back pain, and 5 percent of
persons present to the hospital with a new episode
• About 10 percent remained unable to work and about 20 percent had persistent symptoms
at one year.
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DISEASES ASSOCIATED WITH LOW BACK PAIN

CLASSIFIED ACCORDING TO ETIOLOGY
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SYMPTOMS
PHYSICAL IMPAIRMENT MEASURES 7
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CLASSIFICATION LBP
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 TREATMENT 14

Causative • Treatment of the underlying disease causing the pain is

given priority in patients complaining of low back pain
Disease originating in abdominal or posterior abdominal organs

• Care must be taken not to miss the time for surgery while
conducting conservative therapy before the operation.
• The criteria for surgical indications are reduced mobility in
everyday life and development of paralysis in lumbar spinal
Surgery stenosis, and progression of the paralysis in lumbar
intervertebral disc hernia.
• If paralysis develops in a patient with a spinal cord tumor,
surgery must be performed without delay.

Psycological • effective for chronic low back pain and psychogenic pain,
and guidance in regard to everyday living should not be
counseling forgotten
 TREATMENT 15

• Rest is usually advised as the first method of reducing low

back pain, without considering surgery.
Conservative • thermotherapy with hot packs, disposable body warmers,
therapy and bathing, pelvic traction by applying traction force to
the lumbar spine is an effective means of physical therapy
for lumbar intervertebral disc hernia

• performing relaxation and stretching exercises to eliminate

Exercise muscle tension, creating a “natural” corset by abdominal
and low back muscle training, and attempting to strengthen
therapy bones by imposing mechanical loads on them are useful in
treating low back pain

• available for curative therapy and symptomatic therapy.

Drug therapy Local infiltration (trigger point) blocks or nerve blocks with
anesthetics also sometimes have a curative effect on low
back pain.
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Musculosceletal System 20

HERNIATED NUCLEUS PULPOSUS

dr. Fitriah Handayani, M.Kes, Sp.N

Medical Faculty
Tadulako University
2019
Herniated Nucleus Pulposus 21

Is prolapse of an intervertebral disc through a

tear in the surrounding annulus fibrosus
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Cervical Herniated Disc 23
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Cervical vs Lumbar Herniated Disc
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 Lumbar HNP
is a localized displacement of intervertebral
disc tissue beyond the physiological margins of
DEFINITION the intervertebral disc space that can result in
low back pain, radicular pain, motor weakness,
numbness, and/or tingling in a myotomal and
dermatomal distribution

• 2% in Western industrial nations, peaking in patients between 30 and

50 years of age.
• Population studies indicate that males are affected twice as often as
females are.
• Almost 95% of all LDHs occur at levels L4/5 and L5/S1 of the lower
lumbar spine
Clinical Presentation 28

• Consisten complaint of localized low back pain that

increases under strain and axial loading.
• Prolonged sitting and upright standing are typically more
debilitating than remaining in a recumbent position.
LBP (lumbago) • Medially herniated discs frequently result in predominant
lumbago without any radicular pain.
• Lateral disc herniation, however, can lead to radicular
pain without the low back pain

• The typical presentation of radicular pain is radiation of (low

back) pain along the dermatome of a peripheral nerve.
• The most common form of radicular pain is sciatica, which
refers to a pain that radiates from the lower spine along the
gluteal region and the back of the upper thigh and calf,
Radicular Pain and into the foot.
• Coughing and sneezing typically lead to an increased pain
sensation.
• Lasegue’s sign is positive in about 95% of all patients
suffering from LDH
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• the MRI and the CT scan, native x-rays

and discography have lost their
relevance in the diagnosis of LDH and
are reserved for special issues only
(e.g.,spondylolysis and
spondylolisthesis)
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Spinal imaging of
lumbar disc herniation
CLINICAL PRESENTATION 31
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Modification of activity 33

Long-term immobilization or abstention from any physical activity is not uniformly

recommended, since bed rest lasting longer than two to four days seems to produce
weakness, stiffness, and increased pain in patients with LDH. Rather, a gradual return to
normal activities should be pursued. The aim is to continue normal daily activities at a
tolerable level of pain or discomfort, without increasing strain

Physical exercise & spinal

manipulation
• supervised moderate aerobic exercise (through physical therapy) during the first month of
symptoms may be beneficial and at the same time minimize debility that can occur due to
inactivity. Low-stress exercises such as swimming, walking, and bicycling are also
recommended
• spinal manipulation by professional physiotherapists may be effective for pain relief in
patients with back pain and radiculopathy and therefore a therapeutic option in the
treatment of LDH
 Analgetics 34

• Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Parcetamol) are

recommended during the first short-term period of pain. NSAIDs do not, however,
appear to have better pain relief than acetaminophen
• Stronger analgesics such as opioids are reserved for patients with severe pain and
should not be prescribed for longer than a few weeks

Steroid
• In daily clinical practice, intravenous administration of glucocorticoids in patients with
sciatica is very common.
• The role of epidural steroid injection (ESI)in LDH treatment is very controversial

Steroid
INDICATION
• Progresive neurologic deficits , Saddle anastesia, Bowel and bladder dysfunction
• Symptoms more than 6months
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