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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
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 .
Passively elongated muscles Neural (Control): Neural elements within the active & passive subsystem giving Dynamic stability . Ligaments. Joints.SPINAL STABILITY SYSTEM 3 Interrelated subsystem Active: Actively contracting muscles (Erectors / Abdominals) Passive: Bone.
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 .
Annual incidence 1520%(USA) Good news: 50% recover in 2 weeks. 90% in 6 wks Bad news: Only 1% chronically disabled Ugly truth: 80% Hospital resources drained .Epidemiology & Natural history Over 80% of population experience some back pain in their lifetime (Quebec task force study on spinal disorders) Overall Prevalence 18%.
Simple Mechanical Backache Vs Sinister Backache Green flag Noninflammatory backache No constitutional symptoms No obvious spinal deformity No neurological deficits or tension signs Not in Extremes of age Red flag Inflammatory Constitutional symptoms Spinal deformity Neurological deficits or tension signs Extremes of age .
noninfective & nonneoplastic pathology Lumbar Disc disease: included Dull backache aggravated by activity Physical signs often slight Neurological deficit nil Extensive radiating pain to lower limbs absent .MECHANICAL BACKACHE Nothing is gravely wrong except the backache itself Non-inflammatory.
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 .
Standing better .lying supine best After 6 hours statistically significant reduction of normal disc height .INTRADISCAL PRESSURE IDP changes with position Sitting worse.
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 .
All column disturbances Facetopathy: Abnormal stress on facet joints Vertebral end plate sclerosis Ligamentum flavum hypertrophy Secondary canal stenosis LBA: Final common pathway .Sequel of Collapse of disc space: Distorted attempt to stability Segmental spinal instability: Motion segment abnormality.
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 .
illness behavior & lack of motivation Adequate sleep: of course yes.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. 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 .
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 .
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 injections: No role 2 weeks Spinal manipualation: Muscle relaxant: No Controversial OR role contraindicated if disc Antidepressant :Only herniation if >3 months .
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 Functional restoration program involv.
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 .
Joints or pelvis Renal & Retroperitoneal tumor Vascular: aneurysm .I.SIMPLE BACKACHE IS NOT SIMPLE Referred pain: High index of suspicion Hips: Compensatory pain Pelvic organs S.
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 Infrared: Deep US Therapy: Deep Increase circulation Wash off cytokines 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 .
78% extension.Surgery: Laminectomy: Cauda equina syndrome: Hemilaminectomy Single Laminectomy : 14% overall instability Cadaver study (Punjabi): Unilat. 15% lateral bending & 126% axial rotation . Or B/L facetectomy increased 63% Flexion.
Surgery: Spinal fusion Rigid stabilization: Spinal fusion + Facetal Fusion Halts abnormal biomechanics at fused level ALIF or PLIF Post. or Postlateral Intertransverse fusion Posterior: Rods & pedicular Screws Anterior: Rods & Screws Address secondary causes: 3600 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 .
4 Wks: TNF.Why 3 .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 demanding: Complications Overall: 4.1% to 25% Retrograde ejaculation: < 9.3% Vascular injury: 2. Paralytic ileus .4% DVT Visceral injury.7% cf 2.
Dynamic stabilization Fusion may fail to relieve pain Preserve movements of motion segment Instruments or artificial ligaments to control movements Load sharing during movements Don’t remove or disturb normal anatomy Augmenting weak ligaments and muscles without fusion Graf ligament recontruction: mimic normal biomechanics Interspinous Spacer (DIAM): no osteoporosis .
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) .Disc replacement Aim: Painless.
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 .
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