You are on page 1of 27

Lower Back Pain

Objectives
• At the end of the session the student
will be enabled to:
• Discuss with understanding risk factors
for lower back injury
• Demonstrate theoretical knowledge of
nursing and collaborative care
management – diagnosis and treatment.
• Describe patient teaching requirements
in managing and preventing further
injury

Etiology & Pathophysiology • Common b/c lumbar region • Bears most of the weight of body • Is the most flexible region of spinal column • Contains nerve roots that are vulnerable to injury or disease • Has an inherently poor biomechanical structure .

Risk factors • Lack of muscle tone • Excess body weight • Poor posture • Cigarette smoking • Stress • Prolonged periods of seating • Repetitive heavy lifting • Vibration .

Causes of musculoskeletal problems • Acute lumbosacral strain • Instability of lumbosacral bony mechanism • Osteoarthritis of lumbosacral vertebrae • Degenerative Disk Disease (DDD) • Herniation of intervertebral disk .

Acute Lower Back Pain • Lasts 4 weeks or less • Symptoms do not appear at time of injury but develop later b/c of gradual ↑ pressure on the nerve by an intervertebral disk • Straight-Leg Raise Test • (+) Disk herniation when radicular pain occurs while lifting the leg in supine position .

g.g. NSAIDs) • Muscle relaxants (e.Outpatient Treatment • Analgesics (e. Flexeril) • Massage & back manipulation • Alternating use of heat & cold compresses • Opioid analgesics for severe pain • Brief period of rest (1-2 days) but avoid prolonged bed rest • Refrain from activities that aggravate the pain .

.

.

g.g. NSAIDs) • Muscle relaxants (e. Flexeril) • Massage & back manipulation • Alternating use of heat & cold compresses • Opioid analgesics for severe pain • Brief period of rest (1-2 days) but avoid prolonged bed rest • Refrain from anything that .Outpatient management • Analgesics (e.

Subjective data • • • • • • • Previous health history Pain – anything which aggrevates it or relieves it Sleep rest pattern Exercise Elimination Occupation Change in role within family .

tight paravertebral muscles on palpation .Objective Data • Guarded movement • Depressed or absent Achilles tendon reflex • Patellar tendon reflex • (+) Straight-Leg Raise Test • ↓ ROM of spine • Tense.

Teaching advice -DOs • Prevent lower back from straining forward by placing a foot on a step or stool during prolonged standing • Sleep in a side-lying position with knees & hips bent • Sleep on back with a lift under knees & legs or on back with 10-inch-high pillow under knees to flex hips & knees • Exercise 15 minutes in the morning & evening regularly • Carry light items close to body • Maintain appropriate body weight • Use local heat & cold application • Use a lumbar roll or pillow for sitting .

Teaching Advice – Do nots • Lean forward without bending knees • Lift anything above level of elbows • Stand in one position for prolonged time • Sleep on abdomen or on back or side with legs out straight • Exercise without consulting health care provider if having severe pain .

Chronic Back Pain .

• Lasts more than 3 months or is a repeated incapacitating episode • Causes • Degenerative Disk Disease (DDD) • Lack of physical exercise • Prior injury • Obesity • Structural abnormalities • Systemic disease .

Spinal Stenosis • Narrowing of vertebral canal or nerve root canals caused by movement of bone into the space • Compression of nerve roots result w/ subsequent disk herniation • Pain starts in low back & radiates to buttock/leg • Worsens w/ walking or standing .

damp weather aggravates back pain • Mild analgesics to ↓ pain & stiffness • Weight reduction • Sufficient rest periods • Local heat & cold application • Exercise & activity throughout day • Antidepressants – Pain relief & sleep problems • Epidural corticosteroid injections .Treatment • Formal back pain program • Rest & local heat application when cold.

Surgical intervention indicated If: • Not responding to conservative treatment • Patient is in consistent pain • Persistent neurologic deficit • Acute intervertebral disc protrusion which requires immediate removal .

↓Reflexes & weakness in hand grips . along distribution of sciatic nerve • Positive Straight-Leg Raising Test • Depressed/Absent Reflexes • Paraesthesia or muscle weakness • Multiple nerve root (Cauda Equina) compression may be manifested as bowel & bladder incontinence or impotence (medical emergency) • Cervical Disk Damage -Radicular pain radiating into the arms & hands.Clinical manifestation • Low back pain • Radicular pain that radiates down buttock & below knee.

Subjective Pain Affectiv Motor e reflex function Sensation L3-L4 Back to Patella buttocks to posterior thigh and inner calf L4 – Back to None L5 buttocks to dorsum of foot and big toe Quadriceps Anterior tibialis Inner aspect of lower leg anterior part of thigh Anterior tibialis extensor hallucis longus. gluteus medius Dorsum of foot and big toe L5 – S1 Gastrocnem Heel and ius. lateral foot hamstring. Back to Achille buttocks to s sole of foot .

Surgical Treatments Laminectomy Spinal Fusion Intradiscal Electrothermoplasty (IDET) Radiofrequency Discal Nucleoplasty (Coblation Nucleoplasty) Interspinous Process Decompression System (X Stop) Diskectomy Percutaneous Laser Diskectomy .

Valium) .Nursing Management Post Operative • Maintain proper alignment of spine • Pillows under thighs of each leg when supine & between legs when side-lying • Fears of any movement that increases pain • Sufficient staff should be available to move patient • Opioids for 24 to 48 hours w/ patient-controlled analgesia (PCA) pumps • Once fluids are being taken. switch to oral drugs & possible muscle relaxant (e.g.

& pulses • Repeat assessments q2-4 hours during first 48 hours post surgery • Paresthesias may not be immediately relieved after surgery • Note new muscle weakness or paresthesias & report to surgeon . capillary refill.Post Operative • Check for cerebrospinal fluid (CSF) leakage • Severe headaches • Monitor peripheral neurologic signs of extremities • Extremity circulation should be assessed by temperature.

Post operative Care • Altered bladder emptying • Use commode or ambulate to bathroom when allowed • Ensure patient privacy • Intermittent catheterization or indwelling catheter may be necessary • Patient usually ambulates as early in postoperative period • Before discharge home will be assessed on the stairs and will need to pass urine normally .

Spinal fusion & bone graft • Longer recovery time • Rigid Orthosis (thoracic-lumbar-sacral brace) used • Teach patient preferred way to put on & take off brace • Logrolling • Sitting or standing and mobility • Posterior iliac crest most common donor site .

pale and clammy and in severe pain. You have t prepare him to go for surgery in the morning • What are your nursing priorities? • What is the nursing diagnosis? • Planning/ Goal setting • Implementation .Class question • A 42 year old man with a large herniated disc at L4/5 has been admitted to your ward he is diaphoretic. On questioning it appears he has not passed urine in the last 24 hours.