Dr.Jagdish G.

Agroya
M.S.(Ortho) D.Ortho (Bom) Consulting Orthopaedic Surgeon Apex Hospital,Latur. Professor Department of Orthopaedics MIMSR Medical College,Latur.

LBP

THE LOW BACK PAIN

Evolutionary Basis

The Low Back Pain is the penalty mankind is paying for his Erect Posture.

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Anatomy

14

 Stabilizing Role of Muscles

Abdominal Muscle

Back Abdominal Extensors Muscle

Back Extensors

Spine Spine

Figure 1

Figure 2
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17

Inter Vertebral Disc (Nucleus Pulposus)

80% Water

Composition :

+
Mucopolysaccharides

Functions

:-

Contributes Approximately 20 to 25% of the total length of vertebral column

Shock Absorber

Holds the Vertebrae together and allows Movement between the bones
Seperates the vertebrae as part of a functional segmental unit acting in consert with facet joint By seperating the vertebrae helps in free passage of nerve roots through 18 intervertebral foramen

Clinical Approach

What is Backache for the patient is the headache for the Doctor ?

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Causes of Low Back Pain

Congenital Causes - Spine bifida - Lumbar Scoliosis - Spondylolysis - Spondylolisthesis - Transitional Vertebra - Facet Tropism - Sprain,Strain - Vertebral fractures - Prolapsed disc - Tuberculosis - Ankylosing Spondylitis - Seronegative Spond Arthritis - Lumbar Spondylolysis - Spinal Canal Stenosis Benign - Osteoid Osteoma - Eosinophilic Granuloma Malignant - Primary :- Multiple Myeloma Lymphoma - Secondaries from other sides

Traumatic Causes

Inflammatory Causes

Degenerative Cause Neoplastic Causes

Metabolic Causes

- Osteoporosis - Osteomalacia

Pain referred from Viscera

- Genito urinary disease

- Pelvic inflammatory diseases - Ca Cervix

Miscellaneous Causes

- Functional Back Pain - Postural Back Pain - Protuberant Abdomen - Occupational bad posture

- Habitual bad posture

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History
Uncommon Congenital deformity Fall from height Infection ( Psoas abcess or tuberculosis) Carrying school bags

Age Children Adult

Posture Traumatic backpain Disc prolapse Ankylosing spondylosis Lumbar Spondylosis

Elderly

Osteoporosis Osteomalacia Spinal Canal Stenosis Degenerative Spondylosis Malignancies Primary 22 Secondary

 History ( Contd.) Sex * More common in females.

Particularly.. * During pregnancy. * H/o. multiple pregnancies and abdominal surgeries. * Obesity * Post menopausal osteoporosis * Pelvic inflammatory diseases (PID) * Female genital malignancies * After S.A. * Faulty Shoe Wears * Psychological disorders 23

 History ( Contd.) Occupation

Sedentary workers Heavy vehicle drivers Weight lifters Any job which requires awkward positioning e.g. Mechanic Surgeons Dentist etc.

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PAIN :

History ( Contd.)
It is the gift of nature.

Definition : Pain is the subjective Emotional reaction. Which is felt at the site of injury but is recognised in Thalamus. The pattern of pain in the low back is an important clue to make perfect diagnosis. PAIN

Pain is an unpleasant sensory and emotional experience associated with potential or actual tissue damage

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History ( Contd.)
1. Localised 2. Diffuse Acute myofascitis Sprain Early disc degeneration Lumbar spondylosis Malignancies Infection Ankylosing Spondylosis 3. Referred pain Pain felt upto the knee joint never below it.

Types :

4. Radicular Pain - Pain felt upto the toes Disc prolapse SOL

PAIN Onset :

History ( Contd.)
1. Acute Trauma Significant or insignificant Disc prolapse Fractures Degenerative spondylosis Recurrent attack of disc prolapse

2. Chronic

Progression :
Max.at onset gradually subsides over the days. Disc prolapse Traumatic injury Remissions and exacerbations Disc prolapse Ankylosing spondylosis Constant pain aggrevated by activity Degenerative spondylosis Progressively increasing Infection SOL 27 Malignancies


PAIN Sleep

History ( Contd.)
Four types of pattern of pain

LBP till patient sleeps Sleep is very peaceful and 1. patient fresh in morning. Causes of this pattern are non cognizable e.g.

Malingaring Psychological Fatigue pain 2. No LBP before or during sleep but pain begins at getting up in the morning and wincess off as the day advances. e.g. Degenerative spondylosis Ankylosing spondylosis Rheumatoid affection
3. No pain before sleep - Patient sleeps well but awakened by pain in the middle of the sleep. This is a very geuinine pain caused by SOL and T.B. of spine (Night Cries) 4. Pain which does not allow to sleep at all. e.g. Malignancy 28 Infection

History ( Contd.)

PAIN LBP Related to Activity

1. Sleeping supine in the bed with knee and hip extended if causes LBP a probable cause is disc prolapse. 2. Turning in the bed if painful a probable cause is sacroiliac arthritis or acute

myofascitis.
3. Sleeping prone if painful may be due to facetal arthropathy. 4. LBP caused while getting up from sitting position on the floor is very classical of spodylolysis or spondylolisthesis. Interestingly the same pain becomes less while patient gets up from the chair. 5. LBP only on standing further increased by walking is diagnostic of spinal canal stenosis. 6. Painful forward bending may be a feature of trauma,infection,acute disc prolapse,malignancy. 7. Coughing,sneezing and straining causing LBP is a diagnostic feature of acute disc prolapse again.

8. LBP after prolonged travelling is due to degenerative lumbar spondylosis.

9. Painful sitting on the floor may be due to sacroiliac arthritis.

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History ( Contd.)

Neurological Symptoms
Common symptoms are.. Parasthesia Tingling Numbness Weakness Bowel and Bladder involvement

Anterior view

Posterior view

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History ( Contd.)
Appearance of LBP associated with Neurological symptoms in lower extremites after standing and walking for certain distance is called Neurogenic Claudication. It is the diagnostic feature of spinal canal stenosis.

Neurogenic Claudication

Extra Skeletel Symptoms

Abdominal complaints e.g. Pancreatitis,Renal stones Retroperitoneal SOL etc. Gyanecological complaints- Irregular menses Menorrhagia Leucorrhoea Foul smelling discharge

Psychological Complaints
Malingaring Hysteria
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Mechanical Posture Acute Disc Prolapse Spinal canal stenosis Spondylolysis Spondylolisthesis Inflammatory

Causes of LBP
Metabolic Neoplastic Meningeoma Visceral Abdominal Genito Urinary Gyanecological Functional Malingaring Psychological Ankylosing Spondylosis Osteoporosis Tuberculosis Rheumatoid Arthritis Pyogenic Arthritis

Osteomalacia Equindimoma Neuro Fibroma Haemangeoma ABC

Degenerative spondy.
Fractures

Multiple Myeloma
Lymphoma Metastatic

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Posture

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Etiology

Disc Prolapse

Degenerative changes with advancing age make the disc increasingly susceptible to trauma such as.. Lifting

Fall on the Buttocks

Direct trauma to the back

Twisting movements 34

 Disc Prolapse(Contd.) Clinical Feature

1. LBP Severe LBP occurs within few hours of injury. Spasm and flatening of Lumbar area LBP on bending forward Sneezing Coughing Straining Standing Sitting LBP on recumbency Subsequent attacks are More severe with less amount of injury. 35

 Disc Prolapse(Contd.) Clinical Feature

2. Sciatic Pain Subsequently LBP and pain starts in the Lower extremity along the distribution of Sciatic nerve(Sciatica) Pain radiates the gluteal regions the back of the thigh,ankle and leg. S1 root compression Post. Lat.calf and heel L5 root compression Ant.Lat.leg and ankle L2 3 4 compression Ant. Aspect of thigh
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 Disc Prolapse(Contd.) Clinical Feature

3. Neurological Symptoms

C/o.parasthesias often describes as pins and needles corresponding to the dermatome of the affected nerve root. Numbness in the leg or foot and weakness of muscles e.g. S1 root weak push off L5 root weak toe extension L4 weak dorseflexion of the foot
In a massive disc prolapse patient may report with CAUDAEQUINA syndrome having paraplegia and bladder and bowel involvement. The chronic disc prolapse patient may report the gross WASTING of muscles.

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1. Posture

Examination
2. Limitation of Movements

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3. Tenderness

Examination

Diffuse but purcussion on spinous process may evoke the pain. 4. Straight leg raising Test

5. Femoral Nerve Stretching Test

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Neurological Examination

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Investigations
1. X-Rays

2. Myelography
3. C.T.Scan 4. MRI Scan
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1. X-Rays

Investigations
Not very much diagnostic in acute disc prolapse but must be done to rule out other affections. Standard projections are A P view, Lat.view,oblique view and PBH prone. But in chronic disc prolapse one may see.. 1. Reduction in disc degenerative osteophytes.

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2. Myelography

Investigations

Due to adventage of MRI myelography is outdated. Disadvantage - Invasive Extra vasation of dye Indirect assessement CT Scan Good for hard structures. Poor visualiations of soft parts like disc. But can be useful if combined with myelography. C.T. Myelo

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4. MRI Scan

Investigations
More versatile investigation. It gives exact anatomical picture of cord,roots and disc in all three planes. i.e. Saggital Coronal Axial

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Pts Name : Sow.Birajdar Chandrakant

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MRI : Lumbar Spine

Yasmin Khan Patel

30/12/2004

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PtsName : Sow.Pawar Sojarbai

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 Treatment
Every disc is not for removal and at the same time no culprit disc should be spared. This decision is based on.. 1. Clinical co-relation on MRI findings Perfect clinical co-relation 2. Response to conservative

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1. Rest

Conservative Treatment
- It reduces intradiscal pressure. Relaxes the nerve roots. Prevents the mechanical irritation of the nerve roots.

The ideal position of rest is ..

The rest should be continued till the acute pain subsides.

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Conservative Treatment

2. Lumbar Traction Controvertial ? Therotically it distracts the disc space so prolapse disc is reduced. 3. SWD and Massage 4. NSAIDS with Muscle Relaxtant 5. Sedatives 6. Curtailment of curtain activities
Activity And Percentage Increasing in Disc Pressure at L3 Coughing or Straining 05 to 35% Laughing 40 to 50% Walking 15% Side bending 25% Small jumps 40% Bending forward 150% Rotation 20% Lifting a 20 Kg weight with the back Straight and knees bent 73% Lifting a 20 Kg weight with the back Bent and knees straight 169%

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Conservative Treatment

7. Back Supports May help during mobilisation. Should be adviced strictly for short term use because of 1. Muscle atrophy further degeneration 2. Psychological dependency 8. Physiotherapy -The purpose of physiotherapy is to.. 1. Unload the disc pressure. 2. Even distribution of load of day today activity. 3. To stretch the nerve root to prevent adhesion. This can be achieved by strengthening Abdominal Muscles Back extensors Hip extensors Hip flexors

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Operative Treatment
The aim of the surgery is to remove the disc compressing the root and the theca. But the question is.

1. IN WHOM ? a) Acute disc prolapse with gross neurological

deficit.

b) Without neurological deficit but LBP is refractory to fair trial of conservative treatment.

2. WHEN 3. HOW

? ?

Immediately a) Conventional laminectomy & discectomy b) Fenestration c) Endoscopic excision

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Spinal Canal Stenosis

Extremely common condition It is caused by reduction in the space of spinal canal. The diagnosis is made only by history. Clinical examination of little value. Clinical Feature : Common in males Above the age of 40 No LBP at rest or sitting Neurogenic claudication As the patient stands and start walking LBP begins. LBP keeps on increasing as the distance increases. LBP may be associated with parasthesias and both LE. At critical point patient cannot walk and sit down. After few minutes patient is fresh to cover the same distance and the cycle repeats. Patient prefers to walk bending forward and flex knee and hip to get rid of symptoms. As the disease advances the claudication distance become less and less. This is the most diagnostic rather only diagnostic clinical information. 53

Spinal Canal Stenosis (Contd.)

Clinical Examination :
No pathological findings in clinical examination. One must ruleout PVD.

Wall test

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Spinal Canal Stenosis (Contd.)

Treatment :

Surgical decompression by doing laminectomy.

Indications :

Increasing LBP Progressive reduction in the claudication distance.

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Spondylolisthesis
It is the condition caused by forward displacement of body of the vertebrae due to the defect in the posterior element. Fairly common cause of LBP many times a symptomatic accidently detected by on X-rays.

Clinical Feature
Common in female with 30 to 40 age Posture Hyperlordotic back Pain Low grade Episodic Worse when standing and walking relieved by sitting and lying down. Pain is restricted to low back, buttocks and thigh never radiates down. Hyperextension of Lower back will the pain. Pain is more while getting up sitting position on the floor. Same pain is very less while getting up from the chair. It is because of hamstring tightness and spasm. Neurological symptoms are usually absent in the initial phase.

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Investigation
X-Rays

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 Treatment
Bed rest Lumbar Traction NSAIDS with MR

Mobilisation with corset

Physiotherapy to improve abdominals and gluteus maximus. Surgery of spinal fusion.

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 Trauma
Trauma can cause two types of backache.. a) Acute Backache It is due to injury to bony elements of vertebrae, ligaments or the muscles.

Clinical Features :

H/o.injury Pain moderate to severe acute onset relived by rest and passage of time,well localised,severe tenderness at the sight of injury,haematoma in the paraspinal region +. Movements are grossly restricted. Neurological deficit may or may not be present.

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 Trauma(Contd.)
a) Acute Backache

Investigations : X-rays may show various degrees of fractures of the vertebrae. CT Scan is indicated only if fracture is not detected on x-rays. MRI is indicated only if neurological deficit is there.
Treatment : Enforced bed rest till pain subsides. NSAIDS with MR Mobilisation with back support. In absence of neurological deficit surgery is indicated only to stabilise the spine if the injury is unstable.

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 Trauma
b) Chronic Backache : The cause of LBP is due to ultered biomechanics of spine due to malalignment of vertebral column. It accelarates the degenerative process. Clinical Feature : H/o.old injury Pain intermitant mild to moderate diffuse more on activity and more after activity(Fatigue pain),Subsides after rest. Investigations : X-Rays may show kyphotic deformative old,healed compression fracture of the body,degenerative changes away from the site of injury. MRI is indicated if associated with neurological complaints. Treatment : Curtailment of activities like forward bending,lifting heavy weight and travelling . NSAIDS with MR SOS Back supports SOS 61 Back extension excercises

 Degenerative Spondylosis
It is a condition caused by degeneration of cartilage with advancing age. Clinical Feature : Elderly person If young some anticedant problem of the spine like Osteopania,postural deformity etc. Pain mild to moderate intermitant diffuse relieved by rest increased by activities. Some times acute severe due to unaccustumed activity. Stiffness May or may not be associated with neurological symptoms of disc prolapse or spinal canal stenosis. Investigations : X-Rays may show deformity( reduction in disc space, affection of facet) MRI is indicated if neurological symptoms are present. Treatment : Bed rest Hot foamentation Massage SOS NSAIDS PT to improve back extensors,abdomen and gluteous 62 muscles.

Ankylosing Spondylosis
Its a condition is characterised by progressive inflammation of joints of the vertebral column leading to ankylosis(Fusion).
Clinical Feature :

Fairly common hereditary Young adult LBP localised to SIJ Morning stiffness Severe Spasm ( Bamboo Spine ) Lordosis reduced Tenderness at SIJ Limitation of movements Chest expansion reduced X-rays may show patchy osteoporosis and increased distance with subchondral Erosion at SIJ. Late cases may show fusion. Lumbar spine fusion of the vertebral bodies may be seen. Symptomatic 63 Physiotherapy

Investigations :

Treatment :

Tuberculosis
It is a condition caused by acid fast bacilia( Mycobactarium Tuberculosis). Common but steady decline in the prevalance.

Common cause of LBP :

Pathology Infection settles in vert body adjucent to intervertebral disc. Destruction and caseation Spreads to disc space Destruction of the body Collapse and kyphotic deformity Caseation and cold abcess Spread to adjucent soft tissue may compress to spinal cord.

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Tuberculosis(Contd.)
Clinical Features : Varies with the stage of the disease i.e. 1) Inflammatory stage 2) Destructive stage Symptoms : No age bar Constitutional symptoms present LBP, Dull ache,Diffuse,Referred or Redicular associated with stiffness due to spasm,Night cries(Children),Sleep disturbances. Movements very painful and restricted. Swelling in paraspinal gluteal,groin region(Cold abcess) Weakness in lower limb with parasthesias(Impending cord compression) Kyphotic deformity(Vertebral collapse) Signs : Short steps gait to avoid jerkin the spine takes time to lie down. Loss of lumbar lordosis. Soft fluctuant in paraspinal gluteal region. Localised tenderness. Forward flexion restricted. Neurological examination may vary from normal paratic plagic

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Tuberculosis(Contd.)
Investigations : Blood Hb X-Rays : ,Lymphocytosis ESR Positive PCR, HIV Test Initially may appear normal. Severe focal osteoporosis of lumbar vertebrae is the diagnostic early feature. Loss of disc space Variable amount of erosion and destruction of vertebral body. Complete anterior collapse. In AP view PSOAS shadow may be prominent due to PSOAS abcess. Indicated when x-rays normal despite strong clinical suspecion. Shows very acurately destruction of the body,disc degeneration,cold abcess and cord compression in an anatomical fashion.

CT Scan

MRI

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Pts Name :-Shri.Gadekar Baswant

24/11/2004

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Tuberculosis(Contd.)

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Pts Name :- Shri. Karpude Mohammad 26/01/2001

Tuberculosis(Contd.)

Pts Name : Shri.Mantri Satyanarayan

69 11/12/2000

Tuberculosis(Contd.)

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Pts Name : Shri.Soni Shrikishan

22/12/2000

Tuberculosis(Contd.)
Treatment : Urgent measures are required to prevent neurological insult. With the adventage of superb chemotherapy agents 90% cases can be treated without surgery. Conservative Treatment : Hospitaliasation Absolute bed rest Lumbar traction Chemotherapy Streptomycin INH Rifampicin Ethambutol Pyrazinamide Mobilisation after 4 to 6 weeks with back support. Surgical Treatment : Indicated when progression continues despite AKT. Surgical objectives are.. Decompression Excision of infected tissue Reduce the spinal deformities 71 Provide stability by spinal fusion

 Osteoporosis
It is a commonest metabolic disorder. Definitions :
Reduction in bone mass per unit of its volume. It occures when the rate of bone resorbtion exceeds the rate of bone formation. Causes : A) B) C) D) E) Senility Post Menopausal Post Immobilisation Endocrinal Cushing Syndrome & Hyperparathyroidism Drug Induced Steroid,Anti epileptic,Antacid

Clinical Features : Usually asymptomatic Kyphotic posture Some times generalised bony pain. Acute pain may occur after a trivial trauma leading to fractures.Commonest sites is dorsal lumbar region,neck femur,colles fracture etc.

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 Osteoporosis(Contd.)
Investigations : X-Rays Ground glass apperance,Wedge vertebrae,Cod fish vertebrae etc.

BMD

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 Osteoporosis(Contd.)
Treatment :Since Etiology is multifactoral treatment is difficult. High protein Diet Calcium Supplementation Androgens Estrogens Vitamin D3 Exercises Caution (Osteoporosis is not a disease rather a disorder. There may be an underlying major or minor condition to cause it.)
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Neoplastic Causes
LBP is a very common presentation of tumours of vertebral column and spinal cord. Multiple Myeloma :It is a fairly common malignant tumor of vertebral column. Clinical Features : Age : 40 to 60 years Acute severe LBP may be localised to low back may rediate down to extremetes. Pain is unremitting progressive and awakens the patient in the night. Investigations : X-Rays Disproportionately severe osteoporosis. Destruction and the collapse of the vertebrae. Lytic cavities Punch out areas in the skull and other bones MRI May show cord compression Blood - Anaemia,ESR very high Low serum proteins with reversal of A-G ratio,Hypercalcimia,Positive serum electro phoresis,Positive bone marrow aspiration for abnormal plasma cells. Urine : BJ proteins positive 75 Treatment : Chemotherapy

Neoplastic Causes(Contd.)
Metastasis :Vertebral column is a very preferred site for secondary deposits. The common primaries are Ca thyroid,Ca bronchus,Ca prostate,Ca breast etc. These tumours often present as LBP or with neurological deficit. These cannot be diagnose on clinical ground but are detected after investigations.

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Chame Maruti 5/2/2002 Mrs.Surve Suman 1/7/2000

Neoplastic Causes(Contd.)

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Pts Name :Bhalekar Satyabhama 25/11/1999

Neoplastic Causes(Contd.)
Tumours of the Spinal Canal :-

Alongwith LBP these tumours often cause neurological symptoms in the lower extremity. Again it is very difficult to diagnose this clinically and are revealed only after investigations. The common tumours are Meningioma, Neurofibroma ,Epindiomoma ,Schwanoma etc..

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Visceral Causes
These are not the true causes of LBP but one is confused because the pain is pointed towards the back. a) Abdominal Causes Pancreatitis Cholaecystitis Renal colic b)Ca Cervix Very common cause of LBP in females Unremitting LBP Leucorrhoea Abnormal PV bleeding Foul smelling discharge etc gives enough information to suspect
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Functional Causes

Malingaring Psychological

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hope that you and

your patients will be benefited from the information we give you tonight.