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Low Back Pain and

Disorders of the Lumbar


Spine

Risk Factors

Occupational Factors (lifting-pulling-pushing-slipping
Sitting-vibration-dissatisfying)

Patient-Related Factors
Age(55years old)
Sex
Anthropometric Factors
Postural Factors

Muscle Strength
Smoking
Psychosocial
EVALUATION OF THE PATIENT
WITH
LOW BACK PAIN
Clinical Evaluation
History(mode of onset-provoking and relieving
factors-effect of posture inactivity- exertion- rest
cough -sneeze presenceat night and interference
with sleep-course-ppn-weakness-urinary
symptom-types of treatments implemented-PH)
MSK Examination
Neurological Examination
Straight-Leg Raising Test
15>AGE>55
TRAUMA
PAIN AT NIGHT
HISTORY OF CANCER
WEIGHT LOSS
DRUG ABUSE
FECAL OR URIN INCONTINENCE
SADDLE ANESTHESIA
PROGRESSIVE MOTOR WEAKNESS
MARKED MORNING STIFNESS
PERIPHERAL JOINT INVOLVEMENT
SKIN RASH-COLITIS-URETHRAL DISCHARGE
Mechanical Low Back Pain
A descriptive TERM
It does not point to a single or particular cause.
stress or strain to the back muscles, tendons, and
ligaments
chronic, dull, aching pain of varying intensity that affects
the lower spine and might spread to the buttocks.
worsens during the day.
no associated neurological symptoms or signs,
correction of static or dynamic postural abnormalities is
helpful.
An exercise program consisting of abdominal and back
strengthening exercise is necessary, and patients often
improve quickly.
Osteoarthritis
occurs with aging and can begin during the third decade of life.
If the disease is symptomatic, the associated pain is centered in the lower back
and is often increased with movement of the spine.

Range of motion of the spine may be limited. Pain is often relieved by rest.
Hypertrophic changes and spurs can compress nerve roots and cause
additional radicular pain.
Radiographs, particularly after the early stages, are diagnostic.

When muscle support is poor, the application of an elastic support to control
pain is advisable. The back support can be used for 6 weeks while attempts
are made to improve the strength of the supporting muscles.
Exercises include abdominal and back muscle strengthening exercises
(preferably isometric exercise
Lumbar Disk Syndrome and
Lumbosacral radiculopathies
Lumbar disk syndrome is a common cause of acute, chronic, or recurrent low
back pain, particularly in young to middle-aged men, but it also occurs in
women, older persons, and even adolescents, especially if they are involved in
strenuous physical activity.
Overall, the mean age of the patient with lumbar disk herniation is the early 40s.
Disk herniation can occur in the midline, but it often occurs to one side.
Pain may be unilateral, bilateral, or bilateral but more prominent on one side.
Irritation or compression of an adjacent nerve root can occur, as is often the case
with laterally extruded ("squeezed toothpaste") disk herniations (Figs. 40-10 and
40-11).
Different degrees and types of disk herniation can occur.
Bulging Disk. A bulge and convexity of the disk beyond the adjacent vertebral
disk margins, but with an intact annulus fibrosus and Sharpey's fibers.
Prolapsed Disk. The disk herniates posteriorly through an incomplete defect
in the annulus fibrosus.

Extruded Disk. The disk herniates posteriorly through a complete defect
in the annulus fibrosus

Sequestered Disk. Part of the nucleus pulposus is extruded through a
complete defect in the annulus fibrosus and has lost continuity with the
present nucleus pulposus.

The pain often radiates into the buttock. the posterior thigh,and lateral calf
or to lateral or medial malleoli(in cases of L5 or S1 radiculopathies).
The pain radiates to the anterior thigh in L3or L4 radiculopathies.

When the disk is extruded, the low back pain is sometimes decreased or even
relieved, but radicular limb symptoms become more prominent.

The most common levels of lumbar disk protrusion, herniation, or extrusion, in
decreasing order of frequency, are L5-Sl, L4-L5, L3-L4, and L2-L3.
Midline disk protrusion may cause low back pain but no significant
radiculopathy.

Large midline disk herniations can cause bilateral
radiculopathies or cauda equine syndrome severe enough to
produce sphincter problems.

Upper lumbar radiculopathies are less commonly caused by disk
disease. When upper lumbar radiculopathy is evaluated, other
etiologic factors, particularly neoplastic disease, should be ruled out.

Examination of the back

paraspinal muscle spasm, loss of lumbar lordosis,

positive straight-leg-raising test, and, sometimes, crossed
straight-leg-raising sign in cases of L5 or S1 radiculopathies.

The chin-chest maneuver might cause low back pain because of
upward traction on the cord and lower nerve roots.
Dorsiflexion of the foot can also cause stretching of the sciatic nerve and
therefore stretching of the attached tendon nerve root, leading to pain. The
same findings may be noted when the patient tries to perform heel-walking or
tries to bend forward.

Coughing, sneezing, or straining causes an increase in abdominal
pressure leading to distention of epidural and intervertebral veins.

MRI has become a major diagnostic tool in the diagnosis of herniated lumbar
disks
It is also very useful for demonstrating several nondiscogenic entities.
However, some herniated disks may be missed by MRI.

Electromyography is very helpful for localizing the level of involvement,
determining whether root involvement is single or multiple, and
differentiating a multiple root from a plexus lesion.
Most patients with discogenic low back pain respond to conservative
management.

Operation is considered when definite radiculopathy and neurological
deficits are present, especially when they are persistent or progressive.
However, in the spectrum of discogenic low back pain, patients in this group
are a definite minority.
Large midline disk protrusions with cauda equina syndrome require urgent
treatment and decompression. .
However, in many patients with lumbar disk syndrome, the major difficulty is
low back pain with only mild, slight, or no evidence of radiculopathy.

The standard surgical procedure is open laminectomy and discectomy.
Posttraumatic Compression
Fracture
Posttraumatic compression fracture usually results from compressive
flexion trauma.
It can also occur spontaneously in patients with osteoporosis,
osteomalacia, multiple myeloma, hyperparathyroidism, and
metastatic cancer.
The upper lumbar spine or the middle to lower thoracic spine is
most commonly affected.

The pain usually is present immediately after the fracture and is
often localized.
There may be accompanying paraspinal muscle spasm, and the
range of motion of the related level of the spine is limited.

Plain radiography, CT, MRI, or bone scanning may be needed-to
establish the diagnosis.
Posttraumatic Compression
Fracture
Sedative rehabilitative measures, especially in the acute phase,
including application of cold for the first 24 to 48 hours, analgesics,
and muscle relaxants, are often necessary.
The pain can be managed with use of a back support, such as a
thoracolumbar support that functions on the basis of three-point
contact.
For provision of extension in cases of thoracic compression
fractures, the three points of contact are the base of the sternum, the
symphysis pubis, and the lumbar spine, as in the J ewett brace

When therapeutic exercises are to be prescribed. extension rather
than flexion exercises should be utilized.
Flexion exercises can increase the incidence of vertebral body
wedging and compression fractures. Extension exercises are effective
for strengthening back muscles at any age.
Spondylolysis and
Spondylolisthesis
Spondylolysis refers to a bony defect in the pars
interarticularis.

Bilateral spondylolysis of the lumbar spine can lead to
anterior slipping of the vertebral body on its adjacent
vertebra and cause spondylolisthesis (in Greek, spondylo
means "vertebra" and listhesis means "sliding on a slippery
surface").
Five types of spondylolisthesis: (1) dysplastic, (2)
isthmic (3) degenerative, (4) traumatic, and (5)
pathological. To these categories, a sixth category is
sometimes added: postsurgical or iatrogenic
spondylolisthesis.
Spondylolysis or spondylolisthesis may cause back pain.

However, the presence of a pars defect (spondylolysis) or
even spondylolisthesis in a patient with back pain does not
necessarily indicate a cause-and-effect relationship.

Spondylolisthesis is two to four times more common in
males.

The pars defect is at L5 in 67% of persons, at L4 in 15%
to 30%, and at L3 in 2%.
It is rare in the cervical region.
Spondylolisthesis can also cause
compression of nerve roots and lead to
radicular pain or neurological deficits in
the lower extremities.

The lumbar lordosis is often exaggerated
in patients with spondylolisthesis, and range
of motion of the lumbar spine may be
limited.

For grades 1 and 2 spondylolisthesis and in older
patients, nonsurgical treatment is
recommended.
The physical therapeutic procedures consist of
application of heat and massage for reduction of
pain and stiffness.
Special attention can be given to reducing the
tightness of the hip flexors, hamstrings, and
Achilles tendons.
A program of stretching exercises is
recommended. During stretching of the back
and lower extremities, flexion of one hip
(related knee) at a time helps reduce the strain
on the lumbar spine.
LUMBAR CANAL STENOSIS
DJD is the most common cause
Pseudo claudication is the most common
manifestation and often is bilateral
Sensory symptoms(66%)
LBP(70%)
DTR AB.(50%)
Weakness(40%)

Level of stenosis:
L4-5 L3-4 L2-3 L5-S1 T12-L1
Treatment:
strengthening the abdominal and lumbar
flexors
Abdominal binder
NSAIDS
Surgical
AS.
It mainly affects spine
Sacroiliitis is usually the first manifestation
Age 20-35
Males>females
HLA-B27+(80-90%)
Morning stiffness & pain in the lower back
improve with activity
BACK EXT.EXC.
Deep breathing Exc.
Posture training
ROM of the proximal joints
Stretching EXC.
Flexed Posture to be avoided
HEAT & MASSAGE before EXC.
Evaluation of chest expantion(<5cm PFT)
NSAID

NEOPLASTIC DISEASE
HALLMARK:pain at rest particularly noctural
painBony metastasis is the most common
cause
Sometimes spInal metastasis is the first
manifestation of canser
Lung-prostate-breast

LBP in pregnancy
Prevalence at 49-76%
Risk factors:
History of prior LBP
Previous pregnancy related LBP
LBP during menses
Pregnant woman s age
The risk of IBP during pregnancy decreases with
age
Pain has a peak at 36 weeks then decreases

Sacroiliac pain
Nacturnal back pain
Mechanical pains
LBP of pregnancy may not disappear with
delivery
Other cause
Remission of RA
PROPHYLAXIS
TREATMENT