LOW BACK PAIN

Ald S Aldy S. R Rambe b

Department of Neurology University of Sumatera Utara, School of Medicine

What is LBP

Low back pain is a common disorder affecting millions of individuals annually. Back pain is the single most common cause for lost workdays in the patients to visit United States and one of the most common reasons for p their primary care physician. It is estimated that approximately 50 to 80% of the adult population suffers from a memorable episode of low back pain each year. In the vast majority of cases no specific diagnosis is made and the symptoms resolve spontaneously. Only a minority of patients present with symptoms specific to an irritated nerve root or have identifiable pathology on radiographic studies. studies The overall prognosis of low back pain is good, with improvement occurring in the majority of cases without aggressive medical intervention.

ANATOMY

ANATOMY

CLASSIFICATION

ACCORDING TO ITS DURATION, , LBP IS DIVIDED INTO : ACUTE : < 2-8 WEEKS SUBACUTE : 2 2-8 8 WEEKS 12 WEEKS CHRONIC : > 12 WEEKS

etiology ti l

Non-specific mechanical back pain Facet joint syndrome Lumbar disc degeneration (lumbar spondylosis) L b di Lumbar disc prolapse l Spondylolisthesis Spinal stenosis Osteoporosis Sero-negative spondyl arthritis (including ankylosing spondylitis) p y ) Vertebral infection Disc space infection Malignancy secondary myeloma and primary Pagets disease, referred-visceral, pancreatic/pelvic, etc

RED FLAGS POSSIBLE SERIOUS SPINAL PATHOLOGY

Age of onset : < 20 or 55 years Violent trauma, eg fall from a height, traffic accident Constant, progressive, non-mechanical pain Thoracic pain History of carcinoma Systemic steroids Drug abuse, HIV infection Systemically y y unwell Weight loss Persistent severe restriction of lumbar flexion Widespread neurological deficit Structural deformity

COMMON ETIOLOGY

1. 1 2. 3 3. 4. 5 5.

Mechanical (deformity, (deformit trauma) tra ma) Inflammation Neoplasm Degenerative Psychological

LBP in pregnancy

PRIMARY MECHANICAL DEARRANGEMENT Ligamentous Strain Muscle strain or spasm Facet join disruption or degeneration Intervertebral disc degeneration g or herniation Vertebral compression fracture Vertebral end-plate microfractures Spondylolisthesis Spinal stenosis Diffuse idiopathic skeletal hyperostosis

THE DISTINCTION AMONG SPONDYLOSIS, SPONDYLOLISIS AND SPONDYLOLISTHESIS

SPONDYLOSIS : refers to osteoarthritis involving the articular surfaces (joints and discs) (j ) of the spine, p , often with osteophyte p y formation and cord or root compression SPONDYLOLISIS : refers to a separation at the pars articularis, which permits the vertebrae to slip slip. Maybe uni or bilateral

THE DISTINCTION AMONG SPONDYLOSIS, SPONDYLOLISIS AND SPONDYLOLISTHESIS

SPONDYLOLISTHESIS : May result from bilateral pars defects or degenerative disc disease. Defined as the anterior subluxation of the suprajacent vertebrae, often producing central canal stenosis : it is th slipping the li i forward f d of f one vertebrae t b on the th vertebrae t b below.

INFECTION
Epidural E id l abcess b Vertebral osteomyelitis Septic discitis Pott Potts s disease (tuberculosis) Nonspecific manifestation of systemic illness

NEOPLASM
Ep Epidural u or vertebral carcinomatous m u

metastases

Multiple myeloma Lymphoma

DEGENERATIVE

1. Osteoarthritis 2 Rh 2. Rheumatoid t id arthritis th iti 3. Thoracic Outlet Syndrome 4 Cervical Spondylosis 4. 5. Marie-Strumpell disease 6. Lumbar disc prolaps p p (Hernia Nukleus Pulposus (HNP) 7. Spinal Stenosis

RADICULOPATHY
ESSENTIALS of f DIAGNOSIS :

Pain in a dermatomal distribution, sensory symptoms along the same dermatome, weakness in a corresponding myotomal distribution, and absent or depressed reflexes. Frequency of incidence in order of occurrence : lumbar > cervical > thoracic Usually caused by a herniated disk or by spondylosis; other causes are infection, infection neoplasm, neoplasm granuloma, granuloma cyst, cyst and hematoma

Lumbar disc prolaps

The earliest change in the NP and AF are probably biochemical and may be part of aging Superimposed trauma accelerates these degenerative changes Th laters The l t of f th the AF separate t and df form circumferential i f ti l tear, t leads l d to t radial tears. NP may extrude producing disc herniation or prolaps Multiple tears produce weakening and circumferential bulging of the AF with loss of disc height Further disc narrowing results from aging of the NP, which changes from gelatinous consistency int the childhood to a fibrotic consistency in adulthood

The disk

Herniated disc

Distribution
Lumbar L b disc di prolaps l (most ( t common) ) L5-S1 (45-50%), L4-5 (40-45%) Cervical disc prolaps C6-7 C6 7 (69%), C5 C5-6 6 (19%) Thoracal disc prolaps (infrequent, < 1%)

Lumbar Disc Prolaps : Grade

Protruded P t d d disk di k : penonjolan j l nukleus kl pulposus l tanpa kerusakan annulus fibrosus Prolapsed disk : nukleus berpindah tetapi tetap dalam lingkaran annulus fibrosus. Extruded disk : nukleus keluar dari annulus fibrosus dan berada di bawah ligamentum longitudinalis g posterior. p Sequestrated disk : nukleus telah menembus ligamentum g longitudinalis g p posterior.

Grade of herniated disc

Clinical symptoms

Lumbar HNP : * severe LBP and lumbar paraspinal spasms, with pain radiating to the buttocks, legs, and feet ( di l pain) (radicular i ) * abnormal vertebral posture * paresthesia, parese, diminished tendon reflexes * pain, sensory loss and weakness typically occur in a radicular pattern. pattern * urinary symptoms, if present, reqquire immediate attention

Ischialgia (sciatic)

Clinical symptoms

Cervical HNP : * pain present in the posterior neck, with spasm of the cervical p paraspinal p musculature and near or over the shoulder blades on the affected side. * radicular pain, aggravated by neck extension, coughing, hi straining, t i i l laughing, hi b di bending, or turning t i the neck to the side; and reduced by abducting the arm and put it behing the head * paresthesia, parese, diminished tendon reflexes

Diagnosis : Neurological examination

Lumbar HNP :
* Lasegue (straight leg raising) test. A positive SLR test is a sensitive indicator of nerve root irritation (sensitivity 95%)., May be positive with disc protrussion, intraspinal tumor or inflammatory radiculopathy Crossed Laseque (crossed SLR) test. g y specific. p Less sensitive but highly Femoral stretch (reverse SLR) test. May detect an L2-4 root or femoral nerve irritation.

* *

Diagnosis : Neurological examination

Cervical HNP : *
Lhermittes sign A painless but unpleasant tingling or electric shock shock- like sensation in the back and spreading instantaneously down the arms and legs following neck flexion (active or passive) Spurlings Spurling s sign Increase in arm pain (brachialgia) associated with compressive cervical radiculopathy following neck rotation and flexion to the side of pain. pain Shoulder abduction test

Diagnosis
RADIOLOGICAL EXAMINATION :

Plain vertebral x-rays : * limited information * disc narrowing, scoliosis, lordosis lumbal Myelography y g p y CT or CT-myelography MRI : the best imaging study

EMG/NCV : 90% abnormal after 1-2 weeks

MRI scan shows L4-5 L4 5 herniated disc

Therapy : Conservative
*
* bed rest : max 2 days recommended Pharmacotherapy : - NSAID - short h t course of f corticosteroid ti t id for f acute t herniated h i t d disc (controversial) - muscle relaxant - for f neuropathic hi pain i : gabapentin, b i 5% lidocaine lid i patch, tramadol, TCA. Nonpharmacologic therapy : - heat, ice, massage, stress reduction, activity limitation, postural modification, physical therapy program - soft cervical collar or lumbar corset

Therapy :Operative
The few Th f absolute b l t indications i di ti : 1. Marked muscular weakness pertaining to a nerve root or roots. 2. Progressive neurologic deficits. 3. Cauda equina syndrome with urinary symptoms 4. Pain that has existed for more than 4 months, has not responded d d to conservative i treatment, and d interferes with normal function.

LUMBAR SPINAL STENOSIS

CLINICAL SYMPTOMS :

neurogenic intermittent claudiation or pseudoclaudication (most frequent) usually bilateral, but maybe unilateral a dull, aching pain the whole lower extremity is generally affected pain provoked by walking and standing, quickly relieved li d by b sitting itti or leaning l i forward f d LBP presents in 65% patients with lumbar spinal stenosis radicular pain is the least common manifestation

MOST FREQUENT CAUSES OF SPINAL STENOSIS

> 25 causes are identified The most common : 1. Idiopathic : the result of shorter than normal pedicles, thickened convergent lamina, and a convex posterior vertebral body. 2. Degenerative (50% of cases) : degenerative changes affect the facets posteriorly allowing instability and subluxation, osteophytes form and narrow the nerve root and the central canal ; and the disc anteriorly allowing ll i the th disc di to t bulge b l into i t the th nerve root t and d central canal.

MOST FREQUENT CAUSES OF SPINAL STENOSIS

3. Degenerative spondylolisthesis : occurs when the facets degenerate, allowing slippage of f th the upper vertebrae t b f forward d over th the l lower vertebrae. 4 Postoperative : 4. occurs after laminectomy or spinal fusion. Stenosis produced by y bone formation and scar tissue is p

INDICATION FOR SURGICAL TREATMENT OF LUMBAR SPINAL STENOSIS

1. Severe and disabling pain (persistent intolerable pain) g distance or standing g endurance 2. Limitation of walking to a degree that compromises necessary activities 3. Severe or progressive muscle weakness or disturbed bl dd and bladder db bowel, l or sexual lf function. ti 4. Poor response to at least 4 weeks of conservative treatment

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