LOW BACK

PAIN

Angela B.M.Tulaar

1
 Definition
 Low Back pain is pain felt in the region
of the lower back, that is the region between
the ribs and the hip, due to several causes,
like impairment of the musculoskeletal
system, neuromuscular system, vascular,
visceral, and psychogenic. Low back pain is only
a symptom, and not a diagnosis. Causes of low
back pain in most patients are not known.
 Low back pain can be local, radicular, or both.
Pain from the lower back region may be referred to
another region, or vice versa, pain from other
region may be referred to the lower back (referred
pain).
2
 Important muscles of the back
L o ng is s im us
c a pitis

I lio c os ta lis L o ng is s im us
c ervic is c ervic is

rtra ns vers a rii S pina lis

c ervic is
M ultifidus

I lio c os ta lis
thora c is
S pina lis
I lioc os ta lis thora c is
lum borum
L ong is s im us

3
 Important Bones and muscles
Prosesus spinosus
Latissimus
dorsi muscle

Erector
Spinae muscle

Gluteus
Maximus muscle
Posterior superior
iliac spine
Sacrum
Coccygeum

Ischial tuberosity

4
 Spinal cord & nerve structure
Vertebral body Spinal cord

Spinal cord Basis cranii

Nerve
root
Nerve root Peripheral
nerve
Neural foramen

Pedicle L1
Conus
Pedicle L2 medullaris
Cauda equina
(dorsal & ventral)
Nerve root
Sacrum

Cauda
equina
5
 C1
C2

Vertebral Region C3
C4
Cervical
C5 Vertebra
& dermatome C3
C2
C2
C6
C7
C8
T1
T2
T3
T4
T5
T6
T7
Thoracal
C5 C5
T8 Vertebra
T9
T10
C6 T11
C6 T12
L1

S3
L2
L3
Lumbal
C8 L4 Vertebra
L5
C8
C7
S1
S2 Sacral
C7 S3
S4 Vertebra
S5

Lateral view

S1
S1
6
 Vertebral Ligaments Lateral view of the
Vertebral structure

Ligamentum Flavum Intervertebral Disc

Intertransversa
Ligament Vertebral
body
Capsulary (Corpus)
Facet
Ligament Posterior
Longitudinal
Ligament Sendi
Interspinous Facet
Ligament

Pedicle

Supraspinous Anterior
Ligament Longitudinal
Ligament
7
Articular Facet in motion Lateral Posterior
Vertebral column Vertebral column
Vertebral body Cervical Cervical

Thoracal Thoracal

Lumbal Lumbal

Sacral Sacral
Disc
Coccyx Coccyx
Flexion Extension
8
 Jaringan dengan sensor nyeri
Ligamen
Posterior
Longitudinal
Diskus

Prosesus
spinosus
Nukleus
Ligamentum
Annulus
flavum

Kapsul
sendi

Korda spinalis
Saraf dan selubungnya
(Dura) 9
 Axial view of the
Intervertebral disc
Annulus fibrosus Annulus fibrosus

Vertebral plate

Nucleus pulposus

Nucleus A
pulposus

Apophyseal ring
10
 Clinical picture

A. Non spesific/lumbago/simple/
benign/idiopathic back pain:
 Frequently seen in the age of 20-55 years
old;
 The patient looks well;
 Pain at the lumbosacral, hip and thigh;
 Mechanical pain, varied with physical
activity and time.
11
 Clinical picture
B. Radicular pain:
 prognosis is fairly good, 50% improved
within 6 weeks;
 unilateral foot pain is worse than back
pain;
 Pain usually radiates to the foot or
toes;
 Numbness and paresthesia;
 Signs of nerve irritation (positive
Straight Leg Raising test /Laseque)
 Local neurological signs (motor,
sensory or reflex pain)
12
Clinical picture
C. Awareness of the presence of Red
Flags (serious spinal involvement):
 Age less than 20 years old or onset
more than 55 years old;
 Non-mechanical pain;
 Pain in the thoracic region;
 History of carcinoma, steroid, and
HIV;
 Looks unwell, loss of weight;
 Outstending neurological signs and
symptoms;
 Structural deformities;
 Cauda Equina syndrome :
13
 Clinical picture
 Cauda Equina syndrome :
- urinary problem;
- loss of anal sphincter tone or
incontinence;
- lower extremity weakness or
walking problems;
- extensive (more than one nerve
root)
- Saddle Anesthesia
14
Neural Activation of Pain PAIN

Afferent peripheral nerve

Aδ-C

Aδ-C
Aδ-C

15
 Causes of Low Back Pain
Mechanical (97%) Non-mechanical (1%) Visceral organ
disease (2%)
Strain, sprain lumbal (70%) Neoplasia (0,7%) Diseases of the Pelvic
Degenerative disc & facet Infection (0,01%) organs (prostatitis,
(10%) -Osteomyelitis endometriosis)
Disc Herniation (4%) -Epidural Absces Renal disease
Spinal Stenosis (3%) (nephrolithiasis,
-ParaspinalAbsces
pyelonephritis,
Osteoporotic Compression -Pott’s disease perinephric absces)
Fracture (4%) -Inflammatory Arthritis Aortic Aneurysm
Spondylolisthesis (2%) (0,3%)
Gastrointestinal disease
Traumatic Fracture (<1%) -Ankylosing spondylitis (pancreatitis,
Congenital Disorders (<1%) -Psoriatic spondylitis cholelithiasis)
-Reiter’s Syndrome
Paget’s disease 16
 CAUSES
OF
LBP
 Degenerative disease
- Disc disease
- Spinal stenosis
- Spondylitis
- Facet joint hypertrophy

17
Osteoarthritic
Articular facet

Lumbal
nerve

Degenerative
disc

Sacrum

Coccyx A
18
Degenerative spondylolisthesis

19
 Spondylolisthesis
Superior articular process
Prosesus Transversus Degenerative Isthmic
Spondylolisthesis Spondylolisthesis
Prosesus Spinosus L3
Intervertebral
foramen
Pars interarticularis L4
Intervertabral
disc
Defek of the pars L5
interarticularis
(spondylolysis) Slipped spine
Anterior Displacement
of L5 on sacrum
(spondylolisthesis)
sacroiliac 1 2
Sacrum Joint surface Fracture of the
pars interarticularis
(posterior part
A of the vertebra) B
20
 Lumbal Spinal Stenosis
Ligamentum Thickening of Hipertrophic
flavum ligamentum facet
flavum

Normal Canal Spinal Stenosis

Difference between normal and stenotic spinal canal 21

Normal Posture in patients with
posture ankylosing spondylitis
22
Herniated Disc (HNP)

Herniated disc

Nucleus
Pulposus

Annulus
fibrosus
Irritated nerve

23
 CAUSES OF LBP
 Neoplasma
- Primary
- Metastatic

 Inflammation :
- arachnoiditis,
- arthritis,
- ankylosing
spondylitis
Severe canal stenosis
Due to facet joint enlargement
And additional soft tissue Kyphosis
24
 CAUSES OF LOW
BACK PAIN

 Infection
- Vertebral osteomyelitis
- Epidural absces
- Urinary tract infection
- Intervertebral discitis

25
 CAUSES OF LOW
BACK PAIN

 Radiculopathy
 Metabolic diseases
- Osteoporosis
- Paget’s disease
- Diabetic Radiculopathy
26
 iliac
bone
2 Sacrum

Sciatic
1
nerve

Sciatic
nerve 27
 CAUSES OF LOW BACK PAIN
 Trauma: vertebral fracture

Wedge fracture
crushed anterior part of the vertebra,
Burst fracture
Reduced vertebral height kyphosis.
If the whole vertebral Neurological damage seldom found.
body (often in osteoporosis) 28
Plain Radiograph & MRI of the vertebra

L1

1 2

A B
29
 CAUSES OF LOW BACK PAIN
 Trauma: lumbar sprain
and strain

30
 CAUSES OF LOW BACK PAIN

 Referred pain:
 abdomen and pelvis

 hip

31
 Diagnosis
 Initial evaluation of back pain is
primarily geared to remove serious
causes that need emergency.
 Success of the evaluation depends on
the carefull and proper anamnesis and
physical examination.
 History of the illness including the
onset, location, type and severity of
pain, factors enhancing or lessening
the pain, trauma, constitutional signs
and psychosocial stessor should be
asked.
32
History of present illness

• description of the symptom and

its duration;
• effect of the symptoms to the
daily activities;
• response to earlier treatments;
• history of trauma.
33
Pain Distribution in Non-spesific Low Back Pain

34
 Past History
 Immunosupressant;
 Loss of weight without clear cause (cancer);
 Persistent pain is an indication for cancer or infection;
 Worsening of pain (intraspinal tumor or infection) or diminishing pain
(hernia nucleus pulposus / HNP) during supine;
 Worse pain in the morning (seronegative spondyloarthropathy:
ankylosing spondylitis, psoriatic arthritis, reactive
spondyloarthropathy, Reiter’s syndrome, Rheumatoid arthritis,
polymyalgia rheumatica, myofascial pain, fibromyalgia syndrome)
 Pain upon sitting position (HNP, facet joint pathology, canal stenosis,
para- spinal muscle pathology, sacroiliac joint pathology,
spondilolysis/spondilolisthesis, non-spesific low back pain)
 Presence of fever (infection)
 Hormonal disturbance (dysmenorrhea, post-menopause/andropause)
 Visceral disturbance (referred pain) 35
 Neurological symptoms
 disturbance in urination;

 saddle anesthesia;

 motor weakness in the

lower extremities (possible
cauda equina syndrome);
 location and radiation of
pain.

36
 Red flags
 Dangerous signs (conditions in low back
pain with serious potentials) :
 cauda equina syndrome (urinary retention,
bilateral neurological signs and symptoms,
saddle anesthesia);
 signs or symptoms of neurological deficits
(paresthesia, paresis and other
neurological signs);
 Trauma;
 loss of weight;

37
 Red flags
 Dangerous signs (conditions in low back
pain with serious potentials) :
 fever;

 use of intravenous medications;

 use of steroids;

 age more than 50 years old;

 severe pain not relieved during the

night;
 worsening pain during supine position.
38
 Yellow flags
 Conditions that can prolong back pain:
 attitudes and beliefs regarding back
pain;
 behaviour;
 compensation problems;
 diagnostic and therapeutic problems;
 emotion;
 family problems;
 occupational problems (job).
39
 Physical examination
 Physical examination is performed
comprehensively with special attention to
specific areas according to history of illness
given by the patient.
 Pain intensity is measured using visual
analoque scale (VAS).
 Examination of the spine includes observation
of gait and posture during walking, palpation,
range of motion, mobility test, and straight leg
raise test. 40
Range of Motion (ROM) examination

Extension

Flexion

Rotation

Lateral bending

41
 Schober test

10 cm
15 cm

42
 SLR
(straight leg raising test)

43
 Physical examination

 Neurological examination is geared to know

the involvement of specific nerve root.

 Evaluation of possible systemic disease to

find the cause of back pain. Examination of
the abdomen, pelvis and rectum is done to
find the source of pain and possible
radiation of pain.

44
 Sciatic nerve pathway

Sciatic nerve

45
Function & innervation of nerve roots in the lower extremity

Motoric Function

L4 L5 S1

Medial eversion Extension of great toe Lateral Eversion

Sensoric Function

L4 L5 S1

Medial side of the foot Dorsum of the foot Lateral side of the foot 46
 Distribution of Radicular Pain

L3 L4 L5 S1
47
 Radiological examinations
 Radiographic examination (plain photo) of the lumbosacral
is not a routine examination, especially for patients with
simple back pain.
 Lumbosacral radiologic examination may support the
diagnosis especially in the presence of history of trauma
and suspicion for infection, neoplasm, or metabolic
diasease.
 Anteroposterior and lateral position is good enough to find
fracture, tumor, infection, instability, spondyloarthropathy
and osteoarthritis of the hip.
 Oblique position is required to evaluate involvement of the
facet joints and pars interarticularis.
48
 Radiological examinations
 Radiographic examination cannot show the
presence of disc herniation or disturbance in the
muscles and ligament.
 Magnetic resonance imaging (MRI) dan CT
scanning are thought for patient with
progressive neurological deficits or suspicion of
infection or neoplasm. Such examinations are
also needed in cases referred for surgery.
Magnetic resonance imaging (MRI), CT scanning
or myelography can confirm the diagnosis of
lumbal canal stenosis. Bone scanning is useful
in situations where radiographic examination
results showed abnormality in the suspicion for
osteomyelitis, neoplasm or fracture.
49
50
 Electrodiagnostic examination
 Electromyographic examination and nerve
conduction tests are needed to distinguish
peripheral neuropathy from radiculopathy or
myopathy. These tests are also useful in
determining the location of the lesion, the extent
of the damage, prediction for recovery and to
determine whether a structural abnormality seen
in the radiological examination is causing a
significant functional effect.
 Patients with doubtful conditions and require
electrodiagnostics such as the above are referred
to the specific competent specialist. 51
 LABORATORY EXAMINATIONS
 Laboratory examinations like Erythrocyte
sedimentation rate (ESR), complete blood count (CBC)
and urinalysis are only requested when having doubts
for the presence of a serious underlying systemic
disease.
 Increased ESR may be found in cases of infections,
neoplasm, and ankylosing spondylitis.
 Anemia may be found in neoplasm and ankylosing
spondylitis.
 Blood culture and Tuberculine test should be done in
suspicion of infection.
 Examination of human leucocyte antigen HLA-B27 is
suggested to be done when there is suspicion for
Ankylosing spondylitis. 52
 DIFFERENTIAL DIAGNOSIS
 The cause of low back pain in
general may be grouped into
trauma, degenerative disease,
neoplasm, infection,
radiculopathy, metabolic, and
radiating pain
 The frequent cause of low back
pain in patients coming to
physicians for consultation is
intervertebral joint dysfunction
related to trauma (72 %), while 10
% are with lumbar spondylosis.
53
 MANAGEMENT
Main Objectives:
- to control pain;
- to prevent disability.

 To identify patients with risk provide

possibility to prevent long term problems in
most cases which is much better than
possible disadvantage due to
underidentification.
54
 Management
 The presence of psychosocial risk
factors does not mean that low back pain is
unreal and not really needed to control the
symptoms.

 most patients with risks can be treated

effectively, without referring to a psychologist.
These patients need a strategy that integrates
the analgesic requirement and physical
modalities to enable him/her to remain active
and return to the normal
55
Management
Initial management includes:
 clinical history and short physical examination
 reassurance and information that there are no red
flags for serious spinal pathology
 reassurance and explanations about no need for
special examination if there are no red flags
 accurate information regarding good prognosis for
recovery
 reassurance and explanations that light activities are
safe
 practical advices to remain active and return to work.

56
 Pharmacological management for
Low Back Pain

Recommended Optional drugs:

drugs:  Opioid < 2 weeks
 Parasetamol  Oral Steroids
 NSAIDs  Antidepresants
 Muscle relaxants
57
 World Health Organisation (WHO)
Analgesic ladder
Strong Opioid
± NSAIDs ±
Adjuvant analgesics
NSAIDs ±
Adjuvant Analgesics
± weak opioid (codeine)

paracetamol
or NSAIDs ± Chronic Pain
Adjuvant analgesics
Persistent or
Pain threshold Pain tolerance increasing pain

0 1 2 3 4 5 6 7 8 9 10
Mild Moderate Severe 58
 Paracetamol and Opioid
Mechanism of action Benefit Side Effects
Paracetamol
• Inhibits synthesis of  Antipyretic and  Minimal to no anti-
prostaglandin in the analgesic activity inflammatory action
central nervous  Well tolerated  Liver Necrosis with
system (CNS)?  Mild side effects overdose, alcohol users

Opioid
• Bound to opioid  Effective in severe  Depresed respiration
receptors, agonist pain  Drowsiness, nausea,
effect inhibiting  Does not cause constipation
pain impulse GI bleeding  Potential for ‘abuse’

59
Non-steroidal anti inflammatory (NSAID)
Mechanism of action Benefit Side Effects
Nonspecific NSAID
 InhibitsCOX-1 and  Anti-inflammatory,  GI,
hypertension,
COX-2 isoenzyme → analgesic, antipyretic edema, disturbance in
inhibits prostaglandin  Long known efficacy renal function and
synthesis against pain bleeding

Specific COX-2 inhibitor

 Selectively
inhibits  Anti-inflammatory,  GI,
hypertension,
COX-2 isoenzyme analgesic, antipyretic edema, renal effects
 Milder GI side effects

60
 NSAID Side effects
Gastrointestinal  Peptic ulcer
 Gastrointestinal (GI) bleeding
 Esophagitis and stricture
 Erosions of small intestines and colon

Renal  Acute renal failure

 Disturbance of water and electrolytes
 Chronic renal failure

Kardiovaskuler  Exacerbation of:

 Hypertension
 Congestive Heart Failure
 Angina
 Disturbance in platelet aggregation
61
 Muscle relaxant for
non-spesific Low Back Pain
 Several resources recommend muscle relaxant only or
in combination with NSAIDs in the management of low
back pain

 Survey from clinical practice showed that 91% of

doctors reports use muscle relaxant

 There is strong evidence that combination with

analgesic or NSAIDs helps and enhances recovery
Van Tulder MW et al. Spine 28(17) 2003:1978-1992
62
 (Brain) Diazepam
Chlormezanone

Primary sites
(Spinal cord)
of action of Eperisone
Tolperisone
several Chlorphenesin
Carbamate
muscle Baclofen

relaxants
Internuncial Neuron

Motor Neuron
(large …. α)
(small …. γ) (Skin)
(Muscle) Dantrolene 63
 EVIDENCE BASED THERAPY IN
LOW BACK PAIN

 Therapy with evidence of clinical

improvement
• Remain active and continue daily activities
• Paracetamol
• Non steroidal anti inflammatory drugs
(NSAIDs)
• Muscle relaxants
64
 GENERAL INDICATIONS: HEAT
Pain; muscle spasm;
contracture; tension myalgia;
production of hyperemia;
increased metabolic process,
resolution of hematoma;
bursitis, tenosynovitis,
fibrositis, fibromyalgia;
superficial thrombophlebitis;
induktion of reflex
vasodilatation; collagen
vascular disease.
Basford JR. Therapeutic Physical Agents. In: DeLisa JA, Gans BM, Walsh NE (eds). Physical
Medicine and Rehabilitation. Principles and Practice. Lippincott Williams & Wilkins, 2005:251-70.
65
  Increased local heat HEAT
directly reduced spindle
sensitivity, and superficial
heating of the skin
indirectly reduced spindle
excitability.
 Pain threshold could be
increased by heat, directly
or indirectly.
Basford JR. Therapeutic Physical Agents. In: DeLisa JA, Gans BM, Walsh NE (eds). Physical
Medicine and Rehabilitation. Principles and Practice. Lippincott Williams & Wilkins, 2005:251-70.
66
 EVIDENCE BASED THERAPY IN
LOW BACK PAIN
 Therapy with evidence of lesser
clinical improvement
• Rest > 2 days
• Transcutaneous electrical nerve
stimulation (TENS)
• Intermittent Traction
• Specific sports / exercises for low
back
• Education brosures about low
back pain symptoms
67
 EVIDENCE BASED THERAPY IN
LOW BACK PAIN
Spray and Stretch / injection
of Myofascial Trigger
points (MTPs)

68
Sit-up parsial untuk memperkuat Latihan untuk mengurangi
otot-otot abdomen peregangan otot punggung

Latihan untuk memperkuat Latihan untuk memperkuat

otot punggung dan panggul otot perut dan panggul

Beberapa variasi latihan ekstensi, mulai dari yang paling ringan ditingkatkan
disesuaikan dengan kekuatan otot-otot ekstensor lumbal 69
 EVIDENCE BASED
THERAPY IN LOW
BACK PAIN
Therapy with potential danger
 Use of narcotic or diazepam
(especially if > 2 weeks)
 Continuous Traction
 Manipulation under general
anesthesia
 Plaster jacket (orthoses)

70
Pilars of low back pain
management
1. IDENTIFICATION OF
RED FLAGS AND
YELLOW FLAGS
2. EDUCATION
3. ACTIVITY
4. MEDICAMENTOUS
THERAPY
5. REFERRAL
6. SURGERY
7. MULTIDISIPLINARY TEAM
71
 SURGICAL INDICATIONS
 Sciatic and possible Disc herniation :
*Cauda equina syndrome
*Progressive and severe neurologic
deficits
*Neuromotor deficits persistent after 4-6
weeks of conservative therapy
*Persistent Sciatica more than 4-6
weeks
72
 SURGICAL INDICATIONS

 Spinal stenosis :
* progressive and severe
neurologic deficits
* persistent low back and lower
extremities pain
* pain improved with trunk
flexion and related to spinal
stenosis
73
 SURGICAL INDICATIONS
 Spondylolisthesis
progressive and severe
neurologic deficits
spinal stenosis with the
above indications
severe low back pain or
sciatica with severe
functional impairment
persistent for one year or
more.
74
GOOD STANDING POSTURE
 Head straight
 Chest forward
 Back straight
 Abdomen tucked-in
 Leg straight, or one leg
supported on a stool
 Arms hanging at the
sides
75
 Sikap Berdiri yang benar:
- Kepala dan punggung tegak; perut
ditarik ke dalam; lengan tergantung lurus
di sisi badan;
- Membungkuk sedikit; satu kaki
Salah
Benar ditopang
Berdiri
Sikap Duduk yang benar:
-Punggung tegak bersandar penuh; saling
menopang kaki;
-Punggung bersandar penuh; kedua kaki
ditopang di atas bangku kecil
Salah
Benar Sikap Berbaring yang benar:
Duduk
- Kepala di atas satu bantal & punggung
lurus; kedua lutut ditopang bantal;
- Tengkurap dengan bantal di bawah perut
dan kedua lengan ke atas kepala;
- Berbaring miring, siku bagian bawah
ditekuk, lengan bagian atas lurus di atas
Salah
Benar Tidur badan, bantal di antara kedua lutut 76
Mengemudi:
- Punggung bersandar penuh;
- Lutut masih tetap sedikit tekuk saat Benar Salah
menginjak rem penuh Mengemudi

Memasukkan/mengeluarkan
barang dalam/dari mobil:
- Punggung tegak, satu kaki diberi
tumpuan; Benar Salah
- Barang diangkat sedekat mungkin Memasukkan/mengeluarkan
dengan tubuh; barang dalam/dari mobil

Bekerja :
- Duduk dengan punggung tegak;
- Meja/tempat menulis sedekat
mungkin dengan tubuh
Benar Bekerja Salah
77
78
 REFERRALS
 For chronic low back pain of >12 weeks
 multidisciplinnary team approach is
proven to be effective.
 Team consists of professional health persons
trained in musculoskeletal, psychoscosial,
special treatment and related specialists
(Rheumatologist, Orthopaedics, Neurologists,
Physical Medicine & Rehabilitation Specialists,
Neurosurgeon).
 Multidisciplinnary team will be able to provide
comprehensive evaluation and management
plan. 79
 ALGORITME PENATALAKSANAAN NYERI PINGGANG AKUT
Ada red flags YA
Kunjungan Pertama Segera rujuk
atau yellow flags? ke spesialis
Riwayat dan
pemeriksaan TIDAK
Penilaian terhadap red
flags dan yellow flags Ikuti Panduan YA
Penatalaksanaan

Evaluasi bila perlu Rujuk ke spesialis yang

4 kompeten dalam menangani
minggu nyeri pinggang akut Rujuk ke
Evaluasi menyeluruh:
spesialis/ bala
Anamnesa dan bantuan
pemeriksaan
Skrining red flags dan Ada red flags?
yellow flags
Pemeriksaan yang perlu Ada yellow flags ? YA
Pikirkan perlunya terapi Restorasi aktifitas tidak
yang terus-menerus memuaskan?
Gagal kembali kerja? Rujuk ke tim
Respon terapi tidak multidisipliner evaluasi
memuaskan? dan perawatan

TIDAK

Ikuti Panduan Penatalaksanaan

6 minggu
TIDAK
Evaluasi ulang YA
keseluruhan PULIH ?
80