LOW BACK PAIN

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

CLASSIFICATION
EPIDEMIOLOGY
Life time prevalence 59%
10% leads to consultation to GP
90% improved in 1 month
up to 70% patient tend to recur
Non-specific mechanical back pain
Facet joint syndrome
Lumbar disc degeneration (lumbar spondylosis)
Lumbar disc prolapse
Spondylolisthesis
Spinal stenosis
Osteoporosis
Sero-negative spondyl arthritis (including ankylosing
spondylitis)
Vertebral infection
Disc space infection
Malignancy secondary myeloma and primary
Pagets disease, referred-visceral, pancreatic/pelvic, etc


etiology
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 unwell
Weight loss
Persistent severe restriction of lumbar flexion
Widespread neurological deficit
Structural deformity

1. Mechanical (deformity, trauma)
2. Inflammation
3. Neoplasm
4. Degenerative
5. Psychological
COMMON
ETIOLOGY
Ligamentous Strain
Muscle strain or spasm
Facet join disruption or degeneration
Intervertebral disc degeneration or herniation
Vertebral compression fracture
Vertebral end-plate microfractures
Spondylolisthesis
Spinal stenosis
Diffuse idiopathic skeletal hyperostosis

PRIMARY MECHANICAL
DEARRANGEMENT

THE DISTINCTION AMONG SPONDYLOSIS,
SPONDYLOLISIS AND SPONDYLOLISTHESIS
SPONDYLOSIS :
refers to osteoarthritis involving the articular surfaces
(joints and discs) of the spine, often with osteophyte
formation and cord or root compression

SPONDYLOLISIS :
refers to a separation at the pars articularis, which
permits the vertebrae to 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
the slipping forward of one vertebrae on the vertebrae
below.
Epidural abcess
Vertebral osteomyelitis
Septic discitis
Potts disease (tuberculosis)
Nonspecific manifestation of systemic
illness
INFECTION
Epidural or vertebral carcinomatous
metastases

Multiple myeloma

Lymphoma
NEOPLASM

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


DEGENERATIVE

The disc
Herniated disc
Distribution
Lumbar disc prolaps (most commo)
L5-S1 (45-50%), L4-5 (40-45%)
Cervical disc prolaps
C6-7 (69%), C5-6 (19%)
Thoracal disc prolaps (infrequent, < 1%)

Grade
Protruded disk : penonjolan nukleus pulposus
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 posterior.
Sequestrated disk : nukleus telah menembus
ligamentum longitudinalis posterior.
Grade of herniated disc
Clinical symptoms
Lumbar HNP :
* radicular pain
* abnormal vertebral posture
* paresthesia, parese, diminished tendon reflexes
Cervical HNP :
* radicular pain, aggravated by neck extension, and
reduced by abducting the arm and put it behing
the head
* paresthesia, parese, diminished tendon reflexes
Ischialgia (sciatic)
Diagnosis
Neurological examination
Lumbar HNP :
* Lasegue (straight leg raising) test
* Crossed Laseque (crossed SLR) test
* Femoral stretch (reverse SLR) test
Cervical HNP :
* Lhermitte test
* Spurlings sign
* Shoulder abduction test
Diagnosis
RADIOLOGICAL EXAMINATION :
Plain vertebral x-rays :
* limited information
* disc narrowing, scoliosis, lordosis lumbal
Myelography
CT or CT-myelography
MRI

EMG/NCV : 90% abnormal after 1-2 weeks
Therapy
CONSERVATIVE
* bed rest
* orthopaedic mattress
* analgetic
* pelvic traction (controversial)
OPERATIVE
Indication :1. Fail conservative treatment
2. Progressive motor dysfunction
3. Recurrence
4. Compression of cauda equina
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 by sitting or leaning forward
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 the disc to bulge into the nerve root and
central canal.
MOST FREQUENT CAUSES OF SPINAL
STENOSIS
3. Degenerative spondylolisthesis :
occurs when the facets degenerate, allowing slippage
of the upper vertebrae forward over the lower
vertebrae.
4. Postoperative :
occurs after laminectomy or spinal fusion. Stenosis
is produced by bone formation and scar tissue
INDICATION FOR SURGICAL TREATMENT
OF LUMBAR SPINAL STENOSIS

1. Persistent intolerable pain
2. Limitation of walking distance or standing
endurance to a degree that compromises
necessary activities
3. Severe or progressive muscle weakness or
disturbed bladder of sexual function.