Low Back Pain

LECTURER: M.K. SASTRY

12 NOVEMBER 2017

acupaincare.india@gmail.com
cell no: 8473814247
**online seminar/classes will start in November.
 Epidemiology
• 80% of the population will have at least one episode
of LBP in their lifetime
• Annually $20 million in direct cost and $50 million
when indirect cost is added
• 3% of workers’ comp case but account 30% of the
cost and receive 75% of the payment
 Common causes of LBP?

• Nonspecific – ligamentous or articular structures,

strain, myofascial disorders, psychosocial factors
• Arthritis
• Spondylolisthesis
• Disc herniation - >95% L4-5, L5-S1
• Spinal stenosis
• Fracture
• Tumor
 History?
• Characterize the pain
• Diffuse, tight, gradual onset, worse after sitting or with cold,
relieved with warmth, associated stiffness – myofascial
disorder
• Brief, shooting, worse with coughing, standing or sitting,
relieved when lying down, radiating down the leg – nerve root,
sciatica
• Persistent, burning, tingling, worse when lying down at night –
peripheral nerve or lumbosacral plexus
• Radiating to buttock, thighs, legs, worse with back extension,
relieved with sitting – spinal stenosis
• Associated with horse saddle – cauda equina syndrome
 History – rule out “red flags”
symptoms?
• Trauma
• Fever
• Weight loss
• Neurologic deficits – numbness, bowel/bladder
incontinence
• History of IVDA, cancer, steroid use
• Last longer than one month
• Associated with abdominal pain
 Physical exam?

• Gait
• Muscle weakness – atrophy, pelvic tilt
• Knee flexion – guard against root traction
• ROM
• Palpation – tenderness, step off
 Physical exam

• Motor strength
• Heel – L5
• Tiptoe – S1
• Sensation – dermatomes
• L4 – big toe
• L5 – middorsum of foot
• S1 – lateral foot
 Physical exam

• Reflex
• Knee – L3, L4
• Ankle – S1
• Straight leg raise
• Crossed straight leg raise - > specificity than straight
leg raise
• Rectal exam
 Inconsistent examinations

• Axial loading
• Whole body rotation at the hip
• Straight leg raise in sitting position
 Tests for patients without “red flags”
symptoms?
• None
• 90% resolve spontaneously in 4 weeks
 Tests with “red flags” symptoms?

• CBC and ESR

• X-ray
• CT scan – fracture, fact joint
 Tests with “red flags” symptoms?

• MRI
• Infection, cancer, disc herniation
• Age >50, asymptomatic, disc bulging 75-80% and 30% disc
protrusion
• Bone scan – cancer
• EMG
• Nerve root involvement after multiple back surgeries
• Fastitious weakness
 Treatments – acute LBP?

• Activity versus bed rest

• Without radiculopathy, activity as tolerated
• With radiculopathy, may consider bed rest < 3 days
 Treatments – acute LBP?

• Medications
• Acute – around the clock rather than prn
• Analgesics: acetaminophen, NSAID, cox-2 inhibitor,
narcotics
• Muscle relaxants – short term
• Subacute/chronic: TCA, SSRI, phenytoin, tramadol,
gabapentin
 Treatments – acute LBP

• Soft tissue injection – controversial

• Back exercise
• Limited benefit
• Not during acute attack
 Treatments – acute LBP

• Disc herniation
• Multiple conservative modalities - >90% resolved
• Discectomy
• Sciatica
• Conservative treatment initially for 1-3 months - 80%
resolved spontaneously
• 73% recurred at least once
 Treatment – chronic LBP?
• Back exercise
• Antidepressants – mixed result, confounding
depression
• Steroid injection in
• Epidural space – may help in some patients, conflicting
reports
• Facets – limited data, one small study showed relief at 6
months but not month 1-3
• Spinal stenosis – laminectomy
• Minimally invasive procedures
• Spinal fusion – multiple laminectomy, unstable
 Treatment – chronic LBP

• Lumbar disc replacement

• Behavior therapy
• Spinal manipulation – mildly effective in some
patients but no better than other routine modalities
• TENS – no benefits
 THANK YOU

**online seminar/classes will be staring in November.

OUR CLINIC:
2ND FLOOR, JKON BUILDING
Opp. Sonaram Field, Sonaram High School
Bharalamukh, Guwahati-781009

Copy right: M K SASTRY