Understanding Low Backache & its basis of treatment

Bhaskar Borgohain MS ortho, DNB ortho, Fellow (Arthroplasty) Asst Professor, Department of Orthopaedics. NEIGRIHMS

MOVEMENT IS LIFE

LIFE IS MOVEMENT

PAINLESS MOVEMENT MEANS ENJOYING A QUALITY OF LIFE

PAINFUL MOVEMENTS MEANS JUST HAVING A LIFE OR EVEN WORSE

Biomechanics is nothing but the scientific study of the movements of the spine; in health & disease Movements are so essential or at times so bizarre

Low back: Lumbo-sacral Spine

Anatomically

Multisegmental column: Connects upper torso to the pelvis Function: Maintains upright position (stability) Yet allow great flexibility for actions: 5 Discs During all ROMs provide a protective conduit for neurological structures within Practically No rotation possible: Facets

Functional components of lumbar spine

Each Lumbar vertebra has 3 Components

Body : To bear weight The Neural Arches: To protect the neural elements Bony Processes: To increase efficacy of spinal muscle actions

SPINAL STABILITY SYSTEM

3 Interrelated subsystem Active: Actively contracting muscles (Erectors / Abdominals) Passive: Bone, Joints, Ligaments, Passively elongated muscles Neural (Control): Neural elements within the active & passive subsystem giving Dynamic stability

LIMITATIONS
Cadaveric:

Muscle

contarctions Neural control Dynamic balancing Translating lab finding to real time situations Clinical implications

Components of Lumbar Spine

Normal biomechanics of spine

Photo

of a gymnast Endless potential Elastic limits: Youngs modulus Pathobiomechanics: LBA

Pain sensitive structures of the spine

Ligaments:

PLL Nerves: sinuvertebral nerve Facet joint capsule Periosteum Meningeal coverings Muscles

LBA: The grey zone

Biological

enigma

Exact cause: 12-15%

Evolutional

paradox Proud spine in Health Terrible back in Disease Back Abuse/ Overuse

Epidemiology & Natural history

Over 80% of population experience some back pain in their lifetime (Quebec task force study on spinal disorders) Overall Prevalence 18%, Annual incidence 1520%(USA) Good news: 50% recover in 2 weeks; 90% in 6 wks Bad news: Only 1% chronically disabled Ugly truth: 80% Hospital resources drained

Simple Mechanical Backache Vs Sinister Backache

Green flag Noninflammatory backache No constitutional symptoms No obvious spinal deformity No neurological deficits or tension signs Not in Extremes of age

Red flag Inflammatory Constitutional symptoms Spinal deformity Neurological deficits or tension signs Extremes of age

MECHANICAL BACKACHE

Nothing is gravely wrong except the backache itself Non-inflammatory, noninfective & nonneoplastic pathology Lumbar Disc disease: included

Dull backache aggravated by activity Physical signs often slight Neurological deficit nil Extensive radiating pain to lower limbs absent

IMPORTANCE OF BIOMECHANICS OF SPINE

Stability Vs Mobility Spinal motion segments Disc & Facet joints close to nerve roots Compressible gel Mobile Ball bearing action

BIOMECHANICAL ANATOMY

Hourglass connection Dynamic balance Abdominal muscle Vs erector spinae group of muscle Intrathoracic pressure and intrabdominal pressure

Dynamic balance

INTRADISCAL PRESSURE

IDP changes with position Sitting worse, Standing better ,lying supine best After 6 hours statistically significant reduction of normal disc height

DDD (Degenerative Disc disease) Pathobiomechanics

Loss of water content Abnormal stresses / biomechanics Further degeneration Facet degeneration Disc prolapse: Weak PLL Discogenic back pain

Poor blood supply: poor healing

WHOOP STRESS

DISC SPACE LOSS: SEQUEL

Sequel of Collapse of disc space: Distorted attempt to stability

Segmental spinal instability: Motion segment abnormality- All column disturbances Facetopathy: Abnormal stress on facet joints Vertebral end plate sclerosis Ligamentum flavum hypertrophy Secondary canal stenosis LBA: Final common pathway

DISC DESSICATION Poor vascularity: Poor healing

Discogenic back pain

Axial

low back pain Sinuvertebral nerve arise from dorsal root ganglion: non-segmental innervations S.V.N. Innervates posterior annulus close to PLL is irritated Disc bulges on axial compression Axial pain begins d/t signal carried by paravertebral sympathetic trunk

Discogenic back pain

Mangement
Goal:

Early return to work Tailored to each patient Interdisciplinary approach Modify activity in acute phase Confirming the diagnosis

Chronic Low Backache

ABNORMAL POSTURE

Lx lordosis Infancy Vs adulthood Muscle weakness Muscle fatigue

MODALITIES OF MANGEMENT
Touching

the back! Counseling: Back Schooling Posture care: Do & Dont list Use of firm mattress Avoiding cumulative microtrauma to spine Developing positive attitude: Depression

Bed rest: Contradictory to the goal

Bed rest of > 2days has serious implications 3% of muscle bulk/ mass is lost daily 6% of bone demineralized in 2 weeks Restriction of social activity & inability to carry out responsibilities PPT depression, illness behavior & lack of motivation Adequate sleep: of course yes, endorphin/ melatonin

MAN Vs SUPERMAN?

Man is a social animal Anatomically & Physiologically we are nothing but Animals We are probably the only Animals that sit for 5 hours in the computer when the body is asking for rest & sleep! Man cannot run faster than a cheetah but he can drive at 100km/hour and stop in less than a second Brunt is taken by the Spine,Discs and Ligaments

BACK SCHOOL - I
Don't

try to be superman Anatomically & Physiologically we are man Maintain good posture Take frequent break at work Use your back but don't abuse it

BACK SCHOOL - II
Smoke

at your own peril Modify your activity to give rest to the tired back Never flog a tired horse Single footstep of a man a giant leap for the mans back

Medications
NSAIDs: 1ST Line Narcotics: Not beyond Trigger point injections: No role 2 weeks Spinal manipualation: Muscle relaxant: No Controversial OR role contraindicated if disc Antidepressant :Only herniation if >3 months

SIMPLE BACKACHE IS NOT SIMPLE

Functional

restoration program involv. interdisciplinary approach if no narcotics or surgery needed Psychological evaluation or Psychiatric analysis whenever possible Treat co morbid condition that may aggravate LBA

SIMPLE BACKACHE IS NOT SIMPLE

Malingerers backache: Compensation

Hoovers

Test Simulation Rotation Test Pelvic Compression Test Sitting SLR Test Adams anterior bending test Sickness absenteeism

SIMPLE BACKACHE IS NOT SIMPLE

Referred pain: High index of suspicion

Hips:

Compensatory pain Pelvic organs S.I. Joints or pelvis Renal & Retroperitoneal tumor Vascular: aneurysm

Cure Vs Curiosity in Backache

Can

we cure backache :yes Can we cure spondylosis: no Does all disc prolapse need operation: no Is it possible to have a normal life after a disc prolapse: yes Can physiotherapy improve spinal biomechanics: yes

Physical therapy
Exercises

: once acute phase is over Heat/Infrared/ US Therapy Electric Stimulation IFT: only if acute phase is over TENS: only if acute phase is over C fibre & Gate theory Endorphin?

Thermal therapy

Heat : Superficial Infrared: Deep US Therapy: Deep

Increase circulation Wash off cytokines Promote healing Relieve spasm Counterirritant Touch

Pregnancy
Pregnancy

aggravates LBA Weight Gain & Pull Of Abdomen Address LBA appropriately First Surgery if indicated: Do First Ligament Laxity Osteomalacia PhysioTh: Impractical (3rd Trimester)

Facet injections
Limited

Indications: Not a common source

of pain Pain in spinal extension & radiation to back of thigh that ends above knee level Multiple Joints and Peculiar nerve supply Doesnt Change the Pathology: Adjunct

Epidural steroids/block
Controversial

indications Decreases sciatic pain Unpredictability: Inoperable patient Undermines the actual disease Complications & Wrong diagnosis

Surgery: Laminectomy:

Cauda equina syndrome: Hemilaminectomy Single Laminectomy : 14% overall instability Cadaver study (Punjabi): Unilat. Or B/L facetectomy increased 63% Flexion, 78% extension, 15% lateral bending & 126% axial rotation

Surgery: Spinal fusion

Rigid stabilization: Spinal fusion + Facetal Fusion Halts abnormal biomechanics at fused level ALIF or PLIF Post. or Postlateral Intertransverse fusion

Posterior: Rods & pedicular Screws Anterior: Rods & Screws Address secondary causes: 3600 Fusion

Surgery: Spinal fusion

Persistent

disabling Discogenic axial low back pain in absence of other organic or psychological component: 70-80% Multilevel discectomy Documented instability

DISC PROLAPSE: SURGICAL INDICATIONS

Acute

neurological complications Gradual but progressive neurological deterioration Persistent radiating pain despite strict bed rest and medication for 3- 4 weeks

Why 3 - 4 Wks: TNF,Cytokines

BULGE

PROTRUSION

EXTRUTION SEQUESTRATION

CONTAINED DISCS

UNCONTAINED DISCS

DISC: TYPES OF INTERVENTIONS

Chymopapain Injection Laser discectomy: (Europe): Anaphylaxis Contained disc Microdiscectomy: Good Endoscopic discectomy: option Intradiscal electrothermal Open discectomy: therapy: Thermally ablate Objectivity + Complete the sinuvertebral nerve Neural decompression fibre of posterior annulus

Endoscopic discectomy:
Transperitoneal video-assisted

Technically demanding: Complications Overall: 4.7% cf 2.3% Vascular injury: 2.1% to 25%

Retrograde ejaculation: < 9.4% DVT Visceral injury, Paralytic ileus

Dynamic stabilization

Fusion may fail to relieve pain Preserve movements of motion segment Instruments or artificial ligaments to control movements Load sharing during movements

Dont remove or disturb normal anatomy Augmenting weak ligaments and muscles without fusion Graf ligament recontruction: mimic normal biomechanics Interspinous Spacer (DIAM): no osteoporosis

Disc replacement
Aim:

Painless, Mobile and Stable Spine, Replaces anatomical structures Correct Soft tissue tensioning crucial for maintaining spinal stability Pain causing structures are physically removed at surgery Long term Safety: FDA ( MoM / MoP)

Gene transfer
Biochemical

changes in nucleus Adenovirus as vector: rat model IRAP (interleukin receptor antagonist) or Lac Z gene Increase synthesis of PG Immune privileged cells of nucleus Prophylactic injections?

ALTERNATIVE THERAPY
Too

many options means too little known The exact cause found in only 12-15% Biofeedback: No role after 2 weeks of trial Acupuncture: No role after 2 weeks of trial Massage: breakdown adhesions Yoga Endorphin!

Summary

LBA In man is a biological enigma Mobility leads to repetitive cumulative microtrauma Microtrauma PPT degenerative changes Microtauma progresses to macrotrauma in prolonged back abuse Degeneration reduces mobility Decrease mobility causes muscle atrophy

Abnormal segmental motion starts Abnormal biomechanics evolves & encroaches neural elements Secondarily encroaches neural elements Low back Pain begins

Thank you