LOW BACK PAIN

THOMAS EKO P.
Bagian/SMF Neurologi FK UNUD/ RS. SANGLAH
DENPASAR

Lecture Topic
1.Overview Low Back Pain
2.HNP

Course Objectives

Know the RED FLAGS in history taking.

Know the Pain Generators of the Lumbar
spine
Know the Guidelines for Imaging of the
spine with low back pain.
Know the general guidelines to
rehabilitation.

BACK GROUND
LBP :
- Imhotep
: Egypt , 3000 BC
- Hippocrates and Galen : Lumbago & Sciatica
Prevalence:
USA
: 15-20%
Copcord Indonesia
: 14-18%
POKDI NYERI PERDOSSI (2002) : 18 %

Ancient History:
The Egyptian physician,
Imhotep, was credited the
earliest (3,000 2,500 BC)
known report of workinduced back pain cases.
He provided medical care
to the workers who built
the great pyramids . . . !

15th Century Turkish TreatmentCauterization

Epidemiology of Back Pain

Who gets it?
60-90% lifetime prevalence.
80-90% have recurrent episode.
What is the Natural history?
80-90% resolves in 1 month.
20-30% remains chronic
5-10% disabling

Back Pain a Huge Problem: Newsweek-April

26, 2004

Alf Nachemson
Whats the cause of back pain?
In most cases

I dont know!

ETIOLOGY
Etiology
~97% of low back pain is mechanical
Despite the many possible causes, making a
specific diagnosis is usually impossible (~85%
of the time)
Nonspecific Mechanical Low Back Pain

AHCPR publication 95-0643

Deyo RA et al JAMA 268:760, 1992
Deyo RA et al NEJM 344:363, 2001
Atlas JA et al J Gen Intern Med 16:120, 2001

Etiology (Contd)

Etiology

Many patients and physicians fear the serious,

systemic causes
~2% will present predominantly with sciatica
~2% have pain referred from visceral disease
~1% have pain caused by serious
nonmechanical spinal conditions
<1% present with the cauda equina syndrome
AHCPR publication 95-0643
Deyo RA et al JAMA 268:760, 1992
Deyo RA et al NEJM 344:363, 2001
Atlas JA et al J Gen Intern Med 16:120, 2001

DIAGNOSIS TRIAGE
( RCGP 1996, A Joint Clinical Practice
Guideline from the ACP and APS 2007
1.Non specific LBP : 85%
2. Radiculopathy ( Nerve root pain)
3. Serious spinal pathologic : 4 %

Ad.1. Non Specific LBP

Age : 20-55 tahun
Good general condition
Pain in buttock, thigh and lumbosacral
above knee
Mechanical
do not refer to specialis

Mechanical NSLBP
pain is worsened with movement
pain is improved with rest

Kathryn Refshauge

14

Non-specific pain distribution

Ad.2. Nerve root pain

( Radiculopathy )

unilateral , worse than non specific LBP

Spreading to lower limb or toe
Parasthesia +
Lasegue ( SLR ) tes +
Localized nerve root compression

Usually does not refer to neurologist before 4 weeks.

Ad.3. Serious spinal pathology

Cancer
Infection eg osteomyelitis
Cauda equina syndrome
Cord compression
Fracture (osteoporotic)
Inflammatory diseases/arthritides
Abdominal or cardio-thoracic pathology

Eliminate serious pathology

(red flags)

unexplained weight loss

night pain
poor general health/systemic symptoms
fever
previous history of cancer
no relief with bedrest
failure to improve with therapy
Kathryn Refshauge

21

RED FLAG : Signs and symptoms indicating

serious spinal pathology e.g. : fracture, cancer,
infection and cauda equina syndrome

Red flags (contd)

history of trauma
steroid use (osteoporosis)
very severe pain/muscle spasm
bowel/bladder frequency (cauda equina
syndrome)
widespread neurological symptoms
non-mechanical behaviour of symptoms
Kathryn Refshauge

23

Red Flags (contd)

Age > 50 years
Constant progressive non-mechanical
pain
Thoracic pain
Persisting severe restriction of lumbar
flexion
Pain that worsens in supine

Yellow flags

Previous history of LBP

Radiating leg pain, NR involvement
Poor fitness
Poor extensor endurance
Poor general health
Psychological distress (fear avoidance
behaviour, depressed)
Kathryn Refshauge

25

Yellow flags (contd)

Much time lost from work

Disproportionate illness behaviour
Low job satisfaction
Personal problems (alcohol, marital,
financial)
Adversarial medico-legal proceedings
Kathryn Refshauge

26

DIAGNOSE
1. Anamnesis
2. Physical and Neurological Examination
3. Specific Examination

Ad.1.ANAMNESIS (Sacred seven)

Onset
Duration
Location-radiation
Property
Quality
What makes pain better / worse.
Red Flag ?
Neurologic Symptoms :
Paresthesias.
Bladder /Bowel retention or incontinence.
Weakness.

Ad.2. Physical and Neurological

Examination
Range of Motion (document range and
pain)
Flexion- 40
Extension- 15
Lateral bending- 30
Rotation- 45

Scoliosis

Motoric
Examination

Clinical symposia-ciba, vol 32, no.6,

1980

Strength tests

L1, L2- Hip flexion (Psoas, rectus femoris)

L2,3,4 Knee extension (Quads)
L2,3,4 -- Hip adductors (adductors and gracilis)
L5 ankle/ toe dorsiflexion (ant. Tibialis, EHL)
L5 Hip abductors (gluteus medius, TFL)
S1- ankle plantarflexion (gastroc/ soleus)
S1 Hip extensors (Gluteus max., Hamstrings)

Sensoric Testing
If there is nerve root compression,
sensation can be disrupted

Sensoric
Examination

L4

L5

Reflexes
L2,3,4- Quads
L5- Medial hamstring
S1- Achilles

Sensation

Pin prick- primarily spinothalamic tract

Vibration/ position sense- dorsal columns
Vibration tested with 256 cps fork!
Position on 3-4th digit

Provocative Maneuvers
Straight Leg Raise (supine or seated)
For L5-S2 radicular symptoms
Femoral Stretch
For L2-4 radicular symptoms
FABERs test
For SI joint, hip joint, lumbar z-joint
symptoms

Lasegue ( SLR ) TEST

The Happy Couple

3. Specific
EXAMINATION
A. NEUROPHYSIOLOGY
- ENMG and H reflex :
neuro/radiculopathy.
- SSEP.
B. RADIOLOGY
- Caudo/myelography
- CT caudo/myelography
- Discography
- MRI

Deyo RA Sci Am 279:48, 1998

Plain Radiographs
Lumbar films correlate poorly with
the presence of low back problems
Many patients without back pain
will have degenerative changes
Many patients with back pain will
not have radiographic abnormalities
Therefore, when degenerative
changes are present, it is very
difficult to know if they are
causative
van Tulder MW et al Spine 22:427, 1997
Deyo RA et al J Gen Intern Med 1:20, 1986
Scavone JG et al Am J Roentgenol 136:715, 1981

Plain Radiographs
Cannot detect disk herniation, spinal
stenosis, or nerve root impingement
May not necessarily see tumor or infection
Therefore, they cannot rule out suspected
malignancy or infection
Rarely detect something that was not
already suspected from the H&P
Most films will be non-diagnostic
So when should they be done?
van Tulder MW et al Spine 22:427, 1997
Deyo RA et al J Gen Intern Med 1:20, 1986
Scavone JG et al Am J Roentgenol 136:715, 1981

Imaging or Not?
Low yield without RED FLAGS present.
Abnormal findings in Asymptomatic.
Psychological.
Anxiety, fear-avoidance- possibly help?
Depression- there must be something
wrong

Guidelines for Imaging

NO RED FLAGS!
Acute pain- symptomatic treatment for 4
weeks, re-evaluate. Image if pain continues.
( AHCPR Guidelines for Acute LBP ).
Sub acute pain- Pain for >4wks. Failed
symptomatic treatment. Image.
Chronic pain- none, unless changes in sxs
Chronic intermittent- TX as acute patients

MYTH #2: Newer imaging tests (CT

and MRI) can always identify the cause
of pain

MRI
There are similar findings in asymptomatic individuals
with MRI*:
52% had bulging of at least one disk
27% had a disk protrusion
1% had a disk extrusion
64% had a disk abnormality at one level
38% had a disk abnormality at more than one level

*Jensen MC et al NEJM 331:69, 1994

**Jarvik JJ Spine 26:1158, 2001

So when are CT and MRI

Indicated?
Tumor, infection, fracture, or other spaceoccupying lesion is strongly suggested by the
clinical findings
Symptoms of the cauda equina syndrome
There are severe or progressive neurologic
symptoms
Sciatica symptoms >1 month and the patient is an
appropriate and willing potential surgical
candidate
AHCPR publication 95-0643
Deyo RA et al NEJM 344:363, 2001
Atlas JA et al J Gen Intern Med 16:120, 2001

MANAGEMENT LBP
1. CONSERVATIVE
2. OPERATIVE

A Joint Clinical Practice Guideline from

the American College Physicians and
Americans Pain Society (2007)
Source
MEDLINE : 1966- November 2006
Cochrane Database of Systematic Review
(2006 Issue 4)
( Chou, R. Ann Intern Med.2007;147:505-514)

Deyo RA Sci Am 279:48, 1998

Deyo RA Sci Am 279:48, 1998

Back Injury Risk Factors - Acute

Acute (traumatic) back injury
may occur due to:
slips, trips and falls;
auto accidents;
sedentary lifestyle (with
occasional lifting);
heavy and/or awkward loads;
improper lifting technique.

Back Injury Risk Factors Chronic

Chronic back injury may result
from poor posture and/or
improper lifting technique
combined with repetitive lifting.
Additionally, genetics and
overall physical fitness may
affect spine health.

Salah

Benar
Benar

Mengemudi

Salah

Berdiri

Benar
Benar

Duduk

Benar

Tidur

Salah

Salah

Salah

Memasukkan/mengeluarkan
barang dalam mobil

Benar

Bekerja

Salah

Pengaturan postur saat membawa barang

Mengangkat barang
Benar

Salah

Membawa barang
didepan tubuh
Benar

Benar

Salah

Salah

Membawa barang
di punggung

Sit-up parsial untuk memperkuat

otot-otot abdomen

Latihan untuk memperkuat

otot punggung dan panggul

Latihan untuk mengurangi

peregangan otot punggung

Latihan untuk memperkuat

otot perut dan panggul

Beberapa variasi latihan ekstensi, mulai dari yang paling ringan ditingkatkan
disesuaikan dengan kekuatan otot-otot ekstensor lumbal

Back Pain Exercise

HERNIATION NUKLEUS
PULPOSUS (HNP)
LUMBALIS

HNP
- Synonime : herniated/ slipped/ruptured lumbar disc
- Prevalence : 1-2 % population
- Most of HNP improve within 4-6 weeks

DEFINITION :
HNP occurs when the nucleus pulposus (gel-

like substance) breaks through the anulus

fibrosus (tire-like structure) of an intervertebral
disc.

PATHOPHYSIOLOGY
- Intervertebrale disc links CV as shock
absorber
- discus : anulus fibrosus and nukleus pulposus

PATHOPHYSIOLOGY
- Degeneration of disc : decrease vascularisation
and elasticity ,
- water content of the nucleus decreases
progresive with age.

Herniated Disc
People between the ages of 30-50 appear to be
vulnerable because the elasticity and water content
of the nucleus decreases with age.
The progression to an actual HNP varies from slow
to sudden onset of symptoms.

Pathophysiology
Disc Degeneration
Narrow Disc space
Microinstability
Vertebral endplate

Nucleus Pulposus drying

Stress capability decrease
Nucleus Pulposus Protusion

irritation
Dorsomedial protusion
Spur formation
Nerve root
compression

Spinal cord
compression

Dorsolateral
protusion

Nerve root compression

Disc Herniation
Pain resulting from herniation may be combined
with a radiculopathy.
caused by nerve compression

The deficit may include sensory changes (i.e.

tingling, numbness) and/or motor changes (i.e.
weakness, reflex loss).

Herniated Disc
There are four stages:

(1) disc protrusion

(2) prolapsed disc
(3) disc extrusion
(4) sequestered disc.

Stages 1 and 2 are referred to as incomplete (bulging

disc)
where 3 and 4 are complete herniations.

RISK FACTOR
- Smoking
- Cough
- Longtime sitting/standing
- Driving.
- Lifting weight material.
- Sudden movement

Location HNP
A herniated disc occurs most often in the
lumbar region of the spine Most
Commonly at the L4-L5 and L5-S1
levels
This is because the lumbar spine carries
most of the body's weight.
Highly mobility : flexion and extention.
- Posterior Longitudinale ligamentum : 1/2

CLINICAL MANIFESTATION
- Sciatic usually sudden onset.
-Depend nerve root compression :
- Sensorik : paresthesia, burning,
numbness,pain,
dermatom distribusion.
- Motoric: muscle weakness.
- Otonom : urination and bowel disturbances.
- Pain worse when increased of intrathecal /
intradiscus pressure

Diagnose
The spine is examined with the patient
laying down and standing.
Due to muscle spasm, a loss of normal
spinal curvature may be noted.
Radicular pain may increase when
pressure is applied to the affected spinal
level.

Diagnose (contd)
A Lasegue test, also known as Straight-leg
Raise Test, is performed.
The patient lies down, the knee is extended,
and the hip is flexed.
If pain is aggravated or produced, it is an
indication the lower lumbosacral nerve roots
are inflamed.
If the contralateral SLR also produces pain,
it is more likely to be from a herniated disc

DIAGNOSE (CONTD)
Other neurological tests are performed to determine
loss of sensation and/or motor function.
Abnormal reflexes are noted; changes may indicate the
location of the herniation.

Radiographs are helpful, but the MRI is the best

method for evaluation

Disc Degeneration: Findings?

Narrowing
Osteophytosis
Vacuum Disc
Endplate sclerosis

Myelography

Extrusion

Extrusion

CLINICAL
EVALUATION
1. ANAMNESIS : same as LBP

CLINICAL
EVALUATION
2. PHYSICAL /NEUROLOGICAL EXAMINATION.
INSPEKSI, PALPASI
De yo dan Rainville : ( LBP + radicular pain ).
- Laseque (SLR) Test
- Strength of dorsoflexion ankles and
toes muscles
( L4-L5)
- Achilles reflexes ( S1).
- Sensory Test of medial (L4), dorsal (L5)
and
lateral (S1) foot.
- Contra lateral Laseque test : very
specific, but
not always positive.
- 90% HNP L4-L5 and L5-S1 can be
detected
d\

3. Specific
EXAMINATION
A. NEUROPHYSIOLOGY
- ENMG and H reflex :
neuro/radiculopathy.
- SSEP.
B. RADIOLOGY
- Caudo/myelography
- CT caudo/myelography
- Discography
- MRI

MANAGEMENT (1)
A. CONSERVATIVE
B. OPERATIVE

MANAGEMENT
A.
KONSERVATIVE
(2)

Most of HNP (90%) px improve in 4-6 weeks.

1. Bed rest : 2-4 days , muscle weakness
when too long bed rest, gradual
mobilisation

2.

Medikamentosa.
- Analgesic : Aspirin, Acetaminophen,
Tramadol.
- NSAID
: Ibuprofen, Natrium Diclofenac,
Etorolac etc
- Kortikosteroid : severe case and
controversy.
- Muscle relaxant : esperisone, tizanidine
etc.
- Opioids : severe case
- Anti depressant : amitriptilin.

MANAGEMENT
(3)

-Steroid epidural INJECTION : ControversY

- Chymopapain Injection : succesfull rate

40%,
complikation >
3. Physical Therapy
- Pelvic Traction : controversy.
- USW diatermi , Hot/cold pack
- TENS : con troversy.
- Korset lumbal : prevention.
- Exercise : Mild exercise.
4. Accupuncture : controversy
5. Education : back school.

usefull

MANAGEMENT
B. OPERATIVE
(4)

- Goal : release irritation and compression

nerve root
-Can not relieve muscle strength but
prevent
worse.
- Effective for radicular pain ( > 90% ) than
back pain.

Operative
-Indication :
-Not improve after 1 month
konsevative treatment
- Severe sciatica.
-Cauda equina syndrome
- Muscle weakness in lower limb.

OPERATIVE
TECHNICH :
- standard discectomy
- microscopic discectomy
- percutaneous discectomy
- laminectomy

HNP CERVICAL