Tutorial

Low Back Pain

Rahma Herviastuti
12/329221/KU/14991

Pembimbing: dr. Wahyu Wihartono, Sp.S, M.Kes

Pembahasan
Low back pain
Definition
acute: <6 wk
subacute: 6-12 wk
chronic: >12 wk
Epidemiology
5th most common reason for visiting a physician
lifetime prevalence: 90%
peak prevalence: age 45-60
most common cause of chronic disability for individuals <45 yr old
90% resolve in 6 wk, <5% become chronic
Anatomy
Muscle support of the back:
Two iliopsoas muscles, which run
along both sides of the spine
Two erector spinae muscles, which
run along the length of the spine
behind it
Many short paraspinal muscles,
which run between the vertebrae
The abdominal muscles
Etiology
Spine
Mechanical
75% nonspecific mechanical derangement: Muscle strain, ligament sprain, spasm, or a combination;
poor posture, decreased strength of stabilizing muscles, or decreased flexibility
15%: specific structural lesions of the spine that clearly cause the symptoms, primarily the following:
Disk herniation, Compression fracture, Lumbar spinal stenosis, Osteoarthritis, Spondylolisthesis
Non mechanical infeksi, tumor
Extraspine
Referred (pyelonephritis, peptic ulcer, disectio aorta)
Other: part of fibromyalgia
However, etiology of back pain, particularly if mechanical, is often multifactorial
Risk Factor
Lifting and/or twisting while holding a heavy object (eg, box, child, nursing home
resident, a package on a conveyor)
Operating a machine that vibrates
Prolonged sitting (eg, long-distance truck driving, police patrolling)
Involvement in a motor vehicle collision
Falls
What to think
Spinal/extraspinal?
Is there a red flag? Red flag bisa untuk mencari penyebab ekstraspinal
Misalkan tidak diketemukan ekstraspinal & red flag, pikirkan apakah:
Nonspecific low back pain
Low back pain with radicular symptoms or spinal stenosis
Low back pain associated with another spinal cause
Physical examination
In the spinal examination, the back and neck are inspected for any visible deformity,
area of erythema, or vesicular rash.
The spine and paravertebral muscles are palpated for tenderness, muscle spasm
neurologic examination Strength and deep tendon reflexes are tested. In patients with
neurologic symptoms, sensation and sacral nerve function (eg, rectal tone, anal wink
reflex, bulbocavernosus reflex) are tested. Pathologic reflex to test corticospinal tract
lesion (eg spinal canal stenosis)
Test for radiculopathy/sciatica
straight leg raise/lasegue: passive
lifting of leg (30-70o) reproduces
radicular symptoms of pain
radiating down posterior/lateral
leg to knee into foot
+Braggard/sicard: dorsiflexion of
foot/big toe during straight leg
raise makes symptoms worse or, if
leg is less elevated, dorsiflexion
will bring on symptoms
crossed straight leg raise (raising of
uninvolved leg elicits pain in leg
with sciatica), more specific than
straight leg raise
Femoral stretch test
Femoral stretch test: with patient prone, flexing the knee of the affected side and
passively extending the hip results in radicular symptoms of unilateral pain in lumbar
region, buttock, or posterior thigh
Patrick test &
contrapatrick test
HNP Lumbal
LUMBAR DISC HERNIATION = Most common cause of Sciatica
definition: tear in annulus fibrosus allows protrusion of nucleus pulposus causing
either a central, posterolateral, or lateral disc herniation, most commonly at L5-S1 >
L4-5 > L3-4
Patophysiology
1. Degeneration
Loss of hyaluronic acid less
water less flexibility decrease
in lumbar height clumping and
bulging of disk

2. Repetitive trauma
Ex: truck driver

3. Multifactorial
Natural History of HNP
Disk degeneration continued deterioration restabilization of spine by collagen stiffen
the spine disk
Patient in 50s / 60s less pain

Shrinkage of a herniated fragment, aided by macrophages and the evoked inflammatory

reaction Spontaneous resolution of sciatica

Surgery indication: 90% resolve in 3 mo;

progressive neurological deficit, failure of symptoms to resolve within 3 mo, or cauda equina
syndrome due to central disc herniation
Pharmacologic
Analgesic
Muscle relaxant
Non-benzodiazepine muscle relaxants (e.g., eperison, cyclobenzaprine) pain
reduction in 1-2weeks, benefit up to 4 weeks
Diazepam very low-quality evidence short course (up to five days) of may also be
beneficial
Analgesics
When to take
imaging?n to
do imaging?
X Ray vs CT/MRI
Plain x-rays can identify most osteoporotic fractures and osteoarthritis.
Do not identify abnormalities in soft tissue (the most common cause of back and neck
pain) or nerve tissue (as occurs in many serious disorders).
Thus, x-rays are usually unnecessary and do not change management.
Non-pharmacology
Saat sudah terjadi LBP
Pencegahan
If developed
Avoiding activities that stress the spine
Bed rest, if required to relieve severe pain, should last no more than 1 or 2 days.
Application of heat or cold.
First 2 days ice. The ice is removed after 20 minutes, then reapplied for 20
minutes over a period of 60 to 90 minutes. This process can be repeated several
times during the first 24 hours. Heat can be applied for the same periods of time
After the pain has subsided, light activity
Prevention
Aerobic exercise, such as swimming and walking, improves general fitness and
generally strengthens muscles.
Muscle-strengthening exercises include pelvic tilts and abdominal curls.
People should avoid standing or
sitting for long periods. If prolonged
standing or sitting is unavoidable,
changing positions frequently may
reduce stress on the back.
Cauda Equina Syndrome
Terima kasih