LOW BACK PAIN

Dr. SUHERMAN,SP.S
CLASSIFICATION

ACCORDING TO ITS DURATION, LBP IS

DIVIDED INTO :
ACUTE : < 2-8 WEEKS
SUBACUTE : 2-8 WEEKS – 12 WEEKS
CHRONIC : > 12 WEEKS
 EPIDEMIOLOGY

•Life time prevalence 59%

•10% leads to consultation to GP
• 90% improved in 1 month
• up to 70% patient tend to recur
 etiology

 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
 Paget’s disease, referred-visceral, pancreatic/pelvic, etc
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
 COMMON
ETIOLOGY

1. Mechanical (deformity, trauma)

2. Inflammation
3. Neoplasm
4. Degenerative
5. Psychological
 PRIMARY MECHANICAL
DEARRANGEMENT

•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
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.
 INFECTION

 Epidural abcess
 Vertebral osteomyelitis
 Septic discitis
 Pott’s disease (tuberculosis)
 Nonspecific manifestation of systemic
illness
 NEOPLASM

• Epidural or vertebral carcinomatous

metastases

• Multiple myeloma

• Lymphoma
 DEGENERATIVE

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
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
* Spurling’s 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.