BACK PAIN

Low
Back Pain

Definition-
Low back pain or pain in the lumbo-
sacral region is triggered by some
combination of overuse, muscle strain,
and injury to the muscles, ligaments, and
discs that support the spine.
Low
Back
Epidemiology of low back
Pain
pain-
• 60%–90% lifetime prevalence
• 80%-90% have recurrent episode.
• Second most common complaint to
prompt a medical evaluation
• Leading cause of long-term work
disability
• Disability and costs related to pain, not
to the disease process.
Low
Back Pain

Natural history of low

back pain-
• 80-90% resolves in 1months
• 20-30% remains chronic.
• 5-10% disabling
Low
Back
Pain Causes of
low back pain-
Injury, inflammation/infection or overuse of
muscles, ligaments, facet joints, and the 
sacroiliac joints.
Pressure on nerve roots in the spinal canal.
Nerve root compression can be caused by
A herniated disc,
Osteoarthritis -which mostly affect the
facet joints hypertrophy
Spondylolysis and spondylolisthesis..
Spinal canal stenosis, or narrowing of the
spinal canal
Fractures of the vertebrae.
Spinal deformities, such as severe scoliosis
 or kyphosis.
Low
Back Pain

Causes of low back

pain(cont)-

Compression fractures.
Compression fractures are more
common among postmenopausal
women with Osteoporosis.
Low
Back
Pain Causes of
low back pain(cont.)-
Less common spinal conditions that can cause
low back pain include:
Ankylosingspondylosis
 Bacterial infection such as osteomyelitis/ TB
 Spinal tumour (primary or secondary)
Pagetsdisease
 Failed back surgery syndrome.
 Use of steroids over a long period of time.
Low
Back
Pain Symptom of low Back pain-

The type, location, and severity of low back pain

 depends upon the cause

A. Due to local cause

B. Due to nerve root involvement
A. Symptom of local back sprain or strain-
Muscle spasms, cramping, and stiffness.
Pain- mostly in the back and buttocks.
Low
Back
Pain
Symptom of low Back
pain-
2. Symptoms of nerve-root pressure-
Leg pain-which is acute or chronic, mild to severe,
sharp, burning or shooting in nature and this pain
extends up to the ankle or foot . It may be constant
or come and go and it is worsed by sneezing,
coughing, straining, breath holding, walking or rest
and during micturition and defaecation. This pain
also depends on various position of patient such as
forward or backward flexion.
This is referred as Sciatica. (along the distribution of
sciatic nerve)
Low
Back Pain
Symptom of low Back
pain-
• Sensory root involvement : pain,
paraesthesia,
• Motor root involvement : muscle weakness,
paresis (loss of power) of muscle, muscle
wasting.
• Autonomic root involvement : Loss of
bladder and bowel control known as
caudaequina syndrome which requires
immediate medical or surgical intervention. .
Low
Back Symptom of low Back pain-
Pain

Symptoms due to arthritis of spine

Pain and stiffness that are confined to the
back and hip region. This pain starts
gradually and lasts longer than 3 to 6
months.
It is generally worse in the morning or after
prolonged periods of inactivity. Arthritis pain
gets better after some physical activities.
Low
Back Pain
Symptom of low Back
pain-
Symptoms or conditions that may occur
with low back pain and require
additional evaluation and treatment
include:
• Depression
• Unexplained weight loss.
• Fever.
• A history of cancer.
• Bladder or bowel problems.
• An illness or condition that affects the immune system,
such as diabetes, chemotherapy for cancer treatment, 
HIV (AIDS), or an organ transplant.
Low
Back
Pain
Risk factors of
low back pain-
Risk factors that Pt cannot change-

• Being middle-aged or older.

• Being male.
• Having a family history of back pain.
• Having had a previous back injury.
• Having had a previous back surgery.
• Being pregnant.
• Having had compression fractures of the spine.
• Having spine problem from birth(congenital)
Low
Back
Pain Risk factors of low back
pain-
Risk factors that Pt can change-
• Not getting regular exercise
• Doing a job or other activity that requires long
periods of sitting, lifting heavy objects, bending or
twisting, repetitive motions, or constant vibration
• Smoking
• Excess body weight
• Having poor posture. 
• Being under stress.
• Having long periods of depression.
• Using medicines long-term that weaken bones,
such as corticosteroids.
Low
Back
Pain
Diagnosis of low Back
pain-
• History
– Medical
– Psychosocial
– Family
– Previous trials
• General examination
– Musculoskeletal
– Neurologic
Low
Back Pain
Diagnosis of low
Back pain-
Pain assessment:
• Description
• Duration
• Intensity
• Alleviating factors
• Aggravating factors
Low
Back Pain
Diagnosis
of low Back pain-
• Neurologic exam
– Gait. Motor, sensory and reflexes
• Regional exam of spine and leg
– Inspection for scoliosis or skin
rash, palpation for bone
tenderness
• Sciatic- and femoral-nerve stretching
tests
– SLR, reverse and contra lateral
SLR
Low
Back Pain Diagnosis
of low Back pain-
• Strength tests:
• L1,L2-Hip flexion (Psoas,Rectusfemoris)
• L2,3,4-Knee extension (Quadratusfemoris)
• L2,3,4-Hip adductors (adductors and
gracilis)
• L5 --- Ankle/toe dorsiflexion(ant.tibialis,EHL)
• L5---Hip abductors (Glutiusmedius,TFL)
• S1—Ankle plantarflexion(soleus/gastroc.)
• S1---Hip extensors
(Glutiusmaximus,Hamsrting)
Low
Back Pain Diagnosis
of low Back pain-
Reflexes:
• L2,3,4-Quadratus femoris
• L5—Medial hamstring
• S1—Achilles
Sensation
• Pin prick-primarily spinothalamic
tract
• Vibration/position sense-Dorsal
columns Vibration tested with
256cps forkPosition on 3-4th digit
Low Diagnosis
Back Pain of low Back pain-
• Guideline for imaging
• 50 years of age.
• congenital spine problems
• The history and physical exam reveal signs of a
serious problem, such as( a fracture, tumor, infection,
or damage or pressure on nerves.)
• History of arthritis in spine.
• History of a previous spine injury or back surgery.
• History of long-term steroid use or a history of drug
abuse.
• Back pain > 4WKS
Symptoms are worse.
• Several episodes of severe pain.
• Considering surgery.
Low
Back Pain Diagnosis of low back
pain by imaging-

Type of imaging
• Lumbosacral x-ray studies with
flexion/ extension/oblique views
• MRI of the spine
• CT with 3-D reconstruction
• CT plus myelography
Differential Diagnosis
of low Back pain-
Low
Diagnosis of
Back Pain low Back pain-
Low
Back Pain
Diagnosis of
low Back pain-
MRI of the spine if patient
demonstrates
• “Red flags”
• Neurologic deficits or progressive
neurologic signs and symptoms
• Pain persisting more than 6 wk
Low
Back
Pain Management of low
Back pain-
General considerations
• Primary therapy related to etiology
• Patient expectations
• Patient education related to pain
treatment
• Pain treatment cost-effectiveness
• Prevention of back pain exacerbations
• Prevention of unnecessary surgery and
suffering (failed-back-surgery syndrome)
Low
Back Pain Management of low
Back pain-

• Pharmacologic agents
– Opioid analgesics
– Anti-inflammatories
– Adjuvants and nonopioid
analgesics
• Nonpharmacologic therapies
– Rehabilitative
– Interventional/surgical
Low
Back Management
Pain
of low Back pain-
Non opioid adjuvant analgesics
• Antidepressants
– TCAs (nortriptyline, amitriptyline,
desipramine)
– SSRIs (paroxetine, sertraline,
fluoxetine)
– Venlafaxine
• Alpha 2-adrenergic agonists
– Tizanidine, clonidine
Low
Back
Pain Management of low
Back pain-
• Comprehensive
assessment of patients is
essential to form the
appropriate treatment
plan.
• In the majority of cases,
pharmacologic treatment
Low
Back Management of low
Pain
Back pain-
• Overall, 90% of patients will
recover within 2 months without
need for any invasive procedure.
• The management of acute back
pain without sciatica or neurologic
deficits calls for a conservative
approach with analgesics and no
bed rest.
Low Management
Back of low Back pain-
Pain
• With sciatica and no neurologic deficits
– Conservative management with analgesics
– Bed rest for 2–3 d
– Activities as tolerated
– Neurologic consultation as needed
• With sciatica and positive neurologic
deficit
– Individualized length of rest
– Analgesics
– MRI study plus urgent neurologic or
emergent neurosurgical evaluation, according
to progression of deficits and symptoms
Low
Back Management of low
Pain Back pain-
Interventional/Surgical
• Disctectomy
• Decompression (laminectomy,
foraminotomy)
• Spinal stabilization
• Vertebroplasty
• Injections
Epidural procedures
Z- joints block
Medial branch block
Low
Back Management of low
Pain Back pain-
Who needs Surgery-

• Unstable spin
• Acute fracture with neurological deficit
• Severe stenosis
• After failure of aggressive non-
operative Rx
• Tomour
• Progressive neurological deficit.
Low
Back Pain Management
of low Back pain-
Rehabilitative therapy-
• Exercises for strength and
flexibility
• Weight-control management
• Behavioral relaxation
techniques
• Alternative medicine and
physiatric modalities
Low
Back Pain Prevention of low
back pain-
• Exercise 
• Protect your back while sitting.
• Try different sleeping position
• Wear low-heeled shoes.
• Maintain body weight.
• Avoid  Smoking –which  increases
osteoporosis
• Eat a nutritious diet. Getting plenty of 
calcium, phosphorus, and vitamin D may
help prevent osteoporosis.
• Manage the stress in life
 Indication Of
Low
Referral
Back Pain To A Specialist-
Low
Back Pain