LOW BACK PAIN

Aldy S. Rambe
Department of Neurology
University of Sumatera
Utara, School of Medicine
What is LBP

 Low back pain is a common disorder affecting millions of individuals

annually.
 Back pain is the single most common cause for lost workdays in the
United States and one of the most common reasons for patients to visit
their primary care physician.
 It is estimated that approximately 50 to 80% of the adult population
suffers from a memorable episode of low back pain each year.
 In the vast majority of cases no specific diagnosis is made and the
symptoms resolve spontaneously. Only a minority of patients present
with symptoms specific to an irritated nerve root or have identifiable
pathology on radiographic studies.
 The overall prognosis of low back pain is good, with improvement
occurring in the majority of cases without aggressive medical
intervention.
ANATOMY
ANATOMY
CLASSIFICATION

ACCORDING TO ITS DURATION, LBP IS

DIVIDED INTO :
ACUTE : < 2-8 WEEKS
SUBACUTE : 2-8 WEEKS – 12 WEEKS
CHRONIC : > 12 WEEKS
 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
LBP in pregnancy
 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
 RADICULOPATHY

ESSENTIALS of DIAGNOSIS :
 Pain in a dermatomal distribution, sensory symptoms along
the same dermatome, weakness in a corresponding
myotomal distribution, and absent or depressed reflexes.
 Frequency of incidence in order of occurrence :
lumbar > cervical > thoracic
 Usually caused by a herniated disk or by spondylosis;
other causes are infection, neoplasm, granuloma, cyst, and
hematoma
Lumbar disc prolaps
 The earliest change in the NP and AF are probably biochemical and
may be part of aging
 Superimposed trauma accelerates these degenerative changes
 The laters of the AF separate and form circumferential tear, leads to
radial tears.
 NP may extrude producing disc herniation or prolaps
 Multiple tears produce weakening and circumferential bulging of the
AF with loss of disc height

Further disc narrowing results from aging of the NP, which changes
from gelatinous consistency int the childhood to a fibrotic
consistency in adulthood
The disk
Herniated disc
Distribution

 Lumbar disc prolaps (most common)

L5-S1 (45-50%), L4-5 (40-45%)
 Cervical disc prolaps
C6-7 (69%), C5-6 (19%)
 Thoracal disc prolaps (infrequent, < 1%)
Lumbar Disc Prolaps : 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 :
* severe LBP and lumbar paraspinal spasms,
with pain radiating to the buttocks, legs, and feet
(radicular pain)
* abnormal vertebral posture
* paresthesia, parese, diminished tendon
reflexes
* pain, sensory loss and weakness typically occur in
a radicular pattern.
* urinary symptoms, if present, reqquire immediate
attention
Ischialgia (sciatic)
Clinical symptoms
 Cervical HNP :
* pain present in the posterior neck, with spasm of
the cervical paraspinal musculature and near or
over the shoulder blades on the affected side.
* radicular pain, aggravated by neck extension,
coughing, straining, laughing, bending, or turning
the neck to the side; and reduced by abducting the
arm and put it behing the head
* paresthesia, parese, diminished tendon reflexes
Diagnosis : Neurological examination

Lumbar HNP :
* Lasegue (straight leg raising) test.
A positive SLR test is a sensitive indicator of nerve
root irritation (sensitivity 95%).,
May be positive with disc protrussion, intraspinal
tumor or inflammatory radiculopathy
* Crossed Laseque (crossed SLR) test.
Less sensitive but highly specific.
* Femoral stretch (reverse SLR) test.
May detect an L2-4 root or femoral nerve irritation.
Diagnosis : Neurological examination

Cervical HNP :
* Lhermitte’s sign
A painless but unpleasant tingling or electric shock- like
sensation in the back and spreading instantaneously down the
arms and legs following neck flexion (active or passive)
* Spurling’s sign
Increase in arm pain (brachialgia) associated with compressive
cervical radiculopathy following neck rotation and flexion to the
side of pain.
* Shoulder abduction test
Diagnosis

RADIOLOGICAL EXAMINATION :
 Plain vertebral x-rays :
* limited information
* disc narrowing, scoliosis, lordosis lumbal
 Myelography
 CT or CT-myelography
 MRI : the best imaging study

EMG/NCV : 90% abnormal after 1-2 weeks

MRI scan shows L4-5 herniated disc
Therapy : Conservative

* bed rest : max 2 days recommended

* Pharmacotherapy :
- NSAID
- short course of corticosteroid for acute herniated
disc (controversial)
- muscle relaxant
- for neuropathic pain : gabapentin, 5% lidocaine
patch, tramadol, TCA.
* Nonpharmacologic therapy :
- heat, ice, massage, stress reduction, activity limitation,
postural modification, physical therapy program
- soft cervical collar or lumbar corset
Therapy :Operative

The few absolute indications :

1. Marked muscular weakness pertaining to a nerve
root or roots.
2. Progressive neurologic deficits.
3. Cauda equina syndrome with urinary symptoms
4. Pain that has existed for more than 4 months, has
not responded to conservative treatment, and
interferes with normal function.
 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. Severe and disabling pain (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 and bowel, or sexual function.
4. Poor response to at least 4 weeks of conservative
treatment
THANK YOU