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Low Back Pain - 1-07
Low Back Pain - 1-07
Low Back Pain - 1-07
2. Spinal cord
3. Conus medullaris
4. Intervertebral disc
5. Filum terminale
(internum)
6. Subarachnoid
space
Sagittal Section through the
Spinal Cord
1. Intervertebral disc
2. Vertebral body
3. Dura mater
4. Extradural or epidural
space
5. Spinal cord
6. Subarachnoid space
Lumbrosacral Dermatones
Common Pathoanatomical Conditions of the Lumbar Spine
Disc Herniation – Physiology
• Tears in the annulus
• Herniation of nucleus
pulposus
Disc Herniation – Physiology
• Compression of the
nerve root in the
foramen leads to pain
Lumbar Disc Herniation –
Treatment
Conservative Tx. Surgical Tx.
– Moderate bed rest • “Microdiscectomy”
– Spinal manipulation • Less than half of an
inch incision
– Physical therapy
• Go home the same or
– Medication next day
• NSAIDs • Good results in up to
• Muscle relaxants 90% of cases
• Rarely narcotics
Results of Surgical Treatment
• Good outcome in 80-90% of cases
• Residual pain may last up to 6 months postop
• Results are worse if pain was present for over 8
months before the operation (permanent nerve
damage?)
Low Back Pain
• Second most common
cause of missed work
days
• Leading cause of disability
between ages of 19-45
• Number one impairment in
occupational injuries
Low Back Pain
• Most episodes of LBP are self
limited
• These episodes become more
frequent with age
• LBP is usually due to repeated
stress on the lumbar spine over
many years (“degeneration”),
although an acute injury may
cause the initiation of pain
Disc Degeneration – Physiology
• With age and
repeated efforts,
the lower lumbar
discs lose their
height and water
content (“bone on
bone”)
• Abnormal motion
between the bones
leads to pain
Disc Degeneration – Treatment
Conservative Tx. Surgical Tx.
– Moderate bed rest • Lumbar fusion
– Spinal manipulation OR
– Physical therapy • Replacement with
artificial disc
– Medication
• NSAIDs
• Muscle relaxants
• Rarely narcotics
Indications for Surgical
Treatment
• Low back pain for at least 2 years
• Incapacitating
• Resistant to physical therapy and medication
• Positive MRI findings (degenerative changes) at
L4-5 and/or L5-S1
• For selected cases:
• Concordant pain on discography
• Psychological evaluation
Natural History
• Failure to Improve
• Hx of Trauma
• Sciatica
-herniated disk
-foramenal or spinal stenosis
-ligamentous hypertrophy
-other space filling lesions: cysts, tumor, abscess
-viral or immune inflammation
-can occur w/ peripheral nerve involvement
• Spinal stenosis
-neurogenic claudication (pseudo claudication)
1 or both legs
-radiation to buttocks, thighs, lower legs
-pain increase with extension (standing, walking)
-pain decrease with flexion (sitting, stooping forward)
Indications for Surgical Referral
Therapy: Non-specific LBP
• NSAIDS
• Muscle relaxants
• Use on schedule than p.r.n.
• Spinal manipulation/ P.T. (effects limited)
• Delay referral until pain persists >3 weeks
– 50% will improve b/f this time period
• Rapid return to normal activities
• Avoid heavy lifting, trunk twisting, vibrations
• Alternative Tx: acupuncture and massage
• Surgery- ineffective unless:
– sciatica, pseudoclaudication, spondylolisthesis
Therapy: Herniated Disks
• If no evidence cauda equina or progressive
neurologic defecit:
– Treat non-surgically minimum one month
– Treat similar to non-specific LBP
– Limited narcotics
– Epidural steroids (helps in some)
• If severe pain or neuro defecits persist:
– CT/ MRI / consider for surgery
• Diskectomy
– Improved relief vs. non-surgery at 4 yrs./ ? 10yrs.
– Percutaneous and laser less effective than std.
– Arhroscopic techniques techniques comparable to
std. surgery
Therapy: Spinal Stenosis
• Conservative management may be useful
• For severe persistant pain decompressive
laminectomy
• Surgery – better pain relief and functional
recovery
• 30% recurrent severe pain in 4 years
– 10% reoperated
Therapy: Chronic LBP
• Sx often difficult to explain
• Intensive exercises help (hard to maintain)
• Anti-depressant therapy useful if
depressed
• Long term opioids – not recommended
• Referral to pain center
• Massage therapy is promising
• Therapeutic goals – optimize daily function
Long Term Outcomes