LOW BACK PAIN

I.

DEFINISI

Low back pain is neither a disease nor a diagnostic entity of any sort. The term refers to pain
of variable duration in an area of the anatomy afflicted so often that it is has become a
paradigm of responses to external and internal stimuli for example, Oh, my aching back is
an expression used to mean that a person is troubled. Low back pain is a leading cause of
disability. It occurs in similar proportions in all cultures, interferes with quality of life
and work performance, and is the most common reason for medical consultations. Few cases
of back pain are due to specific causes; most cases are non-specific. Acute back pain is the
most common presentation and is usually self-limiting, lasting less than three months
regardless of treatment. Chronic back pain is a more difficult problem, which often has strong
psychological overlay:
work dissatisfaction, boredom, and a generous compensation system contribute to it.Nyeri
punggung bawah bukan penyakit atau diagnosis. Istilah ini mengacu pada nyeri pada daerah
anatomi yang bersangkutan sebagai respon terhadap rangsangan eksternal dan internal. Nyeri
punggung bawah adalah penyebab utama kecacatan. Hal ini terjadi dalam jumlah yang sama di
semua budaya, mengganggu kualitas hidup dan prestasi kerja. Beberapa kasus nyeri punggung
tidak spesifik. Nyeri punggung akut yang paling umum, berlangsung kurang dari tiga bulan
tanpa pengobatan. Nyeri punggung kronis adalah masalah yang lebih sulit, yang sering
berhubungan dengan psikologis yang kuat.
Ehrlich GE. Low back pain. Bulletin of the World Health Organization 2003; 81 (9):6716.
It is generally acknowledged that most patients with low back pain (LBP) are without a
specific medical diagnosis due to the lack of an identified pathology that matches the patients
symptomsMaluf, Sahrmann and Van Dillen (2000) have developed a classification system
comprising five categories based on assessment of muscular stability, alignment, asymmetry,
and
flexibility of the lumbar spine, pelvis, and hip joints. The recording of movements and
activities in daily functioning that provoke the patients familiar symptoms is of particular
interest in the system. Secara umum nyeri punggung bawah (LBP) bukan diagnosa medis
karena kurangnya identifikasi patologi yang cocok dengan gejala dan tanda pada pasien.
Maluf, Sahrmann dan Van Dillen (2000) telah mengembangkan sistem klasifikasi yang terdiri
lima kategori berdasarkan penilaian stabilitas otot, asimetri, dan fleksibilitas tulang belakang
lumbar, panggul, dan sendi pinggul. Gerakan dan kegiatan yang dilakukan sehari-hari yang
menyebabkan gejala yang sama pada pasien.

Petersen T, M. Laslett, H. Thorsen, C. Manniche, C. Ekdahl, S. Jacobsen. Diagnostic

classification of non-specific low back pain. A new system integrating patho-anatomic
and clinical categories. Physiotherapy Theory and Practice 2003; 19: 213-237.
low back pain (LBP) is posterior trunk pain between the ribcage and the gluteal folds. It also
includes lower extremity pain that results from a low back disorder (sciatica/radiating low
back pain), whether there is trunk pain or not. Sciatica is radiating, lower extremity pain and
may not be associated with back pain. Sciatica should be distinguished from axial low back
pain.
a.
b.
c.
d.

Acute LBP: Back pain <6 weeks duration

Subacute LBP: Back pain >6 weeks but <3 months duration
Chronic LBP: Back pain disabling the patient from some life activity >3 months
Recurrent LBP: Acute LBP in a patient who has had previous episodes of LBP from a
similar location, with asymptomatic intervening intervals.

low back pain (LBP) adalah nyeri punggung belakang antara tulang rusuk dan lipatan glutealis,
termasuk nyeri ekstremitas bawah dari penyakit punggung bawah (nyeri punggung bawah
yang menyebar),disertai nyeri punggung atau tidak.nyeri yang menyebar, nyeri tungkai bawah
juga dapat tidak berhubungan dengan nyeri punggung. Nyeri punggung harus dibedakan:
a. akut LBP: nyeri punggung kurang dari 6 minggu
b. subakut LBP: nyeri punggung lebih dari 6 minggu, kurang dari 3 bulan
c. kronis LBP: nyeri punggung membatasi pasien dari beberapa aktivitas kehidupan
berlangsung lebih dari 3 bulan
d. LBP Berulang: LBP akut pada pasien yang telah memiliki episode sebelumnya dan
LBP dari lokasi yang sama, dengan interval intervensi tanpa gejala.
Anthony, chiodo. Acute low back pain. UMHS Low Back Pain Guideline Update 2010; 114.
II.

EPIDEMIOLOGI

The one-year point prevalence of low back problems in the U.S. population is 15-20%. Eighty
percent of the population will experience at least one episode of disabling low back pain
during their lifetime. Approximately 40% of persons initially seek help from a primary care
physician, 40% from a chiropractor, and 20% from a subspecialist. Acute LBP is the second
most common symptomatic reason for office visits to primary care physicians, and the most
common reason for office visits to orthopedic surgeons, neurosurgeons, and occupational
medicine physicians. Recurrence of LBP is common, 60-80% of patients experience
recurrence within two years. Prevalensi satu tahun nyeri punggung bawah dalam populasi AS
adalah 15-20%. Delapan puluh persen dari populasi akan mengalami minimal satu episode
kelumpuhan dari nyeri punggung selama hidup mereka. Sekitar 40% dari orang awalnya
mencari bantuan dari seorang dokter layanan primer, 40% dari chiropractor, dan 20% dari

subspecialist. Kambuhnya LBP umum terjadi, 60-80% pasien mengalami kekambuhan dalam
waktu dua tahun.
Anthony, chiodo. Acute low back pain. UMHS Low Back Pain Guideline Update 2010; 114.
a national survey to identify the most common symptoms complained of bythe public revealed
low back pain to be the most common complaint, with a rate of 93 persons per 1,000
population, and among persons 65 years of age and older, the rate was 201 persons per 1,000.
Although we tend to think of poor vision, forgetfulness, etc., as becoming the most common
symptoms as people grow older, the elderly actually complain of low back pain about twice as
much as these other symptoms.2) Thus, low back pain troubles many people in all decades of
life, and they are hoping for a life
free of low back pain. survei nasional untuk mengidentifikasi gejala yang paling umum
dikeluhkan oleh masyarakat mengungkapkan nyeri pinggang menjadi keluhan umum, dengan
93 orang per 1.000 penduduk, dan di antaranya 65 tahun dan lebih tua, rata-rata adalah 201
orang per 1.000.
Yasufumi H. Classification, Diagnosis, and Treatment of Low Back Pain. JMAJ 2004;
47(5): 227233.
In a recent health survey of the New Zealand population, 16.9% of participants reported that
chronic pain affected their lives and 47.5% of those with chronic pain nominated the back or
neck as a site of pain symptoms. Dalam sebuah survei kesehatan terbaru dari populasi Selandia
Baru, 16,9% dari populasi melaporkan bahwa nyeri kronis mempengaruhi kehidupan mereka
dan 47,5% dari orang-orang dengan nyeri kronis terletak di belakang atau leher sebagai
penyebab gejala nyeri.
Chris DG1 Greg M, Hamilton H. Prognostic factors associated with low back pain
outcomes. J PRIM HEALTH CARE 2014;6(1):2330.
backache is a remarkably common condition, hardly if ever one will not get some sort of back
pain in his life. It is estimated that 60-90% of the adult population have experienced low back
pain. 2-5% affected on a yearly basis, 10-20% of female manifested back pain during
menstrual period. sakit punggung adalah kondisi yang sangat umum. Diperkirakan 60-90%
dari populasi orang dewasa mengalami nyeri punggung. 2-5% didapatkan tahunan, 10-20%
dari wanita nyeri punggung terjadi selama periode menstruasi.
Hamdan TA, Mubdir AMS. NON-SPONDYLOGENIC LOW BACK PAIN. Bas J Surg,
September 2002;8:150-8.

III.

PATOFIOLOGI

1. Low back pain caused by trauma

Acute muscular low back pain (sprained back) occurs when exposure to an external
force, such as in a collision with a person or while lifting a heavy object, damages muscles and
fascia, while lumbar intervertebral disc herniation occurs when an intervertebral disc collapses
and compresses nerves anteriorly, and traumatic vertebral body fractures occur when a
vertebral body collapses as a result of a fall, etc. Chronic muscular low back pain develops
when repetitive muscle use is performed over and over again, and fragile vertebral body
fractures associated with osteoporosis occur when bone fragility progresses and bones collapse
even in the absence of exposure to major external force.
2. Low back pain caused by inflammation
Tuberculous spondylitis or purulent spondylitis develops when tubercle bacilli or pyogenic
bacteria destroy vertebral bodies or intervertebral discs. If the vertebrae are connected like
bamboo, the patient has ankylosing spondylitis, a rheumatic disease that is negative for
rheumatoid factor.
3. Low back pain caused by tumors
Malignant tumors, such as lung cancer, stomach cancer, breast cancer, prostate cancer, etc.,
sometimes metastasize to the lumbar spine, and disseminated metastasis to the lumbar spine is
one of the pathological pictures of multiple myeloma. When tumors such as neuromas or
angiomas develop in the lumbar cord or lumbar spine, patients experience intense low back
pain.
4. Low back pain caused by degeneration

As construction workers advance in age, their incidence of low back pain increases, and the
increases are attributable to the development of lesions associated with degeneration of the
lumbar spine and surrounding tissues. Degeneration leads to the development of spondylosis
deformans, lumbar intervertebral disc degeneration, intervertebral articular low back pain,
lumbar non-spondylolytic spondylolisthesis, ankylosing spinal hyperostosis, and lumbar spinal
stenosis.
5. Low back pain due to other causes
In addition to diseases that arise in the structures that compose the lower back, which is the
pivot of the body, pain arising from diseases of intra-abdominal organs, including the liver,
gallbladder, and pancreas, and referred pain are also seen among the diseases that give rise to
low back pain. Pain also arises from posterior abdominal organs, including the uterus, ovaries,
and urine bladder. The existence of psychogenic pain associated with hysteria and depression
must also not be forgotten.
1. LBP yang disebabkan oleh trauma
Nyeri otot pada LBP (terkilir yang mengenai punggung) terjadi ketika paparan kekuatan
eksternal, seperti tabrakan dengan seseorang atau mengangkat benda berat, kerusakan otot dan
fasia, sedangkan herniasi disc intervertebralis lumbal terjadi ketika disk intervertebralis rusak
dan menekan saraf anterior, traumatis vertebral terjadi ketika kolumna vertebral kolaps, nyeri
punggung kronis terjadi ketika penggerakan otot berulang dilakukan dan berlebihan, dan
fraktur kolumna vertebral berhubungan dengan osteoporosis terjadi ketika kerapuhan tulang
menyebabkan fraktur bahkan tanpa adanya paparan utama atau kekuatan eksternal.
2. LBP yang disebabkan oleh peradangan
Spondilitis tuberkulosis atau purulen spondylitis terjadi ketika basil tuberkulosis atau piogenik
bakteri merusak kolumna vertebral atau intervertebralis. Jika tulang belakang terhubung
seperti bambu, pasien bisa mengalami ankylosing spondylitis, penyakit rematik yang faktor
rematoidnya negatif
3. LBP yang disebabkan oleh tumor
Tumor ganas, seperti kanker paru-paru, kanker lambung, kanker payudara, kanker prostat, dll,
kadang-kadang bermetastasis ke tulang belakang lumbar, dan metastasis disebarluaskan ke
tulang belakang lumbar adalah salah satu gambar patologis beberapa myeloma. Ketika tumor
seperti neuromas atau angioma berkembang di lumbal cord atau lumbar spine, pasien
mengalami nyeri punggung menetap.
4. LBP yang disebabkan oleh degenerasi
Sebagai pekerja konstruksi pada usia tua, Insiden nyeri punggung mereka
meningkat, disebabkan lesi yang berhubungan dengan degenerasi tulang belakang lumbar dan
jaringan sekitarnya. Degenerasi mengarah ke perkembangan spondylosis deformans,

degenerasi intervertebral disc lumbar, LBP intervertebralis artikular, spondylolisthesis lumbar

non-spondylolytic, hyperostosis ankylosing tulang belakang, dan stenosis lumbar.
5. LBP karena penyebab lain
Selain penyakit yang timbul dalam struktur yang membentuk punggung bawah, yang
merupakan poros tubuh, nyeri yang timbul dari penyakit organ intra-abdominal, termasuk hati,
kandung empedu, dan pankreas, dan disebut nyeri juga terlihat di antara penyakit yang
menimbulkan nyeri punggung bawah. Nyeri juga timbul dari posterior organ perut, termasuk
rahim, ovarium, dan kandung kemih. Adanya nyeri psikogenik terkait dengan histeria dan
depresi harus juga termasuk disini.
Yasufumi H. Classification, Diagnosis, and Treatment of Low Back Pain. JMAJ 2004;
47(5): 227233.
Precise identification of the underlying cause of back pain is very vital for the
eradication of pain, this can be achieved by the combination of identifying the pathological
process (like inflammatory, neoplastic, degenerative, metabolic, traumatic, infective) and the
anatomical structure involved (like myopathic, neuropathic, osteopathic, arthropathic, or
ligomentopathic). We can reach this goal by getting a proper history, and physical examination
followed by perfect investigation. However, there are many classifications for low back pain,
for example, Macnab 2 classify low back pain into: Viscerogenic, Neurogenic, Spondylogenic
and Psychogenic back pain.
Jayson classify back pain into3,4:
A) Primary back pain which include: i) cutaneous and subcutaneous, ii)myo-fascial (muscle
and fascia) both may be affected by trauma, spasm, fatigue and inflammation. iii) articular and
ligamen-tous, which include: Apophyseal and sacroiliac joints and Spinal ligaments. iv)
osseous (vertebral and sacral), which include: Intervertebral and Periosteal. v)vascular and
vi)Dural
B)Secondary backache which is either due to compressive or degenerative lesions
C)Referred backache from: gyneco-logical, urinary tract, prostate and appendix
D)Psychosomatic backache: depression and anxiety, hysteria and malinge-ring.
Mennell 5 mentioned that back pain may arise from local pain, referred pain (pain referred to
the spine and pain of spine origin referred to the leg or buttocks), radicular pain and muscular
spasm.
Finneson6 gave a detailed list of causes of low back pain but without classifcation.
However, it is very difficult to gather the vast numbers of causes of low back pain under one
umbrella.

We suggest the following classification for low back pain, because we feel it is easy to
remember and cover to some extent a wide range of causes. Back pain may arise from
spondylogenic, non-spondylogenic and non-specific causes.
A-Spondylogenic causes
Spondylogenic back pain may be defined as: pain derived from the spinal column and its
associated structure. The pain is aggravated by general and specific activities and is relieved to
some extent, by recumbency. In spondylo-genic pain, the diagnosis may be reached by history
of spine problem like degene-rative changes, previous similar condi-tion or trauma to the
spine.
The pain is usually severe, and acute in nature, well localised, improve to some extent by rest
and get worse by exercise and activity, that puts the spine in action. There may be associated
tender spot in the back, and the associated radiculo-pathy support this diagnosis. Investigations usually prove that the pathological process is located in the spinal column or its related
structure.
The pain may be derived from lesions involving the bony components of the spinal
column, from changes in sacroiliac joints, or most commonly, from changes occurring in the
soft tissues 7.
Spondylogenic lesions constitute the most common source of low back pain seen in
clinical practice. The patho-logical changes are usually due to: trauma, infection, neoplastic,
metabolic, congenital anomalies and degenerative causes.
Pain of spine origin may be referred to the buttocks and legs. Disease affecting the upper
lumbar spine may refer pain to the lumbar region, or anterior thigh, while disease affecting the
lower lumbar spine may result in pain referred to the buttocks, posterior thighs or rarely the
calves or feet.
Classic radicular pain is usually sharp and radiates from the spine to the leg within the
territory of a nerve root. Coughing, sneezing or voluntary contra-ction of abdominal muscles
(lifting heavy objects or straining at stool) often elicits radiating pain.
The pain associated with muscle spasm, although of obscure origin, is commonly associated
with many spine disorders.
Spondyloginc back pain result usually from mechanical or chemical irritation of the
nociceptive receptor nerve end-ings embedded in the various lumbo-sacral tissues. In this
situation, then, the pain is experienced by the patient, with varying degree of precision, in
those tissue within which the pathological disturbance, whether mechanical or chemical or
both, is operating; and within this category further subdivision is possible in terms of the
particular

tissues containing the irritated nocicep-tive nerve ending.

B-Non-Spndylogenic low back pain
The origin of pain is usually located outside the anatomical structure of the spinal column and
its related structure. The pain is either referred to the back and there are no structured changes
in the anatomy of the back or there is some sort of changes in the anatomical structure of the
back which is usually secondary or compensatory changes. Also the back may be involved by
a systemic process that involves almost every part of the body, which is usually associated
with some established anatomical and pathological changes in the back structures.
The patient describes, feels, and believes that the pain is located in his back, and on so
many occasions it is not easy to change this feeling.
The pain is usually dull aching in nature, located in one side of the back, usually not very
severe, and poorly localised. Rarely it is sudden and excru-ciating and spread to the buttocks
and legs as in dissecting aneurysm of the aorta.
Usually there is no history suggestive of spinal disorder but history of the underlying
condition, other characteris-tics of the pain may provide clue to its origin: for example,
backache due to peptic ulcer may be induced after ingestion of an orange, alcohol or coffee
and relieved by food and antacids. Fatty foods are more likely to induce back pain associated
with biliory disease. Malposition of the uterus may lead to sacral pain after standing for
several hours. There are no abnormal physical findings in the back unless there is secondary
structural changes. There may be some singe or symptoms related to the underlying
pathology like urinary, gastero intestinal, gynecological or vas-cular manifestations.
On some occasions the pathological process is obviously manifested outside the
spinal column and investigation usually prove that the lesion is primarily non-spondylogenic
in origin. Constitu-tional and systemic disturbance usually supports the diagnosis of nonspondylo-genic back pain.
Non-spondylogenic back pain may be the first obvious presentation of a hidden flame,
like a retroperitoneal sarcoma or a retroverted uterus, and usually improve after treating the
suspected non-spody-logenic pathology.
The pain arises usually from tissue or organ whose innervation is segmentally related to that
of the superficial tissues of the lumbosacral region, and this variety constitutes referred
backache with no structural changes in the back.
So, non-spondylogenic back pain can be classified into two categories: A- Non
spondylogenic back pain without structural changes in the back which consist of referred pain
and psychosomatico disorders. B- Non-spondylogenic back pain with secondary structured

changes in the spinal column or its related structure which may arise because of a systemic
disease or a localised pathology away from the spine.
C-Non-specific causes of low back pain
This term covers a residual groups in whom no clear diagnosis could be made despite a
thorough clinical evaluation and investigation, but some of them at a later follow up can be
include into the spondylogenic or non-spondylogenic low back pain.
Identifikasi penyebab nyeri punggung sangat penting untuk pemberantasan nyeri, ini dapat
dicapai dengan kombinasi mengidentifikasi proses patologis (seperti peradangan, neoplastik,
degeneratif, metabolik, trauma, infeksi) dan struktur anatomi yang terlibat ( seperti miopati,
neuropati, osteopathic, arthropathic, atau ligomentopathic). Kita dapat mencapai tujuan ini
dengan mendapatkan anamnesa yang tepat, dan pemeriksaan fisik diikuti dengan investigasi
yang sempurna. Namun, ada banyak klasifikasi untuk nyeri punggung bawah, misalnya,
Macnab

yang

mengklasifikasikan

nyeri

punggung

ke:

Viscerogenik,

neurogenik,

Spondylogenic dan psikogenik. Jayson mengklasifikasikan:

A) nyeri punggung Primer yang meliputi: i) kulit dan subkutan, ii) myofasia (otot dan fasia)
keduanya dapat dipengaruhi oleh trauma, kejang, kelelahan dan peradangan. iii) artikular dan
ligamen, yang meliputi: Apophyseal dan sendi sacroiliac dan ligamen tulang belakang. iv)
tulang (vertebra dan sakral), yang meliputi: intervertebralis dan Periosteal. v) pembuluh darah
dan vi) Dural
B) nyeri punggung sekunder karena lesi tekan atau degeneratif
C)nyeri punggung yang menyebar: gynecologis, saluran kemih, prostat dan usus buntu
D) nyeri punggung psikosomatik: depresi dan kecemasan, histeria.
Mennell

menyebutkan nyeri punggung mungkin timbul dari rasa nyeri

lokal, nyeri

menyebar (nyeri menyebar ke tulang belakang dan nyeri berasal dari tulang belakang
menyebar ke kaki atau bokong), nyeri radikuler dan kejang otot.
Nyeri punggung mungkin timbul dari spondylogenik, non spondylogenic dan non-spesifik.
a. Spondylogenic
Nyeri punggung Spondylogenic dapat didefinisikan sebagai: nyeri berasal dari tulang
belakang dan struktur yang terkait. Diagnosis dapat dicapai denganadanya riwayat masalah
tulang belakang seperti perubahan degeneratif, dan kondisi sebelumnya atau trauma pada
tulang belakang. Nyeri mungkin berasal dari lesi yang melibatkan komponen tulang dari
tulang belakang, dari perubahan sendi sacroiliac, atau paling sering dari jaringan lunak. Lesi

Spondylogenic merupakan sumber yang paling umum dari nyeri punggung bawah terlihat
dalam praktek klinis. Perubahan pato-logis biasanya karena: trauma, infeksi, neoplasma,
metabolik, kelainan kongenital dan penyebab degeneratif. Nyeri punggung bawah
Spondyloginc biasanya dari iritasi mekanis atau kimia reseptor saraf nociceptif yang berakhir
di jaringan lumbo-sakral.
b. Nyeri punggung bawah Non-Spndylogenik
Asal nyeri biasanya terletak di luar struktur anatomi tulang belakang dan struktur terkait.
Nyeri ini menyebar ke belakang dan tidak ada perubahan terstruktur dalam anatomi tulang
belakang. Tulang belakang mungkin terlibat dengan proses sistemik yang melibatkan hampir
setiap bagian dari tubuh, yang biasanya dikaitkan dengan beberapa perubahan anatomi dan
patologis yang menyebabkan perubahan struktur tulang belakang.
Nyeri biasanya dari jaringan atau organ yang persarafannya

segmental terkait jaringan

superfisial dari daerah lumbosakral, dan jenis ini merupakan nyeri punggung dengan tidak
ada perubahan struktural di tulang belakang. Jadi, nyeri punggung non-spondylogenic dapat
diklasifikasikan ke dalam dua kategori: nyeri punggung Non spondylogenic tanpa perubahan
struktural di tulang belakang yang terdiri dari nyeri yang menyebar dan gangguan
psikosomatik. Nyeri punggung B- Non-spondylogenic dengan perubahan struktur sekunder di
tulang belakang atau struktur terkait yang mungkin timbul karena penyakit sistemik atau
patologi lokal jauh dari tulang belakang.
c. Penyebab nyeri punggung Non-spesifik
Istilah ini mencakup kelompok yang tidak ada diagnosis yang jelas dapat dibuat meskipun
evaluasi klinis dan investigasi, tetapi beberapa dari mereka di kemudian menindaklanjuti
dapat mencakup ke nyeri punggung bawah spondylogenic atau non-spondylogenic.
Hamdan TA, Mubdir AMS. NON-SPONDYLOGENIC LOW BACK PAIN. Bas J Surg,
September 2002;8:150-8.

Langevin HM, Karen JS. Pathophysiological model for chronic low back pain
integrating connective tissue and nervous system mechanisms. Medical Hypotheses
2006;1-7.
IV.

RIWAYAT PENYAKIT

Sciatica is radiating, lower extremity pain and may not be associated with back pain. Sciatica
should be distinguished from axial low back pain.
a.
b.
c.
d.

Acute LBP: Back pain <6 weeks duration

Subacute LBP: Back pain >6 weeks but <3 months duration
Chronic LBP: Back pain disabling the patient from some life activity >3 months
Recurrent LBP: Acute LBP in a patient who has had previous episodes of LBP from a
similar location, with asymptomatic intervening intervals.

Nyeri punggung harus dibedakan:

a. akut LBP: nyeri punggung kurang dari 6 minggu
b. subakut LBP: nyeri punggung lebih dari 6 minggu, kurang dari 3 bulan
c. kronis LBP: nyeri punggung membatasi pasien dari beberapa aktivitas kehidupan
berlangsung lebih dari 3 bulan

d. LBP Berulang: LBP akut pada pasien yang telah memiliki episode sebelumnya dan
LBP dari lokasi yang sama, dengan interval intervensi tanpa gejala.

Anthony, chiodo. Acute low back pain. UMHS Low Back Pain Guideline Update 2010;
1-14.
V.

GEJALA KLINIS

a. Akut LBP
Acute low back pain is common and episodes by defi nition last less than 3 months. In
a few cases there is a serious cause, but generally the pain is non-specifi c and precise
diagnosis is not possible or necessary. If the pain radiates down the leg, below the knee, there
is a greater chance that symptoms are caused by a herniated disc. After an acute episode there
may be persistent or fl uctuating pain for a few weeks or months. Even severe pain that
signifi cantly limits activity at fi rst, tends to improve, although there can be recurring
episodes and occasional pain afterwards. Acute low back pain does not cause prolonged loss
of function unlike chronic back pain.
Nyeri punggung bawah akut adalah umum dan episode kurang dari 3 bulan. Dalam
beberapa kasus ada penyebab yang serius, tetapi umumnya rasa sakit nonspesifik dan
diagnosis yang tepat tidak mungkin atau diperlukan. Jika rasa sakit menjalar ke bawah kaki,

di bawah lutut, ada kemungkinan besar bahwa gejala disebabkan oleh herniasi disc. Setelah
episode akut mungkin menetap atau hilang timbul selama beberapa minggu atau bulan.
Bahkan nyeri bertambah berat sehingga akan membatasi aktivitas pertama kali, cenderung
untuk meningkatkan, meskipun nyeri dapat episode berulang sesekali setelah itu. Nyeri
punggung akut tidak menyebabkan hilangnya Fungsi berkepanjangan tidak seperti nyeri
punggung kronis.
b. Kronik LBP
Chronic back pain is defi ned as pain lasting more than 3 months. It may cause severe
disability. Chronic back pain may be associated with Yellow Flags psychosocial barriers to
recovery. Patients with symptoms lasting more than 8 weeks have a rapidly reducing rate of
return to usual activity. They are likely to experience diffi culties returning to work and suffer
work loss.
Nyeri punggung kronis adalah nyeri yang berlangsung lebih dari 3 bulan. Hal itu
dapat menyebabkan cacat berat. nyeri punggung kronis dapat berhubungan dengan bendera
kuning barier psikososial untuk pemulihan. Pasien dengan gejala yang berlangsung lebih dari
8 minggu sulit kembali ke aktivitas biasa. Mereka mungkin mengalami kesulitan bekerja dan
menderita kerugian pekerjaan.
The New Zealand Acute Low Back Pain Guide (1999 review) and Assessing Yellow Flags
in Acute Low Back Pain: Risk Factors for Longterm Disability and Work Loss 1997.
VI.

DIAGNOSIS
a. Anamnesis
patients awaken with morning pain or develop pain after minor forward bending,

twisting, or lifting. It is also important to note whether it is a first episode or a recurrent

episode. Recurrent episodes usually are more painful with increased symptoms. Red flags are
often used to distinguish a common, benign episode from a more significant problem that
requires urgent workup and treatment (Table 2).5,6,8 A recent study shows that some red
flags are more important than others, and that red flags overall are poor at ruling in more
serious causes of low back pain.8 Patients with back pain in the primary care setting (80
percent) tend to have one or more red flags, but rarely have a serious condition.8 However,
physicians should be aware of the signs and symptoms of cauda equina syndrome, major
intra-abdominal pathology, infections, malignancy, and fractures (Tables 15,6 and 25,6,8).
Cauda equina syndrome and infections require immediate referral. Family physicians should
rely on a comprehensive clinical approach rather than solely on a checklist of red flags.

Pain from spine structures, such as musculature, ligaments, facet joints, and disks, can refer
to the thigh region, but rarely to areas below the knee. Pain related to the sacroiliac joint often
refers to the thigh, but can also radiate below the knee. Irritation, impingement, or
compression of the lumbar root often results in more leg pain than back pain. Pain from the
L1-L3 nerve roots will radiate to the hip and/or thigh, whereas pain from the L4-S1 nerve
roots will radiate below the knee.
b. Pemeriksaan fisik
Neurologic examination of the lower extremities includes strength, sensation, and
reflex testing (Table 3), even in the absence of significant sciatica. A straight leg raise test is
positive for L4-S1 nerve root pain if it radiates below the knee. A reverse straight leg raise
test (extending hip and flexing knee while in the prone position) is positive for L3 nerve root
pain if it radiates into the anterior thigh. A central, paracentral, or lateral disk herniation may
affect different nerve roots at the same level. Examination of the lumbosacral, pelvic, and
abdominal regions may provide clues to underlying abnormalities relating to back pain
a. Anamnesis
pasien terbangun dengan nyeri pagi hari atau munculnya nyeri setelah gerakan maju
membungkuk, memutar, atau mengangkat. Hal ini juga penting untuk dicatat apakah itu
adalah episode pertama atau episode berulang. Episode berulang biasanya lebih menyakitkan
dengan gejala meningkat. Bendera merah sering digunakan untuk membedakan umum,
episode jinak dari masalah yang lebih signifikan yang memerlukan pemeriksaan yang khusus.

Sebuah penelitian baru menunjukkan bahwa beberapa bendera merah yang lebih
penting daripada yang lain, Pasien dengan nyeri punggung pada layanan primer (80 persen)
cenderung memiliki satu atau lebih bendera merah, tapi jarang dengan kondisi serius Namun,
dokter harus menyadari tanda-tanda dan gejala sindrom cauda equina, besar patologi intraabdominal, infeksi, keganasan, dan fraktur tulang.

Sindrom cauda equina dan infeksi

membutuhkan rujukan segera. Dokter keluarga harus bergantung pada pendekatan klinis yang
komprehensif daripada hanya pada daftar bendera merah. Nyeri dari struktur tulang belakang,
seperti otot, ligamen, sendi, dan disk, dapat mengarah ke daerah paha, tapi jarang ke daerahdaerah di bawah lutut. Nyeri yang berhubungan dengan sendi sacroiliac sering merujuk paha,
tetapi juga dapat memancarkan di bawah lutut. Iritasi atau kompresi akar lumbal sering
menyebabkan nyeri kaki lebih dari nyeri punggung. Nyeri dari akar saraf L1-L3 akan
menyebar ke pinggul dan / atau paha, sedangkan rasa sakit dari akar saraf L4-S1 akan
menyebar di bawah lutut.
b. Pemeriksaan fisik
Pemeriksaan neurologis dari ekstremitas bawah meliputi kekuatan, sensasi, dan
pengujian refleks, bahkan tanpa adanya nyeri panggul yang signifikan. Sebuah tes leg raise
(menaikkan kaki) lurus akan positif untuk L4-S1 nyeri akar saraf jika ia menjalar ke bawah

lutut. tes leg raise terbalik (memperpanjang pinggul dan melenturkan lutut sementara di
posisi rawan) akan positif untuk L3 nyeri akar saraf jika ia menjalar ke paha anterior. Sebuah
herniasi disk pusat, paracentral, atau lateral dapat mempengaruhi akar saraf yang berbeda
pada tingkat yang sama. Pemeriksaan daerah lumbosakral, panggul, dan perut dapat
memberikan petunjuk untuk kelainan yang mendasari yang berkaitan dengan nyeri punggung
bawah.

CASAZZA BA. Diagnosis and Treatment of Acute Low Back Pain . American Family
Physician 2011; 85( 4):343-50.

Anthony, chiodo. Acute low back pain. UMHS Low Back Pain Guideline Update 2010;
1-14.
VII.

DIAGNOSIS BANDING

CASAZZA BA. Diagnosis and Treatment of Acute Low Back Pain . American Family
Physician 2011; 85( 4):343-50.

Anthony, chiodo. Acute low back pain. UMHS Low Back Pain Guideline Update 2010;
1-14.
VIII.

PEMERIKSAAN PENUNJANG
If a serious condition is suspected, magnetic resonance imaging (MRI) is usually most

appropriate. Computed tomography is an alternative if MRI is contraindicated or

unavailable.10 Clinical correlation of MRI or computed tomography findings is essential
because the likelihood of false-positive results increases with age.12-14 Radiography may be
helpful to screen for serious conditions, but usually has little diagnostic value because of its
low sensitivity and specificity.10
Laboratory tests such as complete blood count with differential, erythrocyte sedimentation rate, and C-reactive protein level may be beneficial if infection or bone marrow
neoplasm is suspected. These tests may be most sensitive in cases of spinal infection because
lack of fever and a normal complete blood count are common in patients with spinal

infection.15 Because laboratory testing lacks specificity, MRI with and without contrast
media and, in many cases, biopsy are essential for accurate diagnosis
Jika kondisi serius dicurigai, magnetic resonance imaging (MRI) biasanya yang paling tepat.
Computed tomography adalah alternatif jika MRI merupakan kontraindikasi. Radiografi
dapat membantu untuk skrining kondisi serius, tetapi biasanya memiliki nilai diagnostik kecil
karena kepekaan dan specifitas rendah.
Tes laboratorium seperti hitung darah lengkap dengan diferensial, tingkat sedimentasi
eritrosit, dan tingkat protein C-reaktif mungkin bermanfaat jika infeksi atau neoplasma
sumsum tulang dicurigai. Tes-tes ini mungkin paling sensitif dalam kasus-kasus infeksi
tulang belakang karena kurangnya demam dan hitung darah lengkap normal umum pada
pasien dengan infeksi tulang belakang karena pengujian laboratorium tidak memiliki
kekhususan, MRI dengan dan tanpa media kontras dan, dalam banyak kasus, biopsi penting
untuk diagnosis yang akurat.
CASAZZA BA. Diagnosis and Treatment of Acute Low Back Pain . American Family
Physician 2011; 85( 4):343-50.
A complete blood count (CBC) and erythrocyte sedimentation rate (ESR) are sufficiently
inexpensive and efficacious for use as initial tests when there is suspicion of cancer or
infection as the cause of acute LBP. In the absence of red flags and high index of suspicion,
or of increasing pain and weakness, imaging studies are usually not helpful during the first 34 weeks of back symptoms. If low back symptoms persist for more than 4 weeks, further
evaluation may be indicated. If radicular symptoms (leg pain and weakness) persist
undiminished for more than 4 weeks, further evaluation is strongly indicated. Reevaluation
begins with a review and update of the history and physical exam to assess again for red flags
or evidence of nonspinal conditions causing back symptoms.
Plain x-rays. Plain x-rays are not recommended for routine evaluation of patients with
acute low back problems within the first 4-6 weeks of symptoms unless a red flag and high
index of suspicion is noted on clinical evaluation. Plain x-rays are recommended for ruling
out fractures in patients with acute low back problems when any of the following red flags
are present: recent significant trauma (any age), recent mild trauma (patient over age 50),
history of prolonged steroid use, osteoporosis, patient over age 70). Plain x-rays in
combination with CBC and ESR may be useful for ruling out tumor or infection in patients
with acute low back problems when any of the following red flags are present: prior
prolonged steroid use, low back pain worse at night and with rest, unexplained weight loss. In

the presence of red flags, especially for tumor or infection, the use of other imaging studies
such as bone scan, CT or MRI may be clinically indicated even if plain x-ray is negative. The
use of lumbar x-rays to screen for spinal degenerative changes, scoliosis, spondylolysis,
spondylolisthesis, or congenital anomalies very rarely adds useful clinical information. Xrays are to be avoided in pregnancy.
MRI, CT, CT-myelography. The use of these imaging tests for patients with acute low
back problems is to define medically or surgically remediable pathological conditions.
Imaging studies must be interpreted in conjunction with the clinical history and physical
examination. In one study, MRI showed significant degenerative change and encroachment
into the spinal canal in more than 50% of asymptomatic older persons; the incidence of
asymptomatic herniated discs was approximately 20% in persons in their 30s. The imaging
findings may not be significant unless they correlate with the findings on physical
examination.
For patients with acute low back problems who have had prior back surgery, MRI
with contrast appears to be the imaging test of choice to distinguish disc herniation from scar
tissue associated with prior surgery.
CT scans are to be avoided during pregnancy. Consultation with a radiologist is strongly
advised when considering MRI scanning during pregnancy.
EMG. EMG testing is not recommended if the diagnosis of radiculopathy is obvious on the
clinical exam. EMG results may be unreliable in detecting subtle nerve damage until a patient
has had significant radiculopathy for over 3 weeks. EMG may be used to help delineate
abnormal neurological exams in patients with risk factors for neuropathy (e.g. alcohol or
diabetes).
Bone Scan. A bone scan is recommended to evaluate acute low back problems when
spinal tumor, infection, or occult fracture is suspected from positive red flags. Bone scans
are contraindicated in pregnancy.
Hitung darah lengkap (CBC) dan tingkat sedimentasi eritrosit (ESR) yang cukup
murah dan berkhasiat untuk digunakan sebagai tes awal ketika ada kecurigaan kanker atau
infeksi sebagai penyebab LBP akut. Dengan tidak adanya bendera merah dan indeks
kecurigaan yang tinggi, atau peningkatan nyeri dan kelemahan, pencitraan biasanya tidak
membantu selama 3-4 minggu pertama gejala kembali. Jika gejala punggung bertahan selama
lebih dari 4 minggu, evaluasi lebih lanjut dapat diindikasikan. Jika gejala radikuler (nyeri
kaki dan kelemahan) terus selama lebih dari 4 minggu, evaluasi lebih lanjut sangat

dianjurkan. Reevaluasi dimulai dengan anamnesis dan pemeriksaan fisik untuk menilai lagi
untuk bendera merah atau bukti kondisi nonspinal menyebabkan gejala kembali.
X-ray polos. X-ray polos tidak dianjurkan untuk evaluasi rutin pasien dengan masalah
nyeri punggung akut dalam 4-6 minggu pertama gejala kecuali bendera merah dan indeks
kecurigaan yang tinggi dicatat pada evaluasi klinis. Sinar-x polos yang direkomendasikan
untuk mengesampingkan fraktur tulang pada pasien dengan masalah punggung akut. Adanya
bendera merah, terutama untuk tumor atau infeksi, penggunaan studi pencitraan lain seperti
CT atau MRI indikasi klinis bahkan jika polos x-ray negatif. Penggunaan sinar-x lumbal
untuk menyaring perubahan tulang belakang degeneratif, scoliosis, spondylolysis,
spondylolisthesis, atau anomali kongenital sangat jarang menambah informasi klinis yang
berguna. Sinar-X yang harus dihindari dalam kehamilan.
MRI, CT, CT-myelography. Penggunaan tes pencitraan ini untuk pasien dengan
masalah punggung akut untuk memutuskan masalah kondisi patologis medis atau
pembedahan untuk diatasi. Pencitraan harus ditafsirkan dalam hubungannya dengan riwayat
klinis dan pemeriksaan fisik.
EMG. Pengujian EMG tidak dianjurkan jika diagnosis radiculopathy jelas pada ujian
klinis. Hasil EMG mungkin tidak dapat diandalkan dalam mendeteksi kerusakan saraf halus
sampai pasien telah memiliki radiculopathy signifikan selama lebih dari 3 minggu. EMG
dapat digunakan untuk membantu menggambarkan uji neurologis yang abnormal pada pasien
dengan faktor risiko neuropati (misalnya alkohol atau diabetes). Scan Tulang disarankan
untuk mengevaluasi masalah punggung akut bila tumor tulang belakang, infeksi, atau fraktur
diduga dari flags red positif. Scan tulang kontraindikasi pada kehamilan.
Anthony, chiodo. Acute low back pain. UMHS Low Back Pain Guideline Update 2010;
1-14.
IX.

TATALAKSANA

a. Patient Education:
Patient education. Exactly what to teach is not proven. Education that diminishes fear
and reinforces a positive outcome appears to have an important effect on outcome. In one
study educating patients to resume usual activity was both safe and therapeutic and led to less
work disability, less pain, and less health care utilization. One randomized controlled trial
showed patients receiving educational booklets had significantly fewer subsequent follow-up
visits over the next year than control populations. Another controlled study shows that a
concrete diagnosis and specific date for recovery result in improved outcomes compared to
less specific prognostication. For example, explain that typically expect recovery for muscle

strain in 7 to 10 days, for ligament sprain in 3 to 4 weeks, or for disk herniation in 8 to 10

weeks. Substantial literature elsewhere in medicine indicates that physician education can
have a positive effect on a disease process. Lack of clear physician communication regarding
the cause of the patients LBP may prolong recovery and is a frequent source of patient
dissatisfaction.
Several randomized controlled trials have shown contradictory results regarding back
schools in acute LBP. Back schools may be more effective in an industrial setting.
Pendidikan pasien. Pendidikan yang mengurangi rasa takut dan memperkuat hasil yang
positif tampaknya memiliki efek yang penting pada hasil. menjelaskan bahwa biasanya
mengharapkan pemulihan untuk cedera otot 7 sampai 10 hari, untuk ligamen keseleo dalam
3 sampai 4 minggu, atau untuk disk herniasi 8 sampai 10 minggu. Literatur substansial
tempat lain dalam kedokteran menunjukkan bahwa pendidikan dokter dapat memiliki efek
positif pada proses penyakit. Kurangnya komunikasi dokter jelas mengenai penyebab LBP
pasien dapat memperpanjang pemulihan dan merupakan sumber yang sering ketidakpuasan
pasien.
b. Heat.
Heat (in the form of a warm shower, bath, or hot pack) and counterirritants (such as
deep heating compounds) distract the patient from the pain, and may have a muscle
relaxing effect. Initial treatment with ice/cold is typically not useful because the site of the
underlying pathology is not commonly superficial.
Panas. Panas (dalam bentuk mandi hangat) dan counterirritants (seperti senyawa
pemanasan ) mengalihkan perhatian pasien dari rasa sakit, dan mungkin memiliki efek relax
otot. Pengobatan awal dengan es / dingin biasanya tidak berguna karena lokasi patologi yang
mendasari tidak biasa dangkal.
c. Spinal manipulation.
Spinal manipulation (by chiropractors, osteopathic physicians, or specially-trained
physical therapists) has been shown in randomized controlled trials to provide
symptomatic relief for low back pain. Relief is rapid and patient satisfaction high, but
multiple treatments are typically provided. However, in trials to date, manipulation does
not improve function (e.g. return to work, decreased disabilities indexes).
Manipulasi tulang belakang (oleh ahli tulang, dokter osteopathic, atau khusus terlatih
terapis fisik) telah ditunjukkan dalam uji coba terkontrol secara acak untuk memberikan
bantuan gejala nyeri punggung bawah. Namun, dalam uji sampai saat ini, manipulasi tidak
meningkatkan fungsi (misalnya kembali bekerja, penurunan indeks cacat).

d. Exercises.
A Cochrane review found that exercise is an effective treatment for low back pain, but
no specific exercise programs have demonstrated a clear advantage. Several authors have
particularly recommended core strengthening exercises, but supporting evidence is not
available. McKenzie exercisesa program of specific conditioning exercises, usually
involving trunk extension, which strives to centralize painmay be effective in relieving
radiating LBP. A program of gradually increased aerobic and back-strengthening exercises
may help prevent debilitation due to inactivity. Aerobic exercise programs, which minimally
stress the back (walking, biking, or swimming), can be started during the first 2 weeks for
most patients with acute LBP. Recommending exercise goals that are gradually increased
result in better outcomes than telling patients to stop exercising if pain occurs.
Sebuah tinjauan Cochrane menemukan bahwa olahraga adalah pengobatan yang
efektif untuk LBP, tetapi tidak ada program latihan khusus telah menunjukkan keuntungan
yang jelas. Beberapa penulis telah sangat direkomendasikan latihan penguatan inti, tapi bukti
pendukung tidak tersedia. Program latihan aerobik, yang minimal menekankan kembali
(berjalan, bersepeda, atau berenang), dapat dimulai selama 2 minggu pertama untuk sebagian
besar pasien dengan LBP akut. Merekomendasikan tujuan latihan yang secara bertahap
meningkat mengakibatkan hasil yang lebih baik daripada berhenti berolahraga jika sakit
terjadi.
e. Activity limitations.
Strong evidence shows that bed rest is not an effective treatment option for acute LBP.
Maintaining usual activities has been shown to improve recovery. It may be appropriate in
some circumstances to limit physical activity, upon weighing the nature of a patients work
and the severity of the pain. Since pain is not objectively quantified, and the physician is
typically not expert in the patients work situation, the patients knowledge of these factors
should be taken into account in making initial activity limitations.
Length of time off work is directly correlated with the risk of long-term disability. Thus a
number of measures should be taken to minimize activity limitations. Activity limitations
should be for a specific time period. Before taking a patient off of work completely, the
physician might consider communicating with the employer to see if light duty or limited
hours are available. Workplace modification improves return to work rates and decreases
disability time. Consultation with an occupational therapist or other allied health professional
with expertise in job site evaluation should be considered. Patients should be followed
frequently through any period of time off work.

Bukti kuat menunjukkan bahwa istirahat bukanlah pilihan pengobatan yang efektif untuk
LBP akut. Mempertahankan kegiatan seperti biasa telah ditunjukkan untuk meningkatkan
pemulihan. Lamanya waktu cuti secara langsung berkorelasi dengan risiko kecacatan jangka
panjang. Sehingga sejumlah langkah harus diambil untuk meminimalkan keterbatasan
aktivitas. Keterbatasan aktivitas harus untuk jangka waktu tertentu. Modifikasi tempat kerja
meningkatkan kembali ke tingkat kerja dan mengurangi waktu cacat. Konsultasi dengan ahli
terapi okupasi dalam evaluasi tempat kerja harus dipertimbangkan.
f. Medications

Injections. In some patients whose symptoms persists after 6 weeks, epidural steroid
injections for the radiating pain of disk herniations or spinal stenosis may be of some short
term relief in decreasing radiating leg pain, however the effect on long-term outcome is not
clear. Steroid injections into the facet joints and sacroiliac joints do not appear to have
significant effect when completed outside the confines of a comprehensive rehabilitation
program. Trigger point injections with local anesthetic and dry needling have been shown
to have short-term effectiveness in the management of low back pain. The use of botulinum

toxin in the management of acute low back pain shows no advantage and increased cost
compared to trigger point injections.
Surgery. Since many patients with radiating pain get better within the first few weeks,
surgery is usually not considered until a patient has failed at least 4 weeks of aggressive
conservative treatment. Patients with progressive neurologic deficits require emergent
surgical evaluation. Patients with pain radiating below the knee, positive neurologic findings,
and disk herniation on imaging studies have faster relief of symptoms with surgery as
opposed to conservative treatment. For disk herniation, long-term outcome is not statistically
different between surgically and conservatively treated patients. The length of disability can
be considerably shortened by surgical intervention. Surgical evaluation should be considered
in patients with symptomatic spondylolisthesis, spinal stenosis, and/or segmental
hypermobility
Suntikan. Pada beberapa pasien yang gejalanya menetap setelah 6 minggu, suntikan epidural
steroid untuk nyeri menjalar dari herniasi disk atau stenosis tulang belakang mungkin
beberapa bantuan jangka pendek dalam mengurangi nyeri yang menjalar ke kaki, namun efek
pada hasil jangka panjang tidak jelas
Bedah. Karena banyak lebih baik dalam beberapa minggu pertama, pembedahan biasanya
tidak dianggap sampai pasien telah gagal setidaknya 4 minggu pengobatan konservatif
agresif. Pasien dengan defisit neurologis progresif memerlukan evaluasi bedah. Pasien
dengan nyeri yang menjalar di bawah lutut, temuan neurologis positif, dan disk herniasi pada
studi pencitraan memiliki bantuan lebih cepat dari gejala dengan operasi sebagai lawan
pengobatan konservatif
Anthony, chiodo. Acute low back pain. UMHS Low Back Pain Guideline Update 2010;
1-14.
X.

PROGNOSIS

Cowan P.

Practice Guidelines For Low Back Pain

Association2008;2-17.

. American Chronic Pain