Back pain

Dr Myint Swe
assciate professor
AIMST University

Intervertebral Disc
Soft fibro-cartilaginous cushions
Between two vertebra
Allows some motion
Serve as shock absorbers

Total 23 discs
th of the spinal column's length
Avascular
Nutrients diffuse through end plates

 Figure -Function of
nucleus pulposus .
The nucleus pulposus
has an intrinsic
pressure that keeps
the vertibra endplate
separated and the
annular fiber sheets
taut.

Causes of back pain

1-Extraspinal causes
2-Spinal causes
A- Mechanical causes
B- Non-mechanical causes

Causes of back pain

1-Extraspinal causes
-Gastrointestinal causes eg. Peptic ulcer ;
Pancreatic tumours.
-Urological causes eg. Pyelonephritis
-Genital causes eg. Utero-ovarian pathology
-Retro-peritoneal eg. Aortic aneurysm
- Psychological

Causes of back pain

2-Spinal causes
A- Mechanical causes
1- congenital disorders
Facet asymmetry
Transitional vertebra eg. Sacralization, lumberization

2- Trauma

Sprain
Fractures & fracture-dislocations
Subluxated facet joints
Spondylolysis & spondylolisthesis

Causes of back pain

2-Spinal causes
A- Mechanical causes-continued
3- degenerative disorders

P.I.D ( prolapsed inter-vertebral disc)

Spondylosis
Spinal stenosis
spondylolisthesis

B- Non-mechanical causes

Causes of back pain

2-Spinal causes
B- Non-mechanical causes
1- tumours
Benign- from neural tissues or bony tissue
Malignant
primary from nerve or bone
Secondary from breast, lungs, kidney, thyroid,
prostate
2- inflammatory diseases
Rheumatoid arthritis, Ankylosing spondylitis
3- infections
Acute-acute discitis
Chronic- tuberculosis
4-metabolic - osteoporosis

 So you must think in cases of LBP

1-to exclude extraspinal causes . Test for
tenderness at renal angle, tenderness in
abdomen , mass in abdomen
2 to exclude non-mechanical causes. Look
for general condition, primary source of
infection & malignancy, specific tenderness
,deformity or gibbus.

Causes

Predisposing factors

Postural stress
Work related stress
Disuse and loss of mobility
Obesity
Debilitating conditions

Precipitating factors
Misuse
Overuse
Abuse or trauma

Clinical diagnosis
History
Present illness
PAIN- onset ?, sudden onset or gradual
WHERE, at back or any referred pain
Pain arising from posterior longitudinal ligament,
from facet joints are referred to low back
Pain arising from compression of nerve & dura are
radiated down the leg in the dermatone pattern
(sciatica)
WHEN- appear even at rest?
on sitting, standing, walking?

Clinical diagnosis
History
Present illness
PAIN- HOW- (character) dull-ache, non-specific
in location
sharp, precise in distribution.
SEVERITY- excruciating, killing, unbearable, intolerable
RELIEVING FACTORS- sitting down? Lying?
AGGRIVATING FACTORS going down stairs?
Walking?

Associated phenomenon- tingling & numbness

or weakness in lower limb

Clinical diagnosis
History
Present illness
Stiffness- sudden onset & complete= PID
Continuous & worst in the morning =
ankylosing spondylitis
Any urinary & bowel symptoms
suggest pressure on cauda equina

Clinical diagnosis
History-continued

Present illness
Past medical history- cough & haemoptysis
Past surgical history- P.U; urinary problems
Gynaecological history post menopausal bleeding,
white discharge per vagina,
UVP.

General constitutional symptoms fever,

loss of weight & appetite,
bowel & micturition problems

Clinical diagnosis
Physical examination
Look
Feel
Move

Standing
prone
supine

Because do not want the patient to be felt pain

again & again by changing position frequently

Clinical diagnosis
Physical examination
on standing position
Look
1- stance & gait ; standing &walking on heel &
tip-toe
2- spine- anterior, posterior & lateral view
Deformity- kyphosis, scoliosis, gibbus, loss of
lumbar lordosis, paravetrebral spasm
Skin-Scar or hair tuff at back
Wasting of gluteal muscle & thigh

Clinical diagnosis
Physical examination
on standing position
Feel
- Tenderness- at each spine,
paravertebral muscles
& S.I joints.
- at renal angle

Clinical diagnosis
Physical examination
on standing position
Range of movements extension
- flexion- must be a gentle arc from
pelvic to
shoulder;
structural scoliosis become apparent when
spine is flexed.
- lateral flexion
- rotation( anchor the pelvic)
- measure lumbar excursion. 10 to 15 cm

Forward bending
Hands are pushing in
opposite direction
Tissues from skin to
central core
Elongate posterior
Compress anterior

Assessing lumbo-pelvic
congruency
Palpation from cervical
spine to pelvis

Clinical diagnosis
Physical examination
-With patient prone
look- how patient gets onto bed. Easily or
groaning?
- gluteal & thigh wasting
-Feel- each spinous process & paravertebral muscle for
tenderness
-Move -femoral stretch test- 2 types
(L2,3,4)
-

Clinical diagnosis
Physical examination
-With patient prone
-Move - continued
-hamstring power, gluteus maximus power are tested.
-saddle anaesthesia(S3,4)
-anal reflex
-poplyteal & tibial pulse

Clinical diagnosis
Physical examination
-With patient supine
look- observe how pt turn .
Feel-*Hip ; Abdomen: to exclude any abn:

* S.I joint= FABER manoeuvre- pain in

groin
suggest hip problem & pain in back suggest SI jt.

*Straight leg raising test( SLR) < 60

* Lasegues test= passive when dorsiflexion of

ankle was done

Straight leg raise (SLR)

Straight leg raised

Femoral flexion
Adduction
Internal rotation
Increase in tensile
force
On sciatic nerve
Related to ischial
tuberosity

Clinical diagnosis
Physical examination
-With patient supine
-Move
* neurological exam: is essential in LBP
* done while standing- walking on toes & heel
- while on prone position- hamstring power
* supine-power : knee extension(L3,4),
big toe dorsiflexion(L 5), planterflexion(S1),
foot inversion(L5), eversion(S1)

Clinical diagnosis
Physical examination
-With patient supine
* neurological exam: is essential in LBP
* reflexes- knee jerk(L3,4)
ankle jerk(S1)- 1- supine
- 2- kneeling on bed
* Sensory- touch & pinprick

Video show
Head and Neck
..\Desktop\videoew Folder\head& neck.W
MV
Spine
..\Desktop\videoew Folder\spine.WMV

Investigations

Urine for REME

ESR
Full blood count
Urine for Benze-Jones protein
Plain X-ray of the spine-AP, Lat , Oblique
C.T
M.R.I
Myelogram
Plasma electrophoresis

Investigations
Bone scan:
Very sensitive but nonspecific
Useful for:
Malignancy screening
Detection for early infection
Detection for early or occult fracture

Guide lines
Very young & very old- PID seldomly
occurred
Elderly- think of compressed # &
Malignancy
Very ill patient- think more serious
disease
Pain free interval is present in PID

Warnings= Red Flag

PID affects at most 2 neurological level. In
multilevel involvement, suspect a
neurological disorder
Severe unrelenting pain, suspect infection
or tumour
If SLR is negative, look for extraspinal
causes carefully
Past history of malignancy

Management
Objectives
A. Alleviation of pain
B. Prevention of recurrences
C.Intervention of progression into chronic pain

Management
Alleviation of pain
1. Reassurance
2. Rest for few days, then early ambulation.
Flexed foetal position ideal
Pillow under knee in supine position
Pillow between the legs on side-lying position

3. Bowel & bladder care

Bedside commode

Management
Alleviation of pain
4.Leaving the bed

Roll over to one side

Sitting by moving side ways
Slowly lean forwards
stand

5. Medication
N.S.A.I.D
Relaxants
Antidepressants

Management
Alleviation of pain
6. Physical modalities
Cold compression
Hot packs
massage

7. Manipulation.
Traditional massage not encourage

Management
Alleviation of pain
8.Tractions
Skin traction- 7 lbs only, a way of enforcing bed
rest
Pelvic traction -20 lbs
Traction by gravity

9. E.D.D. epidural steroids

Epidural injection of Depo-medrol 80mg + normal
saline 30cc in OT.

Management
Alleviation of pain
10. Nerve root block
11. facet joint injection
12. Acupuncture( TENS)
13- injection at Multifidus triangle.

Management
B. Prevention of recurrences
Life style modification
Standing
Sitting
lifting

Exercises
Back strengthening exercise
Flexion exercise
Sit-up exercise & straight leg raising exercise are not
advised.

Management
Objectives
A. Alleviation of pain
B. Prevention of recurrences
C.Intervention of progression into chronic pain

Management
C.Intervention of progression into chronic pain
Exercise as advised by physiotherapist

Forces
of Activity

Muscular
Strength

INJURY

Strong Back = Healthy Back

All chronically disabled low back pain

patients have in common one major
problem
: they have stopped using their bac
ause
of pain,

Wasting of trunk musculature

Decrease in muscular and cardiovascular endu
Stiffness of ligaments and joints
sprains
strains
muscle spasms

Avoidance of Activity

The Deconditioning Syndrome