Low back pain

1. Low Back Pain
-An Easy Approach To a Difficult Problem
Dr. Dipak Maharjan

2. • 80% of the population in their lifetime
• The most common cause of disability
OCNA J Carragee, M Hannibal

3. Natural History
60% recover in 1 week
M. Ritter JBJS Am. 87 2006

4. Purpose
• Structures for LBA
• History taking
• Examination
• Relevant Investigations
• Management

5. Approach according to Structure
• Skin
• Muscles and Fascia
• Bone/Spine
• Intervertebral Disc
• Spinal Cord and Nerve roots
• Visceral Diseases

6. Skin lesions

7. Musculo-fascial pain

8. Muscle spasm

9. Bony causes
Degenerative
Infective
Developmental
Trauma
Tumors
Pathologic Conditions

10. Degenerative Spine

11. Spondylosis

12. Degenerative Scoliosis

13. Infections
• Bacterial/ Pyogenic Infections
• Tuberculous Spondylitis
• Fungal Infections

14. Tb Spine

15. Pyogenic Spondylitis

16. Bony causes
Degenerative
Infective
Developmental
Trauma
Tumors
Pathologic Conditions

17. Kyphoscoliosis

18. Developmental High Grade Listhesis

19. Isthmic Spondylolithesis L4L5

20. L3 Primary Bone Tumor

21. Malignancy

22. Old Vertebral Fracture

23. Vertebral fracture

24. Osteoporosis

25. Inflammatory Spondyloarthropathy

26. Disc Prolapse

27. Post op Discitis

28. Relevant History in LBA
• Pain
• Walking Distance
• Weakness
• Bowel and Bladder habits
• Diabetes, Smoking, Family hx Malignancy

29. Pain – STAR X2
• Site - Localized to lowback
• Type – Sharp Shooting, tingling, numb
• Associated Factors –
Constituent symptoms of TB, Mg
• Radiation – Back of thigh, Calf,
upto ankle, toes
• Severity – VAS
• Time – Duration, Continuous
• Aggravating Factors –
Sneezing, walking, climbing down
• Relieving Factors – rest,
leaning forward

30. Walking Distance
• No pain on walking
• Can walk a few kms.
• Pain after walking a few steps

31. Neurology
• Weakness – unsteady gait
• Sensory deficits – numbness, can feel less
• Bowel/ Bladder – unable to void, incontinence
constipation
sexual dysfunction

32. Clinical examinations
Inspection
Palpation
Movements
SLR
Neurological examination

33. INSPECTION
• SKIN AND SUBCUTANEOUS TISSUE
• GAIT
• LIST
• DEFORMITY

34. Herpes Zoster

35. LIST

37. PALPATION
• SPINAL TENDERNESS
• PARASPINAL MUSCLE SPASM
• STEP OFF DEFORMITY - Listhesis
• SWELLING

38. SLRT

39. NEUROLOGIC EXAMINATION
• Motor Examination
• Sensory Examination
• Reflexes
• Per-rectal examination

40. Heel/Toe Walking

41. Motor Examination
• L2: Hip Flexors
• L3: Knee Extensors
• L4: Ankle Dorsiflexors
• L5: Toe Extensors
• S1: Ankle Plantorflexors & Toe Flexors

42. Sensory Examination

43. Examn …. Contd…
• Reflex – Ankle Jerk S1
• Dorsalis Pedis Pulsation
• Posterior Tibial Pulsation

44. Per – rectal Examination
• Perianal Sensation – S3S4S5
• Anal Wink
• Anal Tone
• Voluntary Anal Contraction

45. Investigations
• Complete Blood Picture
• ESR, CRP
• Liver Function test
• Renal Function Test
• RA factor, HLA B27, ANA
• Bone Scan
• CT guided/Open Biopsy, Tissue Culture

46. Investigations
• X- rays , Dynamic views
• CT scans
• MRI

47. Tb/ Mg – L5 25/M

48. Tb/ Mg – L5

49. Tb/ Mg L5

50. Treatment
NSAIDS
Muscle relaxants
Physiotherapy
Selective Nerve Block/ ESI

51. Surgery
IVDP
Degenerative Spinal stenosis
Spondylolisthesis
Infective spondilitis
Tumours
Trauma

52. Lumbar Disc Herniation

53. DISCECTOMY

55. Lumbar Canal Stenosis

56. LAMINOTOMY AND DECOMPRESSION

57. L4L5 Degenerative Listhesis

59. Posterior Lumbar Interbody Fusion

60. ISTHMIC LISTHESIS

61. Developmental High Grade Listhesis

63. Special Instruments

64. TB Spine L3L4

66. Infective Discitis

69. TUMORS- L3 ABC

70. Any Questions?

71. THANK YOU