Low Back Pain LBP By Dr JASIM HASAN

Low Back Pain (LBP) By Dr. JASIM HASAN (Consultant orthopedic surgeon)

INTRODUCTION The Neanderthal man did not suffer from low back pain, because he was not yet fully vertical. LBP is experienced by 80 to 90% of the population. LBP is second only to headache as a frequent source of pain in the body. Low back pain is one of the commonest problems in orthopaedic practice, behaving as a modern day epidemic affecting 60 to 75% of the working population.

Introduction Examining a patient with backache can itself • cause both backache and headache. • Natural history of LBP • * 80 -90% resolves in 1 month • * 20 -30% remains chronic • * 5 -10% disabling •

Risk factors of LBP Risk factors that patient can change: 1. Not getting regular exercise. 2. Doing a job or other activity that requires long periods of sitting, lifting heavy object, bending or twisting, repetitive motion or constant, vibration. 3. Smoking. 4. Excess weight. 5. Having poor posture. 6. Being under stress. 7. Having long periods of depression. 8. Using medicine long-term that weaken bone, such as corticosteroids.

Risk factors(contd. ) Risk factors that patient cannot change: 1. Being middle aged or older. 2. Being male. 3. Having F/H of back pain. 4. Having had previous back pain. 5. Having had previous surgery. 6. Being pregnant. 7. Having had compressed # of spine. 8. Having spine problem from birth(congenital).

Causes of LBP • Low back pain seems to be multifactorial in origin. Still there are significant number of patients who do not have an identifiable cause for back pain and can be termed as non -specific back pain. • As such, the list of causes of backache can be a very long one, but the common causative factors are:

CAUSES OF LBP………………. . 1. Posture: 2. Congenital defects: 3. Injury: 4. Intervertebral disc pathology: 5. Spinal stenotic syndrome: 6. Ankylosing spondylitis and rheumatoid spondylitis(sacroiliatis): • 7. Infective conditions: 8. Neoplastic conditions: 9. Degenerative arthrosis of spine: • • •

CAUSES OF LBP……………. • • 10. Senile osteoporosis: 11. Other causes in ladies: 12. Metabolic: 13. Malingerer’s backache: 14. Compensation backache: 15. Abdominal and pelvic causes: 16. General(miscellaneous) causes: 17. Idiopathic:

Patients with LBP Specific LBP (10%) Non-specific LBP (90%) • i. e symptoms caused by a specific patho-physiological mechanism, e. g P. I. D , infection, #, neoplasm, cauda-equina syndrome, osteoporosis, rh. Spondylitis, etc • i. e symptoms due to unknown cause. According to duration of LBP: LBP can be • * Acute---- < 6 weeks • * Subacute---- >6 weeks but < 3 months • * Chronic------- > 3 months

Red flags: may signal serious cause of LBP • • • - H/O OF CANCER - UNEXPLAINED WT. LOSS - IV DRUG USE - PROLONGED USE OF CORTICOSTEROIDS - OLDER AGE - MAJOR TRAUMA - OSTEOPOROSIS - FEVER - BACK PAIN AT REST OR AT NIGHT - BOWEL OR BLADDER DYSFUNCTION

How to evaluate patient with LBP • Best to start with: 1. Careful history( your best diagnostic tool) and physical examinations 2. Imaging and labs when indicated Diagnosis of LBP: HISTORY: • Pain assessment - Description - Duration - Intensity - Alleviating factors - Aggravating factors • Medical • Psychosocial • Family • Previous trails

Evaluation( contd. ) • General exam: -Musculoskeletal -Neurological: Gait, motor, sensory &reflexes - Regional exam. Of spine & legs: Inspection for scoliosis or skin rash Palpation for bone tenderness - Sciatic & femoral nerve stretching tests - Strength tests - Reflexes - Sensations

Evaluation( contd. ) • Imaging for LBP 1 - Plain X-ray: usually unnecessary & not helpful( LSSX-ray-AP/LAT. /with flexion-extension and oblique views). It is indicated in: • Age> 50 years • No improvement after 4 -6 weeks • Trauma • Findings suggestive of systemic diseases or worrisome findings 2 - MRI : Shows tumor and soft tissues(e. g. PID) more better than CT scan. Almost never an emergency except in cauda equina syndrome. It is also indicated after 6 weeks if have sciatica. 3 - CT scan: Soft tissues(discs, spinal canal) are poorly visualized. • Shows bone( e. g. #) very well. • Good in acute situations(trauma). • Sagittal reconstruction is mandatory 4 - CT-myelography: Shows the spinal cord & nerve contour better. It is indicated if MRI not available or contraindicated. • CT& MRI are reserved for suspected malignancy, infection or persistent neurological deficit. (N. T Expensive diagnostic tests cannot always identify the cause of LBP)

PREVENTION OF LBP It means that establishing a healthy life style: 1. Exercise regularly. 2. Protect your back while sitting. 3. Try different sleeping position. 4. Wear low heeled shoes. 5. Maintain body weight. 6. Avoid smoking. 7. Eat nutrition diet: getting plenty of calcium, posphorous & vit. D to prevent osteoporosis & drink plenty of water. 8. Manage the stress in life.

RECOMMENDATIONS 1. Best way to deal with LBP is to prevent it. 2. Remember that, LBP is a symptom not a diagnosis. 3. Be able to recognize the difference between the simple LBP and serious one. 4. Determine the site of LBP pathology.

Thank you