Low Back Pain

Low Back Pain• Second cause of pain in body• Leading cause of sick leave• Is a symptom not disease• 50-80% of adult will have LBP during their life• M=F but after 60 yrs F>M• Only 1% of acute LBP is due to lumbar

radiculopathy• Lumbar radiculopathy often occur during 4th &5th

decades

Risk Factors• Occupational factors

• Lifting, pulling, pushing, twisting, sitting

• Patient-Related factors• Age, Gender, Anthropometric, postural, spine

mobility, Muscles strength, Physical fittness, Smoking, Psychological

Etiology• Degenerative• Inflammatory• Infection• Metabolic• Neoplastic• Traumatic• Congenital/Developmental• Musculoskeletal

• Viserogenic• Vascular• Psychologic• Post op.

Normal posture• Line of gravity passes

from C1 to C7 to T10 & lumbosacral junc. To hip joint

Clinical Evaluation• Hx• P.E:

• Inspection• Palpation• ROM(tape, inclinometers)• Neurological Exam

• Gait• MSR• MMT• Sensory

• Imaging

• EMG/NCS• Bone Scan

Mechanical LBP• Nondiscogenic LBP, provoked by activity

& relieved by rest• Often due to stress or strain on back

muscles, tendon, lig. • Chronic, dull aching pain spreed to buttock• No assosiated with neurologic symp. • Not increased with cough or sneeze• Deconditioning & decompensation

Osteoarthritis• O.A of vertebral body• O.A of facet joint

O.A of facet joint• Localized pain• Epizodic• Usually abrupt onset• Limited extension• Pain increased with activity & relieved by rest

O.A of facet joint(cont.)• Treatment:• Weight control• Rest• Analgesic or NSAIDs• Manipulation • Exercise(Q.L ex., pelvic tilt, flexibility ex.,

avoid ext.) • Avoid prone sleeping

Radiculitis & Radiculopathy• Common cause of acute, chronic or

recurrent LBP particularly in young to middle aged mens

• Mean age: early 40s

Radiculitis & Radiculopathy• Bulging disk• Prolopsed disk• Extruded disk • Sequestered disk

• L5,S1: radiated pain often to buttock, post. Thigh, lateral culf, med. Or lat. Maleoli

• L3,4: radiated pain to ant. Thigh• When disk extrude LBP is decrised & leg

symptoms are more prominent• In upper lumbar radiculopathy: other cause

(eg: neoplastic) should be R/O.• Provocative maneuver• P.E• Lab test

Treatment• Conservative • Surgery if:

• Progressive neurological deficit• Sphicter compromised• Large midline disk protrusion with cauda

equina syndrome• Unresponce to 4-6 weeks comprehensive

conservative treatment

Spondylolysis & Spondylolisthesis• Spondylolysis: bony defect in pars interarticularis• Spondylolisthesis : Bilateral lysis lead to ant. Slipping

• Listhesis:• Dysplastic• Isthmic (lytic, elongated, acute Fx)• Degenerative• Traumatic• Pathologic

• LBP(+/- radicular symptome)• Increased lumbar lordosis• Hamstring tightness(standing with flex knee)

Imaging study• L.S x-ray(lat, oblique)• Flexion/extension view for segmental

instability• MRI, CTS, EMG/NCV if:

• Root symptoms• Neurological defect• pseudoclaudication

Treatment• post traumatic: 10-12 weeks immobilization• Chronic LBP: strengthening ex.• In persistant pain: L.S corset• Grade1&2 & in older patient: non surgical

• Modality• Massage• Stretching ex.• Flexion ex.• Abdominal binder

• Surgury : • Advance listhesis beyound grade 2• Young patient with heavy sport or physical job• Severe symptomatic slip