Dec 26, 2015
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