Epidemiology of Low back pain

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1 Low Back Pain

2 Definition Pain felt in your lower back may come from the spine, muscles, nerves, or other structures in that region. It may also radiate from other areas like the mid or upper back, a inguinal hernia, or a problem in the testicles or ovaries

3 Epidemiology of Low back pain Worldwide prevalence: prevalence is 65% to 80%. Low back pain is the leading cause of activity limitation and work absence throughout much of the world and is associated with an enormous economic burden In united states The second most frequent reason for visits to physician. Fifth ranking cause of admission to hospital. Third most common cause of surgical procedure Lumbar discectomy is the most surgical procedure for LBP

4 Risk factors smoking, obesity, age, female gender, physically strenuous work, sedentary work, psychologically strenuous work, Workers' Compensation insurance, job dissatisfaction and psychological factors such as somatization disorder, anxiety, and depression

5 Etiology Non - Spinal Causes of Low Back Pain Spine Related Causes of Back Pain

6 Non-Spinal Related Causes Bladder Infection Kidney Disease Ovarian Cancer Ovarian Cyst Testicular Torsion Pelvic Infections Appendicitis Pancreatitis Prostate Disease Gall Bladder Disease Abdominal Aortic Aneurysm

7 Spine Related Causes Arthritis Fibromyalgia Kyphosis Lordosis Rheumatoid Arthritis Ankylosing Spondylitis Arachnoiditis Bone Cancer Chiari Malformation Compression Fractures Discitis Epidural Abscess Piriformis syndrome Osteomyelitis Osteophytes Ruptured Disc Spina Bifida Spondylolisthesis Spinal Stenosis Spinal Cord Injury Spinal stenosis Sprain or Strain Synovial Cysts Bertolotti's syndrome Facet Joint Syndrome

8 Bertolotti's syndrome (transitional vertebra) is characterized by the presence of a variation of the fifth lumbar (L5) vertebra with a large transverse process, either articulated or fused with the sacral basis or iliac crest, producing a chronic, persistent lower back pain. ( p %4 to 36%) patients should treated similarly as patients with nonspecific back pain. surgical intervention unclear.

9 Piriformis syndrome Piriformis syndrome causes pain in the buttock, while sitting,tingling in back or buttock which may radiate down the leg. It is due to the sciatic nerve being impinged by a tight piriformis muscle deep in the buttocks.i

10 Annular fissures (tears) separations between the annular fibers of the intervertebral disc or separations of annular fibers from their attachments to the vertebral bone. Several small studies found no correlation between the presence of annular fissure and back pain

11 Schmorl's nodes Schmorl's nodes, representing herniation of the nucleus pulposus into the adjacent end plate, (20% of MRI studies in patients without back pain) Although Schmorl's nodes are associated with degenerative changes in the lower back, they are not an independent risk factor for back pain

12 Modic changes specific signal changes in the vertebral endplate and adjacent bone marrow on a spine MRI Modic changes are of unclear clinical significance. 6 to 10 percent of asymptomatic adults and are common in patients with back pain, prevalence increases with age & degenerative disc changes. it is unclear whether the presence of these changes is helpful in guiding the selection of treatment options Type 1 and type2 type3

13 Radiculopathy symptoms related to a spinal nerve root. Damage may result from degenerative changes in the vertebrae, disc protrusion, and other causes.

14 Disc Herniation In the lumbar spine, at least 90% of disc herniations occur at the L5 S1 or L4 5 levels. L3 4 herniations make up only 5% of cases, with the remainder occurring at L2 3 and L1 2 Clinically, a herniated disc at one level usually affects the nerve root that exits at the level below. For instance, a left L4 5 disc herniation usually compresses the left L5 nerve root

15 Clinical Findings of Common Lumbar Disc Herniations Disc Nerve Root Pain L3 4 L4 Anterior thigh, anterior leg, and medial ankle L4 5 L5 Posterior hip and posterolateral thigh and leg L5 S1 S1 Hip, buttock, and posterior thigh and leg Sensory Change Motor Deficits Reflex Loss Anterior leg Quad Knee jerk Medial dorsum of foot and occasionally medial ankle Lateral foot and ankle Foot and toe extension Plantar flexion None Ankle jerk

16 Test of Lasègue SLR: Sensitivity: 91% Specificity:26% cross or contralateral straight leg raising): sensitivity 29% specificity 88%

17 Indication for MRI: Radicular pain > 6 weeks Why 6 weeks waiting?

18 18 The rate of spontaneous regression: 96% for disc sequestration 70% for disc extrusion 41% for disc protrusion 13% for disc bulging The rate of complete resolution of disc herniation was 43% for sequestrated discs and 15% for extruded discs

19 19 Nonspecific back pain majority of patients seen (>85 percent) will have nonspecific low back pain, meaning that the patient has back pain in the absence of a specific underlying condition that can be reliably identified. Many of these patients may have musculoskeletal pain. Most patients with nonspecific back pain improve within a few weeks

20 Low Back Pain approach History Physical Exam Diagnostic Studies

21 Diagnostic Studies Plain X-Ray MRI CAT Scan Bone Scan Laboratory tests

22 Plain radiographs indicated, anteroposterior and lateral views of the lumbar spine are usually adequate. Oblique and other views increase the risks of radiation exposure, particularly for women, and add little new diagnostic information Flexion-extension views may be helpful in patients who have had surgical fusion procedures or for whom instability is a concern. Plain radiographs are a option for when concerned for fracture,infection,malignancy or ankylosing spondylitis

23 MRI Provide more detailed images of soft tissues (disc & Nerve roots) 1. Spinal stenosis 2. Disc bulge 3. Spinal tumors 4. Infections 5. Compressive lesions 6. Cauda equine. MRI enhancement with gadolinium allows the distinction of scar from disc in patients with prior back surgery. Note : -If red flags are present, MRI should be undertaken even if X-ray is normal. -MRI is preferable to CT scanning when neurological signs and symptoms are present

24 CT-scan Most of boney spinal pathology 1. Trauma 2. Osteomylitis 3. Infection 4. Tumors 5. Cases where MRI is contraindicated (e.g. pacemaker or metallic clips) More radiation exposure

25 Radionuclide (bone scan) Useful when radiographs of the spine are normal Especially 1. Osteomyelitis 2. Occult fracture 3. Metastasis 4. Paget s disease (metabolic, bone turnover) 5. ankylosing spondylitis (Inflammatory condition) 6-,Certain tumors (osteiod osteoma= benign)

26 Imaging indication Reserve imaging for patients with severe or progressive neurologic deficits or when serious underlying conditions are suspected on the basis of history and physical examination Avoiding imaging in acute low back pain(usually 4or 6 weeks waiting)

27 Red flags Failure to improve after 4-6wk of conservative therapy Unrelenting night pain or pain at rest Progress motor or sensory deficit Age > 50 History of cancer or current cancer Unexplained weight loss

28 Laboratory tests ESR/CRP HLA B27 Ag(95% of AS sufferers are HLA B27 positive) Ca, vit D, Alkalinephosphatase) prostate specific antigen Monoclonal band immunoelectrophoresis urine light chains

29 Referral to spine specialist Cauda equina syndrome Intractable pain Serious spinal pathology is suspected Progressive neurological deficits

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