Department of Neurology. Utara, School of Medicine

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1 LOW BACK PAIN Aldy S. Rambe Department of Neurology University of Sumatera Utara, School of Medicine

2 What is LBP Low back pain is a common disorder affecting millions of individuals annually. Back pain is the single most common cause for lost workdays in the United States and one of the most common reasons for patients to visit their primary care physician. It is estimated that approximately 50 to 80% of the adult population suffers from a memorable episode of low back pain each year. In the vast majority of cases no specific diagnosis is made and the symptoms resolve spontaneously. Only a minority of patients present with symptoms specific to an irritated nerve root or have identifiable pathology on radiographic studies. The overall prognosis of low back pain is good, with improvement occurring in the majority of cases without aggressive medical intervention.

3 ANATOMY

4 ANATOMY

5 CLASSIFICATION ACCORDING TO ITS DURATION, LBP IS DIVIDED INTO : ACUTE : < 2-8 WEEKS SUBACUTE : 2-8 WEEKS 12 WEEKS CHRONIC : > 12 WEEKS

6 etiology Non-specific mechanical back pain Facet joint syndrome Lumbar disc degeneration (lumbar spondylosis) Lumbar disc prolapse Spondylolisthesis Spinal stenosis Osteoporosis Sero-negative spondyl arthritis (including ankylosing spondylitis) Vertebral infection Disc space infection Malignancy secondary myeloma and primary Paget s disease, referred-visceral, pancreatic/pelvic, etc

7 RED FLAGS POSSIBLE SERIOUS SPINAL PATHOLOGY Age of onset : < 20 or 55 years Violent trauma, eg fall from a height, traffic accident Constant, progressive, non-mechanical pain Thoracic pain History of carcinoma Systemic steroids Drug abuse, HIV infection Systemically y unwell Weight loss Persistent severe restriction of lumbar flexion Widespread neurological deficit Structural deformity

8 COMMON ETIOLOGY 1. Mechanical (deformity, trauma) 2. Inflammation 3. Neoplasm 4. Degenerative 5. Psychological

10 LBP in pregnancy

11 PRIMARY MECHANICAL DEARRANGEMENT Ligamentous Strain Muscle strain or spasm Facet join disruption or degeneration Intervertebral disc degeneration or herniation Vertebral compression fracture Vertebral end-plate microfractures Spondylolisthesis Spinal stenosis Diffuse idiopathic skeletal hyperostosis

13 THE DISTINCTION AMONG SPONDYLOSIS, SPONDYLOLISIS AND SPONDYLOLISTHESIS SPONDYLOSIS : refers to osteoarthritis involving the articular surfaces (joints and discs) of the spine, often with osteophyte formation and cord or root compression SPONDYLOLISIS : refers to a separation at the pars articularis, which permits the vertebrae to slip. Maybe uni or bilateral

14 THE DISTINCTION AMONG SPONDYLOSIS, SPONDYLOLISIS AND SPONDYLOLISTHESIS SPONDYLOLISTHESIS : May result from bilateral pars defects or degenerative disc disease. Defined as the anterior subluxation of the suprajacent vertebrae, often producing central canal stenosis : it is the slipping i forward of one vertebrae on the vertebrae below.

15 INFECTION Epidural abcess Vertebral osteomyelitis Septic discitis Pott s disease (tuberculosis) Nonspecific manifestation of systemic illness

16 NEOPLASM Epidural or vertebral carcinomatous metastases Multiple myeloma Lymphoma

17 DEGENERATIVE 1. Osteoarthritis 2. Rheumatoid arthritis 3. Thoracic Outlet Syndrome 4. Cervical Spondylosis 5. Marie-Strumpell disease 6. Lumbar disc prolaps p (Hernia Nukleus Pulposus (HNP) 7. Spinal Stenosis

18 RADICULOPATHY ESSENTIALS of DIAGNOSIS : Pain in a dermatomal distribution, sensory symptoms along the same dermatome, weakness in a corresponding myotomal distribution, and absent or depressed reflexes. Frequency of incidence in order of occurrence : lumbar > cervical > thoracic Usually caused by a herniated disk or by spondylosis; other causes are infection, neoplasm, granuloma, cyst, and hematoma

19 Lumbar disc prolaps The earliest change in the NP and AF are probably biochemical and may be part of aging Superimposed trauma accelerates these degenerative changes The laters of fthe AF separate and dform circumferential ltear, leads to radial tears. NP may extrude producing disc herniation or prolaps Multiple tears produce weakening and circumferential bulging of the AF with loss of disc height Further disc narrowing results from aging of the NP, which changes from gelatinous consistency int the childhood to a fibrotic consistency in adulthood

20 The disk

22 Herniated disc

23 Distribution Lumbar disc prolaps (most common) L5-S1 (45-50%), L4-5 (40-45%) Cervical disc prolaps C6-7 (69%), C5-6 (19%) Thoracal disc prolaps (infrequent, < 1%)

24 Lumbar Disc Prolaps : Grade Protruded ddisk : penonjolan jl nukleus pulposus tanpa kerusakan annulus fibrosus Prolapsed disk : nukleus berpindah tetapi tetap dalam lingkaran annulus fibrosus. Extruded disk : nukleus keluar dari annulus fibrosus dan berada di bawah ligamentum longitudinalis posterior. Sequestrated disk : nukleus telah menembus ligamentum longitudinalis posterior.

25 Grade of herniated disc

26 Clinical symptoms Lumbar HNP : * severe LBP and lumbar paraspinal spasms, with pain radiating to the buttocks, legs, and feet (radicular pain) * abnormal vertebral posture * paresthesia, parese, diminished tendon reflexes * pain, sensory loss and weakness typically occur in a radicular pattern. * urinary symptoms, if present, reqquire immediate attention

27 Ischialgia (sciatic)

28 Clinical symptoms Cervical HNP : * pain present in the posterior neck, with spasm of the cervical paraspinal p musculature and near or over the shoulder blades on the affected side. * radicular pain, aggravated by neck extension, coughing, straining, i laughing, bending, or turning the neck to the side; and reduced by abducting the arm and put it behing the head * paresthesia, parese, diminished tendon reflexes

29 Diagnosis : Neurological examination Lumbar HNP : * Lasegue (straight leg raising) test. A positive SLR test is a sensitive indicator of nerve root irritation (sensitivity 95%)., May be positive with disc protrussion, intraspinal tumor or inflammatory radiculopathy * Crossed Laseque (crossed SLR) test. Less sensitive but highly specific. * Femoral stretch (reverse SLR) test. May detect an L2-4 root or femoral nerve irritation.

30 Diagnosis : Neurological examination Cervical HNP : * Lhermitte s sign A painless but unpleasant tingling or electric shock- like sensation in the back and spreading instantaneously down the arms and legs following neck flexion (active or passive) * Spurling ssign sign Increase in arm pain (brachialgia) associated with compressive cervical radiculopathy following neck rotation and flexion to the side of pain. * Shoulder abduction test

31 Diagnosis RADIOLOGICAL EXAMINATION : Plain vertebral x-rays : * limited information * disc narrowing, scoliosis, lordosis lumbal Myelography y CT or CT-myelography MRI : the best imaging study EMG/NCV : 90% abnormal after 1-2 weeks

32 MRI scan shows L4-5 herniated disc

33 Therapy : Conservative * bed rest : max 2 days recommended * Pharmacotherapy : -NSAID -short course of corticosteroid t idfor acute herniated itd disc (controversial) - muscle relaxant - for neuropathic pain : gabapentin, 5% lidocaine i patch, tramadol, TCA. * Nonpharmacologic therapy : - heat, ice, massage, stress reduction, activity limitation, postural modification, physical therapy program - soft cervical collar or lumbar corset

34 Therapy :Operative The few absolute indications : 1. Marked muscular weakness pertaining to a nerve root or roots. 2. Progressive neurologic deficits. 3. Cauda equina syndrome with urinary symptoms 4. Pain that has existed for more than 4 months, has not responded dd to conservative treatment, and interferes with normal function.

35 LUMBAR SPINAL STENOSIS CLINICAL SYMPTOMS : neurogenic intermittent claudiation or pseudoclaudication (most frequent) usually bilateral, but maybe unilateral a dull, aching pain the whole lower extremity is generally affected pain provoked by walking and standing, quickly relieved by sitting or leaning forward LBP presents in 65% patients with lumbar spinal stenosis radicular pain is the least common manifestation

37 MOST FREQUENT CAUSES OF SPINAL STENOSIS > 25 causes are identified The most common : 1. Idiopathic : the result of shorter than normal pedicles, thickened convergent lamina, and a convex posterior vertebral body. 2. Degenerative (50% of cases) : degenerative changes affect the facets posteriorly allowing instability and subluxation, osteophytes form and narrow the nerve root and the central canal ; and the disc anteriorly allowing the disc to bulge into the nerve root and central canal.

38 MOST FREQUENT CAUSES OF SPINAL STENOSIS 3. Degenerative spondylolisthesis : occurs when the facets degenerate, allowing slippage of fthe upper vertebrae forward over the lower vertebrae. 4. Postoperative : occurs after laminectomy or spinal fusion. Stenosis is produced by bone formation and scar tissue

39 INDICATION FOR SURGICAL TREATMENT OF LUMBAR SPINAL STENOSIS 1. Severe and disabling pain (persistent intolerable pain) 2. Limitation of walking distance or standing endurance to a degree that compromises necessary activities 3. Severe or progressive muscle weakness or disturbed bladder and bowel, or sexual function. 4. Poor response to at least 4 weeks of conservative treatment

40 THANK YOU

Degenerative Disease of the Spine

Degenerative Disease of the Spine Introduction: I. Anatomy Talk Overview II. Overview of Disease Processes: A. Spondylosis B. Intervertebral Disc Disease III. Diagnosis IV. Therapy Introduction: Myelopathy