Low Back Pain J o h n G i l l i c k, M D UCSD Clinical Professor Internal Medicine and Anesthesiology, non-salaried
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1 Low Back Pain J o h n G i l l i c k, M D UCSD Clinical Professor Internal Medicine and Anesthesiology, non-salaried 1
2 Chronic Recurring Low Back Pain 2
3 jsgillick 3
4 Chronic Recurring Low Back Pain CUMULATIVE TRAUMA APPROACH TO Low Back Pain 4
5 Chronic Recurring Low Back Pain Back Pain is a SYMPTOM not a DIAGNOSIS 5
6 Chronic Recurring Low Back Pain Back pain symptoms May be relieved by: A. Increasing central tolerance; (drugs) B. Central blocking of thalamic reception; (drugs) C. Interference with spinal neural receptors; (drugs) D. Severance of neural pathways; (drugs surgery) E. Silencing the site or origin; (injection - surgery); or F. Removal of the causes. (behavioral mod. & balance) 6
7 Chronic Recurring Low Back Pain Back pain symptoms REMOVED by: Elimination of the causes Make the DIAGNOSIS! 7
8 Chronic Recurring Low Back Pain Archives of Internal Medicine Controversies in Internal Medicine: July 8, 2002 Lack of evidence-based research for idiopathic low back pain: the importance of a specific diagnosis. --Abraham & Killackey-Jones 8
9 Radiographic studies: Spine: 2000; 25: Back Pain -Causation- what is the value? *DIAGNOSTICS Spine: 1997; 22: N England J Med: 1994; 331: Spine: 1995; 20: Screening VALUE = Zilch or less J Bone Joint Surg Am: 1990; 72: JAMA: 2003; 279,21: (value plain X-ray to 6 wk.) 9
10 Chronic Recurring Low Back Pain Asymptomatic Adults MRI Abnormalities Disc degeneration 46-72% Bulging Disc 24-81% Disc Herniation 22-40% Annular tear 14-56% Stenosis 1-21% - FINDINGS - NOT DIAGNOSES! Boden 1990 Jensen 1994 Stadnik 1998 Weinhaupt
11 Chronic Recurring Low Back Pain ALL Back pain Muscular-myofascial components Caused / Continued by CUMULATIVE TRAUMAS 11
12 MOST Chronic Recurring Low Back Pain Back pain COMES FROM CHRONIC MUSCULAR SPASM 1º (muscle - motor unit - fatigue) 2 ndary (nerve entrapment) MUSCLE FATIGUE 12
13 Chronic Recurring Low Back Pain Ongoing Back Pain Symptoms are 95% Musculo Myofascial IDIOPATHIC = DIAGNOSIS (?) in origin SYMPTOMS CAUSE 13
14 MAKE THE Diagnosis DETERMINE THE SPECIFIC ANATOMICAL MUSCULAR-MYOFASCIAL DYSFUNCTION(S) THEN Chronic Recurring Low Back Pain IDENTIFY THE Causes FOR THE ANATOMICAL MUSCULO-MYOFASCIAL DYSFUNCTION(S) Primary & Secondary Precipitant Cause (s) All Contributing Cause (s)s 14
15 Chronic Recurring Low Back Pain Highest estimate: <10% Spinal canal: Intervertebral path: Disc rupture, Radicular < (<1%) operable disc Highest estimate: <5% Structural: stenosis, fracture, unstable < ( <½ %) operable Lowest estimate: Etiology = >85% Idiopathic: (musculo,ligamentous, myofascial, facet, etc.) 15
16 Chronic Recurring Low Back Pain 16
17 Back Pain Diagnosis - Causation 17
18 Chronic Recurring Low Back Pain ANALOGY 18
19 Chronic Recurring Low Back Pain The precipitant: may be a specific event. Cause of pain is rarely singular usually multiple 19
20 Chronic Recurring Low Back Pain BACK PAIN is a Cumulative-trauma Phenomenon www. 20
21 jsgillick 21
22 Chronic Recurring Low Back Pain TWELVE CONSIDREATIONS in DIAGNOSIS and MANAGEMENT of LOW BACK PAIN 22
23 5-- Specific Diagnoses; 7 Contributors Structural injuries disruptions, sudden or gradual: (2) -- <5% Chronic Recurring Low Back Pain -2 Structure pathology Specific nerve-cord pressure Structural instability/damage Specific strain injuries (Jolting) episodic, may be chronic, recurring: (3) -- 45% -3 Jolt, jarring episodic Ilio-psoas muscle strain Costo-vertebral dysfunction SI joint strain/ dysfunction Axial support- muscle strain-sprains --- specific identifiable postural muscles --45% Postural contributors chronic disruptions Behavioral or Anatomical: (7) --Effect 90% -4 Behaviors / mechanics Sleep position Loss of arch height Wallet in the back pocket Stick-shift vehicle -3 Anatomical shape Short upper-arm length Leg length difference Short hemi-pelvis 23
24 Chronic Recurring Back Pain SPECIFIC DIAGNOSES Structure pathology INTERVERTEBRAL Diagnoses -2 2% Primary 12% Prevalence Specific nerve-cord pressure Structural instability/damage 24
25 Chronic Recurring Back Pain SPECIFIC DIAGNOSES Jolting - episodic TAUMA - JOLT Diagnoses -3 45% Primary 50% Prevalence Ilio-psoas muscle strain Facet Dysfunction (Lumbar-Thoracic) SI joint strain/ dysfunction 25
26 Chronic Recurring Back Pain SPECIFIC DIAGNOSES Postural muscle strains DEFAULT 45% Primary LOW BACK Quatrus lumborum* Ilio-costalis* Pyriformis* (Ilio-psoas) Gluts-min, mid, max* Multifidi 90% Prevalence HIP, LEG, GROIN Pyriformis* Tensor fascia lata* Gluteus min, mid, max* (Ilio-psoas) Rarely alone usually in multiples 26
27 Chronic Recurring Back Pain PRECIPITANT CHARACTERISTICS 7- PLAYERS in ONSET & in MAINTENANCE of the BACK PAIN CONDITION Behavior / mechanics 90%+ FACTORS -7 Sleep position Loss of arch height Wallet in the back pocket Stick-shift vehicle Anatomical shape - postures Short upper-arm length Leg length difference Short hemi-pelvis 27 www.
28 LOW BACK PAIN 2 Structure pathology 3 Jolting - episodic Postural muscle strains 7- PLAYERS in ONSET & in MAINTENANCE of the BACK PAIN CONDITION 28
29 Chronic Recurring Back Pain SPECIFIC DIAGNOSES Structure pathology Play a role in < 15% S-1 Specific nerve-cord pressure S-2 Structural instability/damage 29
30 Back Pain -- Specific Diagnosis S-1. Specific nerve, cord pressure: S-1 Structure 30
31 Back Pain -- Specific Diagnosis S-2. Structural stability/ damage: S-2a Structure compression fractures Elizabeth
32 Structure spondylolysis/ Spondylolisthesis Back Pain -- Specific Diagnosis S-2b Karl 32
33 Chronic Recurring Back Pain SPECIFIC DIAGNOSES Start Jolting Jolting - Play a role in 35% + episodic J-1 Ilio-psoas muscle strain J-2 Facet dysfunction (Lumbar-thoracic) J-3 SI joint strain/ dysfunction 33
34 Ilio psoas strain J-1. Ilio psoas strain Back Pain -- Specific Diagnosis Sudden, acute strain may become chronic J 1 Jolting - episodic 34
35 Ilio psoas strain 20 +% of acute OccMed back injuries Back Pain -- Specific Diagnosis First onset is Jolting Trauma Jerking catch Auto collision Fall Bike Digging Can turn chronic 35+% chronic disabling idiopathic back problems - groin pains - - totally numb leg - 35 J 1
36 Ilio psoas strain Back Pain -- Specific Diagnosis J 1 36
37 Ilio psoas strain Back Pain -- Specific Diagnosis J 1 37
38 Ilio psoas strain Related Neuropathies come & go Specific Diagnosis Back Pain J 1 38
39 Ilio psoas strain Back Pain -- Specific Diagnosis J 1 Diagnosis Treatment 39
40 Ilio psoas strain Back Pain -- Specific Diagnosis J 1 40
41 J-2. Facet Dysfunction (Lumbar-Thoracic Strain) Facet Dysfunction Back Pain -- Specific Diagnosis Jolting sudden J 2 Thoracic strain THORACIC FACET SD 41
42 Facet Dysfunction Thoracic strain THORACIC FACET SD Back Pain -- Specific Diagnosis J 2 42
43 Facet Dysfunction Back Pain -- Specific Diagnosis Thoracic Facet J 2 Often recurring / chronic 5+ % chronic disabling idiopathic mid-back problems -Low back, mid back, shoulder, neck, arm Costochondritis Twist & reach Fall Jerk arm Sleep wrong Fall, hit chest Overhead pull 20 +% of acute OccMed back injuries - Non-cardiac chest pain Idiopathic neuropathy of the upper extremity 43
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