Low Backache
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Transcript of Low Backache
Understanding Understanding Low BackacheLow Backache& its & its basis of basis of treatment treatment
Bhaskar BorgohainBhaskar Borgohain MS ortho, DNB ortho, Fellow (Arthroplasty)MS ortho, DNB ortho, Fellow (Arthroplasty) Asst Professor, Department of Orthopaedics. Asst Professor, Department of Orthopaedics. NEIGRIHMSNEIGRIHMS
MOVEMENT IS LIFE
LIFE IS MOVEMENT
PAINLESS MOVEMENTPAINLESS MOVEMENTMEANS MEANS
ENJOYING A ENJOYING A QUALITY OF LIFEQUALITY OF LIFE
PAINFUL MOVEMENTSPAINFUL MOVEMENTSMEANSMEANS
JUST HAVING A LIFEJUST HAVING A LIFEOR EVEN WORSEOR EVEN WORSE
Biomechanics is nothing but the scientific Biomechanics is nothing but the scientific study of the movements of the spine;study of the movements of the spine;
in health & diseasein health & disease
Movements are so essential or at times so Movements are so essential or at times so bizarrebizarre
Low back: Lumbo-sacral SpineLow back: Lumbo-sacral Spine
Anatomically Multisegmental column: Anatomically Multisegmental column: Connects upper torso to the pelvisConnects upper torso to the pelvis
Function: Maintains upright position (Function: Maintains upright position (stabilitystability) ) Yet allow great Yet allow great flexibilityflexibility for actions: 5 Discs for actions: 5 Discs During all ROMs provide a During all ROMs provide a protective conduitprotective conduit
for neurological structures within for neurological structures within Practically No rotation possible: FacetsPractically No rotation possible: Facets
Functional components of lumbar Functional components of lumbar spinespine
Each Lumbar vertebra Each Lumbar vertebra has 3 Componentshas 3 Components
Body : To bear weightBody : To bear weight The Neural Arches: The Neural Arches:
To protect the neural To protect the neural elementselements
Bony Processes: To Bony Processes: To increase efficacy of increase efficacy of spinal muscle actionsspinal muscle actions
SPINAL STABILITY SYSTEMSPINAL STABILITY SYSTEM
3 Interrelated subsystem3 Interrelated subsystem ActiveActive: Actively contracting muscles : Actively contracting muscles
(Erectors / Abdominals)(Erectors / Abdominals) PassivePassive: Bone, Joints, Ligaments, : Bone, Joints, Ligaments,
Passively elongated musclesPassively elongated muscles NeuralNeural ( (ControlControl): Neural elements within ): Neural elements within
the active & passive subsystem giving the active & passive subsystem giving Dynamic stabilityDynamic stability
LIMITATIONSLIMITATIONS
Cadaveric:Cadaveric: Muscle contarctionsMuscle contarctions Neural controlNeural control Dynamic balancingDynamic balancing Translating lab finding to real time Translating lab finding to real time
situationssituations Clinical implicationsClinical implications
Components of Lumbar SpineComponents of Lumbar Spine
Normal biomechanics of spineNormal biomechanics of spine
Photo of a gymnastPhoto of a gymnast Endless potentialEndless potential Elastic limits: Young’s modulus Elastic limits: Young’s modulus Pathobiomechanics: LBAPathobiomechanics: LBA
Pain sensitive structures of the Pain sensitive structures of the spinespine
Ligaments: PLLLigaments: PLL Nerves: sinuvertebral nerveNerves: sinuvertebral nerve Facet joint capsuleFacet joint capsule PeriosteumPeriosteum Meningeal coveringsMeningeal coverings MusclesMuscles
LBA: The grey zoneLBA: The grey zone Biological enigmaBiological enigma Exact cause: 12-15%Exact cause: 12-15% Evolutional paradoxEvolutional paradox Proud spine in HealthProud spine in Health Terrible back in DiseaseTerrible back in Disease Back Abuse/ OveruseBack Abuse/ Overuse
Epidemiology & Natural history Epidemiology & Natural history
Over 80% of population experience some back Over 80% of population experience some back pain in their lifetime pain in their lifetime
(Quebec task force study on spinal disorders)(Quebec task force study on spinal disorders) Overall Prevalence 18%, Annual incidence 15-Overall Prevalence 18%, Annual incidence 15-
20%(USA)20%(USA) Good news: 50% recover in 2 weeks; 90% in 6 Good news: 50% recover in 2 weeks; 90% in 6
wkswks Bad news: Only 1% chronically disabledBad news: Only 1% chronically disabled Ugly truth: 80% Hospital resources drainedUgly truth: 80% Hospital resources drained
Simple Mechanical Backache Simple Mechanical Backache Vs Vs
Sinister BackacheSinister Backache
Green flagGreen flag Noninflammatory Noninflammatory
backachebackache No constitutional No constitutional
symptomssymptoms No obvious spinal No obvious spinal
deformitydeformity No neurological deficits or No neurological deficits or
tension signstension signs Not in Extremes of ageNot in Extremes of age
Red flagRed flag InflammatoryInflammatory Constitutional symptomsConstitutional symptoms Spinal deformitySpinal deformity Neurological deficits or Neurological deficits or
tension signstension signs Extremes of ageExtremes of age
MECHANICAL BACKACHEMECHANICAL BACKACHE
Nothing is gravely Nothing is gravely wrong except the wrong except the backache itselfbackache itself
Non-inflammatory, non-Non-inflammatory, non-infective & non-infective & non-neoplastic pathology neoplastic pathology
Lumbar Disc disease: Lumbar Disc disease: includedincluded
Dull backache Dull backache aggravated by activityaggravated by activity
Physical signs often Physical signs often slightslight
Neurological deficit nilNeurological deficit nil Extensive radiating Extensive radiating
pain to lower limbs pain to lower limbs absentabsent
IMPORTANCE OF IMPORTANCE OF BIOMECHANICS OF SPINE BIOMECHANICS OF SPINE
Stability Vs MobilityStability Vs Mobility Spinal motion Spinal motion
segmentssegments Disc & Facet joints Disc & Facet joints
close to nerve rootsclose to nerve roots Compressible gelCompressible gel Mobile Ball bearing Mobile Ball bearing
actionaction
BIOMECHANICAL ANATOMY BIOMECHANICAL ANATOMY
Hourglass connectionHourglass connection Dynamic balanceDynamic balance Abdominal muscle Vs Abdominal muscle Vs
erector spinae group erector spinae group of muscleof muscle
Intrathoracic pressure Intrathoracic pressure and intrabdominal and intrabdominal pressurepressure
Dynamic balanceDynamic balance
INTRADISCAL PRESSUREINTRADISCAL PRESSURE
IDP changes with IDP changes with positionposition
Sitting worse, Sitting worse, Standing better ,lying Standing better ,lying supine bestsupine best
After 6 hours After 6 hours statistically significant statistically significant reduction of normal reduction of normal disc heightdisc height
DDD (Degenerative Disc disease) DDD (Degenerative Disc disease) PathobiomechanicsPathobiomechanics
Loss of water content Loss of water content Abnormal stresses / Abnormal stresses /
biomechanicsbiomechanics Further degenerationFurther degeneration Facet degenerationFacet degeneration Disc prolapse: Weak Disc prolapse: Weak
PLLPLL Discogenic back painDiscogenic back pain
Poor blood supply: poor healing
WHOOP STRESSWHOOP STRESS
DISC SPACE LOSS: SEQUELDISC SPACE LOSS: SEQUEL
Sequel of Collapse of disc space: Sequel of Collapse of disc space: Distorted attempt to stabilityDistorted attempt to stability
Segmental spinal instability: Segmental spinal instability: Motion segment Motion segment abnormality-abnormality- All column disturbances All column disturbances
Facetopathy: Abnormal stress on facet jointsFacetopathy: Abnormal stress on facet joints Vertebral end plate sclerosisVertebral end plate sclerosis Ligamentum flavum hypertrophyLigamentum flavum hypertrophy Secondary canal stenosisSecondary canal stenosis LBA: Final common pathwayLBA: Final common pathway
DISC DESSICATIONDISC DESSICATIONPoor vascularity: Poor healingPoor vascularity: Poor healing
Discogenic back painDiscogenic back pain Axial low back painAxial low back pain Sinuvertebral nerve arise from dorsal root Sinuvertebral nerve arise from dorsal root
ganglion: non-segmental innervationsganglion: non-segmental innervations S.V.N. Innervates posterior annulus close S.V.N. Innervates posterior annulus close
to PLL is irritatedto PLL is irritated Disc bulges on axial compressionDisc bulges on axial compression Axial pain begins d/t signal carried by Axial pain begins d/t signal carried by
paravertebral sympathetic trunkparavertebral sympathetic trunk
Discogenic back painDiscogenic back pain
Mangement Mangement
Goal: Early return to workGoal: Early return to work Tailored to each patientTailored to each patient Interdisciplinary approachInterdisciplinary approach Modify activity in acute phaseModify activity in acute phase Confirming the diagnosisConfirming the diagnosis
Chronic Low BackacheChronic Low Backache
ABNORMAL POSTUREABNORMAL POSTURE
Lx lordosisLx lordosis Infancy Vs adulthoodInfancy Vs adulthood Muscle weaknessMuscle weakness Muscle fatigueMuscle fatigue
MODALITIES OF MANGEMENTMODALITIES OF MANGEMENT
Touching the back!Touching the back! Counseling: Back SchoolingCounseling: Back Schooling Posture care: Do & Don’t list Posture care: Do & Don’t list Use of firm mattressUse of firm mattress Avoiding cumulative microtrauma to Avoiding cumulative microtrauma to
spinespine Developing positive attitude: DepressionDeveloping positive attitude: Depression
Bed rest: Contradictory to the goalBed rest: Contradictory to the goal Bed rest of > 2days has serious implicationsBed rest of > 2days has serious implications 3% of muscle bulk/ mass is lost daily3% of muscle bulk/ mass is lost daily 6% of bone demineralized in 2 weeks6% of bone demineralized in 2 weeks Restriction of social activity & inability to carry Restriction of social activity & inability to carry
out responsibilities PPT depression, illness out responsibilities PPT depression, illness behavior & lack of motivationbehavior & lack of motivation
Adequate sleep: of course yes, endorphin/ Adequate sleep: of course yes, endorphin/ melatoninmelatonin
MAN Vs SUPERMAN?MAN Vs SUPERMAN?
““Man is a social animal”Man is a social animal” Anatomically & Physiologically we are nothing Anatomically & Physiologically we are nothing
but but AnimalsAnimals We are probably the only Animals that sit for 5 We are probably the only Animals that sit for 5
hours in the computer when the body is asking hours in the computer when the body is asking for rest & sleep!for rest & sleep!
Man cannot run faster than a cheetah but he can Man cannot run faster than a cheetah but he can drive at 100km/hour and stop in less than a drive at 100km/hour and stop in less than a secondsecond
Brunt is taken by the Spine,Discs and LigamentsBrunt is taken by the Spine,Discs and Ligaments
BACK SCHOOL - IBACK SCHOOL - I
Don't try to be supermanDon't try to be superman Anatomically & Physiologically we are manAnatomically & Physiologically we are man Maintain good postureMaintain good posture Take frequent break at workTake frequent break at work Use your back but don't abuse itUse your back but don't abuse it
BACK SCHOOL - IIBACK SCHOOL - II
Smoke at your own perilSmoke at your own peril Modify your activity to give rest to the tired Modify your activity to give rest to the tired
backback Never flog a tired horseNever flog a tired horse
“ “Single footstep of a man a giant leap for Single footstep of a man a giant leap for the man’s back”the man’s back”
Medications Medications
NSAIDs: 1NSAIDs: 1STST Line Line Narcotics: Not beyond Narcotics: Not beyond
2 weeks2 weeks Muscle relaxant: No Muscle relaxant: No
rolerole Antidepressant :Only Antidepressant :Only
if >3 monthsif >3 months
Trigger point Trigger point injections: No roleinjections: No role
Spinal manipualation: Spinal manipualation: Controversial OR Controversial OR contraindicated if disc contraindicated if disc herniationherniation
SIMPLE BACKACHE IS NOT SIMPLE BACKACHE IS NOT SIMPLESIMPLE
Functional restoration program involv. Functional restoration program involv. interdisciplinary approach if no narcotics or interdisciplinary approach if no narcotics or surgery neededsurgery needed
Psychological evaluation or Psychiatric Psychological evaluation or Psychiatric analysis whenever possibleanalysis whenever possible
Treat co morbid condition that may Treat co morbid condition that may aggravate LBAaggravate LBA
SIMPLE BACKACHE IS NOT SIMPLESIMPLE BACKACHE IS NOT SIMPLE Malingerers backache: Malingerers backache:
Compensation Compensation
Hoover’s TestHoover’s Test Simulation Rotation TestSimulation Rotation Test Pelvic Compression TestPelvic Compression Test Sitting SLR TestSitting SLR Test Adams anterior bending testAdams anterior bending test Sickness absenteeismSickness absenteeism
SIMPLE BACKACHE IS NOT SIMPLESIMPLE BACKACHE IS NOT SIMPLE Referred pain: High index of Referred pain: High index of
suspicionsuspicion Hips: Compensatory painHips: Compensatory pain Pelvic organsPelvic organs S.I. Joints or pelvisS.I. Joints or pelvis Renal & Retroperitoneal tumorRenal & Retroperitoneal tumor Vascular: aneurysmVascular: aneurysm
Cure Vs Curiosity in BackacheCure Vs Curiosity in Backache
Can we Can we curecure backache :yes backache :yes Can we cure spondylosis: noCan we cure spondylosis: no Does all disc prolapse need operation: noDoes all disc prolapse need operation: no Is it possible to have a Is it possible to have a normal normal life after a life after a
disc prolapse: yesdisc prolapse: yes Can physiotherapy improve spinal Can physiotherapy improve spinal
biomechanics: yesbiomechanics: yes
Physical therapyPhysical therapy Exercises : once acute phase is overExercises : once acute phase is over Heat/Infrared/ US TherapyHeat/Infrared/ US Therapy Electric StimulationElectric Stimulation IFT: only if acute phase is overIFT: only if acute phase is over TENS: only if acute phase is overTENS: only if acute phase is over C fibre & Gate theoryC fibre & Gate theory Endorphin?Endorphin?
Thermal therapyThermal therapy
Heat : SuperficialHeat : Superficial Infrared: Deep Infrared: Deep US Therapy: Deep US Therapy: Deep
Increase circulationIncrease circulation Wash off cytokinesWash off cytokines Promote healingPromote healing Relieve spasmRelieve spasm CounterirritantCounterirritant Touch Touch
Pregnancy Pregnancy
Pregnancy aggravates LBAPregnancy aggravates LBA Weight Gain & Pull Of AbdomenWeight Gain & Pull Of Abdomen Address LBA appropriately FirstAddress LBA appropriately First Surgery if indicated: Do FirstSurgery if indicated: Do First Ligament LaxityLigament Laxity OsteomalaciaOsteomalacia PhysioTh: Impractical (3PhysioTh: Impractical (3rdrd Trimester) Trimester)
Facet injectionsFacet injections
Limited Indications: Not a common source Limited Indications: Not a common source of pain of pain
Pain in spinal extension & radiation to Pain in spinal extension & radiation to back of thigh that ends above knee levelback of thigh that ends above knee level
Multiple Joints and Peculiar nerve supplyMultiple Joints and Peculiar nerve supply Doesn’t Change the Pathology: AdjunctDoesn’t Change the Pathology: Adjunct
Epidural steroids/blockEpidural steroids/block
Controversial indicationsControversial indications Decreases sciatic painDecreases sciatic pain Unpredictability: Inoperable patientUnpredictability: Inoperable patient Undermines the actual diseaseUndermines the actual disease Complications & Wrong diagnosisComplications & Wrong diagnosis
Surgery: Laminectomy:Surgery: Laminectomy:
Cauda equina syndrome: Hemilaminectomy Cauda equina syndrome: Hemilaminectomy Single Laminectomy : 14% overall instabilitySingle Laminectomy : 14% overall instability Cadaver study (Punjabi): Cadaver study (Punjabi):
Unilat. Or B/L facetectomy increasedUnilat. Or B/L facetectomy increased
63% Flexion,63% Flexion,
78% extension,78% extension,
15% lateral bending &15% lateral bending &
126% axial rotation126% axial rotation
Surgery: Spinal fusionSurgery: Spinal fusion
Rigid stabilization: Rigid stabilization: Spinal fusion Spinal fusion ++ Facetal FusionFacetal Fusion
Halts abnormal Halts abnormal biomechanics at biomechanics at fused levelfused level
ALIF or PLIF ALIF or PLIF Post. or PostlateralPost. or Postlateral Intertransverse fusionIntertransverse fusion
Posterior: Rods & Posterior: Rods & pedicular Screws pedicular Screws
Anterior: Rods & Anterior: Rods & ScrewsScrews
Address secondary Address secondary causes:causes:
3603600 0 FusionFusion
Surgery: Spinal fusionSurgery: Spinal fusion
Persistent disabling Persistent disabling Discogenic axial lowDiscogenic axial low back painback pain in absence of other organic or in absence of other organic or psychological component: psychological component: 70-80%70-80%
Multilevel discectomyMultilevel discectomy Documented instabilityDocumented instability
DISC PROLAPSE: SURGICAL DISC PROLAPSE: SURGICAL INDICATIONS INDICATIONS
Acute neurological complicationsAcute neurological complications Gradual but progressive neurological Gradual but progressive neurological
deteriorationdeterioration Persistent radiating pain despite strict bed Persistent radiating pain despite strict bed
rest and medication for 3- 4 weeksrest and medication for 3- 4 weeks
Why 3 - 4 Wks: TNF,CytokinesWhy 3 - 4 Wks: TNF,Cytokines
CONTAINED DISCS UNCONTAINED DISCS
BULGE PROTRUSION EXTRUTION SEQUESTRATION
DISC: TYPES OF INTERVENTIONSDISC: TYPES OF INTERVENTIONS
Chymopapain InjectionChymopapain Injection (Europe): Anaphylaxis(Europe): Anaphylaxis
MicrodiscectomyMicrodiscectomy: Good : Good optionoption
Open discectomyOpen discectomy: : Objectivity + Complete Objectivity + Complete Neural decompressionNeural decompression
Laser discectomy: Laser discectomy: Contained discContained disc
Endoscopic discectomy:Endoscopic discectomy: Intradiscal electrothermal Intradiscal electrothermal
therapytherapy: Thermally ablate : Thermally ablate the sinuvertebral nerve the sinuvertebral nerve fibre of posterior annulusfibre of posterior annulus
Endoscopic discectomy: Endoscopic discectomy: Transperitoneal video-assistedTransperitoneal video-assisted
Technically Technically demanding: demanding:
ComplicationsComplications Overall: 4.7% Overall: 4.7% cf cf
2.3%2.3% Vascular injury: 2.1% Vascular injury: 2.1%
to 25%to 25%
Retrograde Retrograde ejaculation: ejaculation: << 9.4% 9.4%
DVTDVT Visceral injury, Visceral injury, Paralytic ileusParalytic ileus
Dynamic stabilizationDynamic stabilization
Fusion may fail to relieve Fusion may fail to relieve painpain
Preserve movements of Preserve movements of motion segmentmotion segment
Instruments or artificial Instruments or artificial ligaments to control ligaments to control movementsmovements
Load sharing during Load sharing during movementsmovements
Don’t remove or disturb Don’t remove or disturb normal anatomynormal anatomy
Augmenting weak Augmenting weak ligaments and muscles ligaments and muscles without fusion without fusion
Graf ligament Graf ligament recontruction: mimic recontruction: mimic normal biomechanicsnormal biomechanics
Interspinous Spacer Interspinous Spacer (DIAM): no osteoporosis(DIAM): no osteoporosis
Disc replacementDisc replacement
Aim: Painless, Mobile and Stable Spine,Aim: Painless, Mobile and Stable Spine, Replaces anatomical structuresReplaces anatomical structures Correct Soft tissue tensioning crucial for Correct Soft tissue tensioning crucial for
maintaining spinal stabilitymaintaining spinal stability Pain causing structures are physically Pain causing structures are physically
removed at surgeryremoved at surgery Long term Safety: FDA ( MoM / MoP)Long term Safety: FDA ( MoM / MoP)
Gene transferGene transfer
Biochemical changes in nucleusBiochemical changes in nucleus Adenovirus as vector: rat modelAdenovirus as vector: rat model IRAP (interleukin receptor antagonist) or IRAP (interleukin receptor antagonist) or
Lac Z geneLac Z gene Increase synthesis of PGIncrease synthesis of PG Immune privileged cells of nucleusImmune privileged cells of nucleus Prophylactic injections?Prophylactic injections?
ALTERNATIVE THERAPYALTERNATIVE THERAPY
Too many options means too little knownToo many options means too little known The exact cause found in only 12-15%The exact cause found in only 12-15% Biofeedback: No role after 2 weeks of trialBiofeedback: No role after 2 weeks of trial Acupuncture: No role after 2 weeks of trialAcupuncture: No role after 2 weeks of trial Massage: breakdown adhesions Massage: breakdown adhesions YogaYoga Endorphin!Endorphin!
Summary Summary LBA In man is a biological LBA In man is a biological
enigmaenigma Mobility leads to repetitive Mobility leads to repetitive
cumulative microtraumacumulative microtrauma Microtrauma PPT Microtrauma PPT
degenerative changesdegenerative changes Microtauma progresses Microtauma progresses
to macrotrauma in to macrotrauma in prolonged back abuseprolonged back abuse
Degeneration reduces Degeneration reduces mobility Decrease mobility Decrease mobility causes muscle mobility causes muscle atrophyatrophy
Abnormal segmental Abnormal segmental motion startsmotion starts
Abnormal biomechanics Abnormal biomechanics evolvesevolves
& encroaches neural & encroaches neural elementselements
Secondarily encroaches Secondarily encroaches neural elementsneural elements
Low back Pain beginsLow back Pain begins
Thank you