Low back pain

Presented byMostafa kamal Abdellatif

Lecturer of Anesthesia departmentAin Shams University

Pain that occurs in an area with boundaries between the

lowest rib and the crease of the buttocks

Types of back pain

Acute back pain

Pain with acut onset and rapid progressive course.

Chronic back pain

Pain that persists longer than the expected time period for healing

greater than 3 months.

What is back pain?

EpidemiologyLow back pain that lasts at least one day and limits activity is a very common and widespread complaint. Over a lifetime, 80% of people have lower back pain,with the difficulty most often begin-ning between 20 and 40 years old.It is most common among women, and among people aged 40–80 years, with the overall number of individuals affected expected to increase as the population ages. Women may be more prone to raise the complaint due to pain related to osteoporosis, menstrua-tion or pregnancy.

Classification

There are many different methods for classi-fication:1) According to origin: Mechanical and Non mechanical2) According to signs and symptoms: Non specific, Radicular and Specific.3) According to chronicity: Acute, Subacute and chronic.

Etiology of back painAcute back pain Acute low back pain is most often caused by a sudden injury to the muscles and ligaments supporting the back. It lasts for six weeks

Subacute back pain

It is from six to tweleve weeks

Chronic back pain :

It prersists more than tweleve weeks

Mechanical Endocrinologic

Rheumatologic Hematologic

Infection Neurologic. Referred

Neoplastic Psychiatric Miscella-neous

Mechanical 85% of all low back pain Muscle, ligament, tendon strain.Discogenic disorders including herniated disc.Apophyseal joint arthritis.Spinal stenosis.Spondylolysis, spondylolisthesis.Scoliosis.

Sources of low back painSuperficial somatic - skinDeep somatic - muscle, joint, tendon, bursa, fasciaRadicular - nerve rootVisceral referred - sympathetic afferentsNeurogenic - mixed motor sensory nervesPsychogenic - cerebral cortex

Pain intensityMinimal - mentioned in passing, normal functionMild - component of symptoms, mild dysfunctionModerate - major component of symp-toms, alters functionSevere - the disease symptom, incapaci-tating function

Diagnosis of low back pain1) History Red flags as cancer, cauda equina syndrome, fracture and infection.

2) ExaminationInspection: No obvious deformities, No erythema or Skin lesions (Zoster)

Palpation:Soft Tissue: we examine 3 clinical zones (Paraspinal muscles, Gluteal muscles, Sciatic area)Bones Primarily palpating spinous processes and facets

Range of movement:Flexion - 80º, Extension - 35º, Side bending - 40º each side

Twisting - 3-18ºStrengthNeurovascularSpecial Tests

3) Radiology

Special testsStraigth leg raising testRaising of stretched limb in supine position, positive test detected by pain in the limb.

Sciatic stretch testIn case of positive SLR, lowering the stretched leg 10 degrees detect pain in foot.

FADIR test:Flexion. AdductionInternal rotation

FABER test:Flexion Abduction External rotation

Hoover testHelps to determine whether pt is malingering, Should be per-formed in conjunction with SLRWhen pt is genuinely attempting to raise leg, he exerts pres-sure on opposite calcaneus to gain leverage

Neurological TestingSensationStrengthReflexes

Choice to do imaging based on:Trauma, chronic steroid use = XRaySuspect abscess, cauda equina = MRIExaminationNew/severe sensory or strength loss = consider MRI

Treatment of back pain

Mild to Moderate single drug v. placebo (active comparator).

Moderate to Severe stable multidrug regimen - flare with withdrawal.

Bed rest for 1-2 weeksMultimodalityBack exercises - flexion and/or extensionAerobic exerciseMedicationsCounterirritant topical therapiesStress management

MedicationsNSAIDsMuscle relaxantsAnalgesicsAntidepressantsAnticonvulsantsAlpha-2 adrenergic agonistsMiscellaneous

NSAIDSImprove pain vs. placebo in controlled trialShort half-lifeacute exacerbations, quick onset

Long half-lifeSustained effectCox - 2 inhibitors

Muscle relaxants Most beneficial in the first week, Shown effective in trials.Similar efficacy,Work best when combined w/ NSAIDs.CyclobenzaprineOrphenadrineMetaxoloneChlorzoxazoneMethocarbamol

AnalgesicsNonnarcoticAcetaminophenTramadolNarcoticShort actingLong acting

AntidepressentsTricyclic and tetracyclic antidepressents as. ami-titriptylline, maprotiline.

AnticonvulsantsGabapentinPregabalin

Interventional therapySimple injections of plain local anaesthetic without adrenalin or cortisone. Specific management includes medial branch and sacroiliac joint blocks, and radiofrequency neurotomy. Patients with long term pain may be referred to a psy-chologist for cognitive behavioural therapy.