DR.MUHAMMAD HAMID ALI
MBBS,FCPS
ASSISTANT PROFESSOR
SAAQ, DEPT. OF NEUROSURGERY
LUMHS/ JAMSHORO
SINDH
LOW BACK

Five lumbar vertebrae

Fibrocartilaginous discs b/w the

(cushions, protection)
ligaments and muscles
(stability)
facet joints
(limits & directs spinal motion)
multifidus muscles
(keep spine straight & stable in movements)
LOW BACK PAIN(LBP)

COMMON PROBLEM
→ 80% population

NO SPECIFIC CAUSE
→ 85% cases

SYMPTOM
not

2ND MOST COMMON

15% all sick leave

1% pt:

1 – 3% pt:
→

90% pt:
improve in one month

80% pt: of sciatica improve with or without surgery
AN ILLNESS
reason to seek medical advise
→ nerve root symptoms
lumbar disc herniation
CLASSIFICATION
ACUTE LBP
SUB-ACUTE LBP
CHRONIC LBP
CLASSIFICATION
Majority has DEGENERATIVE
Degenerative disc
Spinal osteoarthritis
Spinal stenosis
MECHANICAL(MUSCULOSKELETAL/NON-SPECIFIC) disorders
Myofascial disease
Fibromyalgia
DEGENERATIVE TYPE
CLSSIFICATION
Minority has NON-DEGENERATIVE LBP
Metabolic
Inflammatory
Infectious
Neoplastic
REFERRED PAIN

From other parts of body
AHCPR classification

Potentially serious spinal condition





Spinal tumors
Spinal infections
Fractures
Cauda equina syndrome
Non-specific back symptoms

Symptoms suggesting neither nerve compression nor a potentially serious
condition
AHCPR classification
Sciatica
Back related lower limb symptoms suggesting nerve root compression
ASSESSMENT
Initial assessment is geared to detecting “red flags”
Pts: with LBP, fever, weight loss, continuous stiffness, acute bone
pain &pain at rest needs to investigate for “red flags”
INITIAL ASSESSMENT
History







Age > 50 years
Previous Ca
Unexplained weight loss
Failure to improve after 1 month therapy
Pain more than 1 month
Immunosuppression
Pain worse at night
→ favor neoplastic lesion
INITIAL ASSESSMENT
History



Skin
infection
Iv drug abuse
UTI or other infection
→ favor spinal osteomyelitis
-age > 50 or 70 years
- trauma
- steroids
- bone pain
→ favor compression fracture
INITIAL ASSESSMENT
History
-LBP radiating to legs
- numbness in legs
- weakness in legs


→ favors herniated lumbar disc(sciatica)
Age > 50 years
Pain or numbness on walking → favors spinal stenosis
INITIAL ASSESSMENT
History

Bladder dysfunction


Saddle anesthesia
→ favors cauda equina syndrome
Unilateral or bilateral leg weakness or pain

Age < 40 years

AM back stiffness
Pain relieved on motion
Pain > 3 months


→ favors ankylosing spondylitis
INITIAL ASSESSMENT
History

Other factors






Work status
Typical job task
Educational level
Failed previous treatment
Addiction
depression
INITIAL ASSESSMENT
Physical examination


More helpful in identifying spinal infection than spinal cancer
Following findings favors spinal infection but may be common in pts:
without infection
 Fever (common in epidural abscess & in osteomyelitis but less common in
discitis
 Vertebral tenderness
 Very limited range of spinal motion
INITIAL ASSESSMENT
Physical examination

Finding favoring neurologic compromise
Weak dorsiflexion of ankle & big toe
Weak planter flexion
Diminished achilles reflex
Diminished light touch sensation over medial malleolus & medial foot
Diminished light touch sensation over dorsum of foot
Diminished light touch sensation over lateral malleolus &lateral foot
Scoliosis
SLR & crossed SLR
FURTHER EVALUATION

Over 95% of cases of LBP


In the initial 4 weeks of symptoms
In the absence of any “red flags” conditions
↓
NO FURTHER TESTING RECOMMENDED
Simple tests such as CBC and ESR along with x-ray of back should be
obtained if any doubt exist relating to back tumor or infection
FURTHER EVALUATION
special tests are performed to evaluate non-degenerative and
“red flags” conditions.
They are divided into 2 groups
1:-Tests to detect physiological dysfunction
A. to detect neurologic dysfunction: EMG, NCV, SEP…
B. to detect non-neurologic diseases: CBC, ESR, UCE, U/S, CAL,VIT.D,
phosphate, magnessium, parathyroid hormone level , alkaline
phosphatase, acid phosphatase, BONE SCAN…
2:- Tests to demonstrate anatomy
X-rays, CT, MRI, bone density, Myelography…
CONSERVATIVE TREATMENT


Indicated where there is no urgency for surgery or
diagnosis is non-specific
or in the absence of “red flags”.
Based on recommendation by AHCPR panel and include the following
① BED REST:Bed rest not more than 4 days by reducing movements and reducing
pressure on the nerve roots.
② AVTIVITY MODIFICATION:Tolerable physical activity to minimize disruption of daily activity.
Avoid lifting heavy weight, prolonged bending & sitting or twisting of
the back.
COSERVATIVE TREATMENT
③ EXERCISE:low stress aerobic exercise, increase gradually for few weeks
④ ANALGESICS:NSIAD, opioids in severe pain
⑤ MUSCLE RELAXANTS:Reduce pain by relieving spasm
⑥ EDUCATION:Reassurance
proper posture, lifting techniques
COSERVATIVE TREATMENT
⑦ SPINAL MANIPULATION THERAPY (SMT):In acute LBP without radiculopathy
⑧ EPIDURAL INJECTIONS:Short term relief of radicular pain
no t useful without radiculopathy
MEDICAL MANAGEMENT

Besides of above discussed measured one must see the basic
cause of disease that may be treatable medically like in
OSTEOMALACIA
Oral ergocalciferol 0.05mg(2000 iu)
U/ Violet rays
if H/O malabsorption then
5mg(200000iu) or 40 to 80 thousands iu iv
RT acidosis corrected with sodium bicarbonate
MEDICAL MANAGEMENT
OSTEOPOROSIS
Ca supplement 1 to 2 gm/day
Estrogen 0.625 mg/day for 3 to 4 weeks
Progesterone 5-10 mg/day for last 10 days of estrogen
Sodium fluoride 5 mg increases healing
T/L braces
Decrease alcohol and tobacco
Increase exercise
MEDICAL MANAGEMENT
PAGET’ DISEASE
Calcitonin 100 microgram/day with
biophosphonate & mithramycin in resistant cases
decompressive laminectomy in severe stenosis
MEDICAL MANAGEMENT
PYOGENIC INFECTION
6 weeks of intravenous antibiotics along with
rest & immobilization
GRANULOMATOUS DISEASES
Anti-fungal
Anti-tuberculous
Antibiotics
MISALLENIOUS
Steroids and chemotherapeutic agents in tumors
Interventional Treatment Options

Neural blockade



Neurolytic techniques



radiofrequency neurotomies
pulse radio frequency
Stimulatory techniques



selective nerve root blocks
facet joint blocks, medial branch blocks
spinal cord stimulation
peripheral nerve stimulation
Intrathecal medication pumps

delivery into spinal cord and brain via CSF
Physical Treatment Options

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Exercise (stabilization training)
Neutral position
Soft tissue mobilization
Transcutaneous electrical nerve stimulation (TENS)
Electrothermal therapy
Complementary measures (acupuncture;
relaxation/hypnotic/biofeedback therapy)
Spinal manipulative therapy
Multidisciplinary treatment programs (back
schools/education/counseling/pain clinic)
SURGICAL TREATMENT

INDICATION for HLD:-
Pts: with < 4 – 8 weeks of symptoms
(A). those with “RED GLAGS” 0r progressive neurological deficit
(B). Intolerable pain refractory to medical management
Pts: with > 4 – 8 weeks of symptoms
Sciatica that is both severe and disabling
SURGICAL TREATMENT
Routine HLD
Discectomy
foraminal or far lateral HLD
partial or total facetectomy
lumbar spinal stenosis
decompressive laminectomy
fracture/dislocation/instability
lumbar spinal fusion
(trauma, tumors, infections, spondylolisthesis)
instrumentation and fusion
Lumbar disc herniation
Outlines
Introduction
 Definition
 Causes
 Types of disc herniation
 Typical locations of disc herniation
 Clinical manifestations
 Diagnostic studies
 Management
 Nursing intervention

Lumbar disc herniation
Introduction
Definition of disc herniation

Abnormal rupture of the soft gelatinous
central portion of the disc (nucleus pulposus)
through the surrounding outer ring (annulus
fibrosus). In about 95% of all disc herniation
cases, the L4-L5 or L5-S1 disc levels are
involved.
Causes of lumbar disc herniation
1.
2.
3.
Trauma or injury to the disc
Disc degeneration
Congenital predisposition
Classification of LDH
Degenerated:
internal deterioration with loss of hydration and disc
space
Bulging:
Circumferential symmetric extension beyond the end
plates
Protruded:
focal or asymmetric extension beyond the interspace
(broad connection b/w the disc & the protruded disc)
Classification of LDH
Extruded disc:
(free fragment): more extreme extension
Sequestered:
free fragment contained by PLL
Contained herniation:
outer margin of anulus fibrosis is intact
(more than a bulge)
Types of disc herniation
There are three types of disc herniation
A. Protrusion / bulge
B. Disc herniation
C. Sequestration (disc rupture)
Typical locations of disc herniation
Central

It is rare condition, it will affect multiple nerve
roots, patient will have back pain more than leg
pain and it may cause incontinence of the
bladder and bowel. Urgent surgical treatment is
necessary if patient presents with neurological
deficits.
Typical locations of disc herniation
Posterolateral

Usually it is the most common location, it
involve one nerve root (the lower one).
Foraminal

It occurs in about 8-10% of all cases. It
involves the exiting nerve.
Clinical manifestations of disc
herniation



If the herniated disc is:
Not pressing on a nerve, you may have an ache
in the low back or no symptoms at all.
Pressing on a nerve, you may have pain,
numbness, or weakness in the area of your body
to which the nerve travels.
Clinical manifestations of disc
herniation

With herniation in the lower (lumbar)
back, sciatica may develop. sciatica is
pain that travels through the buttock
and down a leg to the ankle or foot
because of pressure on the sciatic
nerve. Low back pain may accompany
the leg pain.
Clinical manifestations of disc
herniation

Leg pain caused by a herniated disc

Usually occurs in only one leg.

May start suddenly or gradually.


May be constant or may come and go
(intermittent).
May get worse ("shooting pain") when sneezing,
coughing, or straining to pass stools.
Leg pain caused by a herniated disc
(cont…)


May be aggravated by sitting, prolonged
standing, and bending or twisting
movements.
May be relieved by walking, lying down,
and other positions that relax the spine and
decrease pressure on the damaged disc.
Clinical manifestations of disc
herniation





Nerve-related symptoms caused by a herniated
disc include:
Tingling ("pins-and-needles" sensation) or numbness
in one leg that can begin in the buttock or behind
the knee and extend to the thigh, ankle, or foot.
Weakness in certain muscles in one or both legs.
Pain in the front of the thigh.
cauda equina syndrome
Diagnostic studies

MRI is the test of choice for evaluation of
disc disease. Its multiplanar capabilities
make it suitable for visualizing far lateral
disc herniation as well as the paravertebral
structures.
Management of disc herniation




The medical management traditionally involves:
Bed rest and analgesics and anti-inflammatory
drugs.
Muscle relaxants help in some. Transcutaneous
electrical nerve stimulation (TENS) helps in about
20% of patients.
Physical therapy such as (exercise, relaxation,
massage, and hot compressors).
Management of disc herniation

Surgical management:
Indications for surgery include failure of
acceptable pain control by nonoperative
measures, progressive neurological deficit.
The traditional approach to lumbar
discectomy (laminectomy) usually under
general anesthesia.
Nursing intervention
Reducing pain
 Bed rest
 Comfortable position such as semi-fowler's with
moderate hip and knee flexion or side lying
position.
 Progressive ambulation
Patient's education
 Exercise
 Proper position
 Avoid lifting
Summary





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
Common problem
Increasing disability
Initial 4 weeks medically, physically
More than 4 weeks and “red flags”
Needs further evaluation
refer to neurosurgeon
Surgery has excellent result in sciatica
THANKS