‫بسم هللا الرحمن الرحیم‬
Low back pain
By
dr HABIBOLLAHI
1
LBP is one of the most common subjective health
complaints in Western populations. In Britain, the
1 year prevalence was 49% and in the Nordic
countries the 1 month prevalence of LBP was 35%.
 Low back pain is one of the most frequent medical
causes of absence from work, and disability arising
from chronic back pain is now a major welfare and
economic problem

2
Low back pain is the fifth most common reason
for all physician visits in the United State
Approximately one quarter of U.S. adults reported having
low back pain lasting at least 1 whole day in the past 3
months, and 7.6% reported at least 1 episode of severe
acute low back pain within a 1-year period
One third of all disability costs in the United States are
related to low back pain.



3
Differential - three broad categories:
1.
2.
3.
4
Mechanical (97%)
Nonmechanical (~1%)
Visceral (~2%)
Differential: Mechanical LBP
Lumbar Strain or Sprain (70%)
Degenerative processes of disc and facets (10%)
Herniated disc (4%)
Osteoporotic Compression Fracture (4%)
Spinal Stenosis (3%)
Spondylolisthesis (2%)
Traumatic Fractures (<1%)
Congenital disease (<1%)










Severe Kyphosis or Scoliosis
Transitional Vertebrae
Spondylolysis
Internal Disc Disruption/Discogenic Back Pain
Presumed Instability



5
Differential - Nonmechanical LBP:
Neoplasia (0.7%)


Multiple Myeloma

Metastatic Carcinoma

Lymphoma and Leukemia

Spinal Cord Tumors

Retroperitoneal Tumors

Primary Vertebral Tumors
Infection (0.01%)


Osteomyelitis

Septic Discitis

Paraspinous Abscess

Epidural Abscesss
Inflammatory Arthritis (0.3%) – note HLA-B27 association.


Ankylosing Spondylitis

Reiter Syndrome

Inflammatory Bowel Disease

Scheuermann Disease (osteochondrosis)

Paget Disease
6
Differential – Visceral Disease:
Pelvic organ involvement:


Prostatitis

Endometriosis

Chronic Pelvic Inflammatory Disease
Renal involvement


Nephrolithiasis

Pyelonephritis

Perinephric Abscess
Aortic Aneurysm
Gastrointestinal involvement


7

Pancreatitis

Cholecystitis

Penetrating Ulcer
Interdisciplinary Team Approach
to Chronic Spinal Disorders
Complex Problem
Interdisciplinary Management
•
•
Physiological
factors
Social
factors
•
•
•
•
Psychological
factors
8
Spine Surgeons
Neurosurgeons
Pain specialists
Psychiatrists/
Psychologists
Physiatrists
Radiologists
TERMINOLOGY
9
Acute low back

Low back pain present for fewer than 4 weeks,
sometimes grouped with subacute low back pain as
symptoms present for fewer than 3 months
10
Chronic low back pain

Low back pain present for more than 3 months.
11
Nonspecific low back

Pain occurring primarily in the back with no signs of a
serious underlying condition (such as cancer, infection, or
cauda equina syndrome), spinal stenosis or radiculopathy,
or another specific spinal cause (such as vertebral
compression fracture or ankylosing spondylitis).
Degenerative changes on lumbar imaging are usually
considered nonspecific, as they correlate poorly with
symptoms.
12
Radiculopathy

Dysfunction of a nerve root associated with pain, sensory
impairment, weakness, or diminished deep tendon
reflexes in a nerve root distribution.
13
Sciatica

Pain radiating down the leg below the knee in the
distribution of the sciatic nerve, suggesting nerve root
compromise due to mechanical pressure or inflammation.
Sciatica is the most common symptom of lumbar
radiculopathy
14
Spinal stenosis

Narrowing of the spinal canal that may result in bony
constriction of the cauda equina and the emerging nerve
roots
15
Straight-leg-raise test

A procedure in which the hip is flexed with the knee
extended in order to passively stretch the sciatic nerve
and elicit symptoms suggesting nerve root tension. A
positive test is usually considered reproduction of the
patient’s sciatica when the leg is raised between 30 and
70 degrees. Reproduction of the patient’s sciatica when
the unaffected leg is lifted is referred to as a positive
“crossed” straight-leg-raise test
16


Spondylosis
A degenerative spinal disease that can involve any part of
the VERTEBRA, the INTERVERTEBRAL .DISK, and the
surrounding soft tissue.
17


Spondylolysis
Deficient development or degeneration of a portion of
the VERTEBRA, usually in the pars interarticularis (the
bone bridge between the superior and inferior facet
joints of the LUMBAR VERTEBRAE) leading to
SPONDYLOLISTHESIS.
18


Spondylolisthesis
Forward displacement of a superior vertebral body over
the vertebral body below
19


Spondylarthritis
Inflammation of the joints of the SPINE, the intervertebral
articulations
20


Osteoarthritis, Spine
A degenerative joint disease involving the SPINE. It is
characterized by progressive deterioration of the spinal
articular cartilage (CARTILAGE, ARTICULAR), usually
with hardening of the subchondral bone and outgrowth
of bone spurs (OSTEOPHYTE).
21


Spondylarthropathies
Heterogeneous group of arthritic diseases sharing clinical
and radiologic features. They are associated with the
HLA-B27 ANTIGEN and some with a triggering infection.
Most involve the axial joints in the SPINE, particularly the
SACROILIAC JOINT, but can also involve asymmetric
peripheral joints. Subsets include ANKYLOSING
SPONDYLITIS; REACTIVE ARTHRITIS; PSORIATIC
ARTHRITIS; and others
22
23
Occupational factors for low back pain
Job related
•
•
•
•
•
•
•
•
•
Manual handling tasks
Lifting
Twisting
Bending
Falling
Reaching
Excessive Weights
Prolonged Sitting
Vibration
24
Related to Individual





Prior Episode
Job Dissatisfaction
Smoking
Obesity
Genetic factors
Back Safety & Lifting

Common Causes of Back Injuries
Heavy Lifting
Twisting
Reaching & Lifting
Carrying &
Lifting
Awkward Postures
Sitting or Standing
25
Slips,Trips & Falls
Back Safety & Lifting
Heavy
Lifting

Job requires heavy lifting:


Use equipment when possible or ask for help.
Try to avoid repetitive lifting over a long period
of time.
Twisting
• Twisting at the waist while lifting or
holding a heavy load.
Reaching
& Lifting
• Injury usually occurs when reaching
over the head, across a table or out
the back of a truck.
26
Back Safety & Lifting
Carrying
& Lifting

Awkward
Positions
• Inappropriate postures that can
contribute to back pain are caused
by poor workstation layout and/or
equipment design.
Slips,Trips
& Falls
• It is very easy to injure your back,
neck or legs while slipping,
tripping or falling.
27
Injury usually occurs when carrying or lifting
objects with awkward or odd shapes.
Back Safety & Lifting
Sitting or
Standing



28
Sitting or standing too long in one position.
Sitting can be very hard on the lower back.
For every one to two hours sitting, stand up
and take a stretch.
For every one to two hours standing, sit
down or move around and stretch.
Back Safety & Lifting

Back Injury Prevention






29
Avoid lifting and bending whenever you can.
Place objects up off the floor.
That way you won’t have to reach down to pick
them up again.
Raise / lower shelves.
The best zone for lifting is between your
shoulders and your waist.
Put heavier objects on shelves at waist level,
lighter objects on lower or higher shelves.
Back Safety & Lifting

Back Injury Prevention

Reducing exposure to known risk factors



Repetition
Awkward Position
Force




30
Object weight
Load Distribution
Object friction
Duration
Back Safety & Lifting

Back Injury Prevention Cont.:

Avoid Hyper extension movements of
the back.
– Avoid Hyper flexion
movements of the back.
31
Back Safety & Lifting

Back Injury Prevention cont.:



Maintain good posture
Lift objects holding them close to your body
Never “twist” when carrying, handling, or
transferring a heavy object
– Avoid “locking out” the knees
– Use proper lifting techniques
32
Back Safety & Lifting
4
1
2
Assess
33
3
Plan
Prepare
Perform
Back Safety & Lifting
Assess

Assess the task:




Assess Your Own Capabilities:



34
Posture
Pacing, rate of work, breaks
Requirements for team handling
Strength, height, etc.
Health problems
Gender, age, fitness
Back Safety & Lifting
Assess
Cont.:

Assess the Load:





Assess the environment:




35
Weight, shape, size
Handles, packaging
Stability
Contents: hot, cold, hazardous
Space constraints
Flooring condition, levels
Temperature, humidity, ventilation
Tidiness, general housekeeping
Back Safety & Lifting
Plan

Task





Route
Consider start and end points

36
What is the most appropriate posture?
Is there mechanical aid available?
Is there anyone else to help?
Can any obstructions be cleared
Back Safety & Lifting
Prepare

Prepare the load:






Prepare yourself and the area:






37
Can the load be split?
Can the load be made more stable?
Make sure contents are evenly distributed?
Move the load’s center of gravity close to yours
Cover sharp / abrasive edges
Check space constraints
Move obstacles
Check final destination
Check housekeeping
Get a good grip on the load
Use PPE where appropriate
Back Safety & Lifting
Perform

Apply principles of biomechanics to reduce the
load on the spine








38
Keep a wide base of support.
Maintain the lumbar curve (low back) as much as
possible.
Get a good grip.
Position feet in direction of travel.
Use smooth controlled movements.
Use friction to minimize force.
Try to avoid twisting and stooping.
Use team lifting where appropriate.
Back Safety & Lifting
Get close
to the load
Slowly
Lift
Proper Lifting
Techniques
Hug the
Load
Squat
Down
Grip the
Load
39
Back Safety & Lifting
Get close
to the load

Proper Lifting Techniques
– Get as close to the load as possible
with your feet wide apart about
shoulder width, with one foot slightly
in front of the other for balance.
• Test the object’s weight before lifting it.
• Ask for assistance from a co-worker
when appropriate.
• Have the object close to the body and
put less force on the low back.
• Avoid rapid, jerky movements.
40
Back Safety & Lifting
Squat
Down

Proper Lifting Techniques Cont.:



Keep yourself in an upright position while
squatting to pick up.
Squat by bending the knees and hips.
Keep the three Curves of the Back properly
aligned:

41
Ears, Shoulders, and Hips are in a straight line.
Back Safety & Lifting
Grip the  Proper Lifting Techniques Cont.:
Load
 Tightening the stomach helps support the spine.
 Do not hold your breath while tightening the
muscles.
 Get a firm grasp of the object before beginning the
lift.



42
Use both hands.
Use whole hand, not just fingers.
Use gloves as needed to prevent “pinched” grips or to
protect the hands during lift.
Back Safety & Lifting
Hug the
Load

Proper Lifting Techniques Cont.:






43
Legs are the strongest muscles in the body – so use
them.
Avoid back flexion.
Hold objects close to body.
Slide the object from the knee on the ground to midthigh.
Keep the head forward.
Hug the object to your
stomach & chest.
Back Safety & Lifting
Slowly
Lift

Proper Lifting Techniques Cont.:







44
Lift with the legs to allow the body’s powerful leg
muscles to do the work.
Flex the knees and hips, not the back.
Avoid bending & twisting at the waist.
Try to keep the back “straight” during the lift.
Do not look down at the object during lift.
Look up to help “straighten” the position of the
back for a safer lift.
Never Bend, Lift, and Twist at the same time.
Back Safety & Lifting
Torque = Load x Distance
Box = 30 lbs.
Body wgt = 170 lbs.
L5/S1 Disk
12 in.
L5/S1 Disk
36 in.
16 in.
0 in.
30 lbs.
30 lbs.
85 lbs.
(30 lbs. x 36 in.) + (85 lbs. x 12 in.) = 2,100 in-lbs.
(Box)
45
(Employee)
85 lbs.
(30 lbs. x 16 in.) + (85 lbs. x 0 in.) = 480 in-lbs.
(Box)
(Employee)
Back Safety & Lifting

Exercises



46
Exercises that work your back, hips,
thighs, and abdominal muscles can
minimize back problems.
Stand behind chair, hands on chair. Lift
one leg back and up, keeping the knee
straight.
Warm up slowly and exercise regularly.
Back Safety & Lifting

Exercises Cont.:

Starting Position: Standing tall, feet shoulder width
apart, chin tucked in




47
Place your palms on the small of your back, fingers pointing
down.
Keep your head up as you lean back slowly as far as possible.
Hold for at least 10 seconds.
Return to starting position and relax.
Back Safety & Lifting

Exercises Cont.:

Wall Squats






48
Stand with back leaning against wall
Walk feet 12 inches in front of body.
Keep abdominal muscles tight while slowly bending both
knees 45 degrees.
Hold 5 seconds.
Slowly return to upright position.
Repeat at least 5 to 10 times.
Back Safety & Lifting

Exercises Cont.:





49
Lie on the floor on back.
Keeping arms folded across chest, tilt pelvis to flatten
back, chin tuck into chest.
Tighten abdominal muscles while raising head and
shoulders from floor.
Hold at least 10
seconds and
release.
Repeat at least
5 to 10 times.
Back Safety & Lifting
• Summary
– Common Causes Of Back Injuries




Heavy Lifting
Twisting
Reaching & Lifting
Carrying & Lifting



Awkward Positions
Sitting or Standing
Slips, trips, and falls
– Back Injury Prevention
• Reduce exposures to known risk factors
50
Back Safety & Lifting
• Summary Cont.:
– Principles of Safe Handling


Assess
Plan


Prepare
Perform
– Proper Lifting Techniques
• Close
• Squat
• Grip
• Hug
• Slowly
– Exercise-Should You?---of course!!!
51
Imaging
52
Plain Radiography:



Most common spinal imaging test. Low cost and ready availability.
AP and Lateral views demonstrate alignment, disc and vertebral body
height, and gross assessment of bone density and architecture. Sacroiliitis
occurs early in Ankylosing spondylitis and is readily detected by plain films.
Agency for Health Care Policy and Research Guidelines currently do not
recommend routine oblique and spot lateral views.




Get oblique if you suspect spondylolysis; good for pars interarticularis.
Get flexion and extension films if you suspect lumbosacral instability.
Get angled sacral views if you suspect ankylosing spondylitis.
Caution using lumbar radiography repeatedly, may damage the gonads,
particularly in reproductive age females.
53
Plain Films - Weaknesses:





Neoplasm - ~50% trabecular bone loss prior to becoming visible
Infection – similar, relatively late appearance of change
Inability to distinguish acute from chronic compression fractures
Disc herniation
Spinal Stenosis
54
CT + MRI:


CT Strengths:

MRI Strengths:

Axial bony anatomy


Cortical bony destruction


Facet degenerative changes


Disk herniation

Soft tissue evaluation in patients who cannot
undergo MRI secondary to claustrophopia or
implanted metal.

CT Myelography good for bony causes of
spinal stenosis
CT Weaknesses:

Discogenic disease (nucleus pulposis rupture,
annulus fibrosis tears)

Spinal canal contents

Discitis







MRI Weaknesses:




55
Better soft tissue contrast than CT
Visualization of disc
Ligamentous pathology
Vertebral marrow and spinal canal
Neoplasm
Infection (may be the best modality with
gadolinium enhancement)
Disc Herniation
Spinal stenosis
Nerve root impingement
Cannot detect cortical bone
Common degenerative disk disease and
disease of facet joints – too nonspecific
Fractures seen best in the axial plane
Subtle annular tears
Bone Scans:






While plain films, CT, and MRI detect bony morphology, bone scintigraphy
detects biochemical changes in bone.
Most useful in detecting the age of compression fractures.
Old fractures will appear “cold” while new fractures will appear “hot”.
Very useful for determining primary bony tumors (usually benign, i.e.
osteoid osteoma, osteoblastoma, aneurysmal bone cyst, and
osteochondroma) degree of metastasis and certain infections (infectious
spondylitis in particular – gallium67 when compared with MRI had better
specificity and sensitivity).
Useful for subtle fractures and infarction.
Useful for metabolic bone disease such as Paget Disease.
56
Discography:




Controversial method for diagnosing discogenic pain.
Used to delineate whether suspicious discs found on MRI were the true
cause of the patients’ pain.
However, the use of discography as an indicator of general disk disease has
been found to be suspect. One study by Holt, et al., found 38% positive
rate when they tested healthy subjects. Can we utilize a test with that
degree of inaccuracy? Recent studies have shown a lower degree of
specificity but the jury is still out.
Good for posterolateral annulus fibrosis tears when CT is used to visualize
the tears with contrast enhancement.
57
Cases:
58
Lateral radiograph showing decreased disk space between L5 and S1.
Consistent with Osteoarthritis and Degenerative Disk Disease.
59
Lateral radiograph showing grade 1 spondylolishthesis. (Grades
correspond to how far forward the posterior border of the spinous
process slides along the sacral platform. Grade 1 = 1-25%, 2 = 2650%, 3 = 51-75%, 4 = 76-100%.)
60
Saggital MRI showing central disk herniation at L5-S1.
61
Severe lumbar degenerative disk disease and osteoarthritis. What
are the four cardinal features of OA?
62
1.
Joint Space Narrowing
2. Osteophytic Spurring
3.
Subchondral Sclerosis
4. Subchondral Cysts
Frontal and lateral radiograph showing L2 compression fracture. How
old is this fracture? Can you tell?
No – get a bone scan.
63
Multiple acute compression fractures in an elderly female. Image
on right is status-post multiple serial vertebroplasties.
64
What kind of patient presents with spondylolysis? Image on right is
oblique view of lumbar spine.
Adolescent athletes. Males>Females 2-3:1. Caucasions>African
Americans 3:1. Gymnasts and Football Players are the two most
frequent types of athletes affected.
65
66
Saggital T1 weighted MRI of the spine showing bony metastases to
the distal thoracic spine. Breast cancer primary.
67
Osteomyelitis. Image is a saggital T1 weighted image showing
osteomyelitis of the lumbar spine at L2-L3. Enterococcus was
isolated.
68
69
Frontal radiograph showing
syndesmophytes bridging the
intervetebral spaces.
Ankylosing Spondylitis: Sacroiliac joints and axial spine undergo progressive ossification.
Ensethoopathy (ossification of ligamentous attachments) is also characteristic. Onset is typically in
young people, usually teens or twenties. Presents as a persistent bachache which is not relieved by
rest and improves with exercise. If you suspect AS, an angled plain film of the pelvis is the best
modality along with AP and lateral films of the lumbar spine.
70
A technetium 99m-bisphosphonate bone scan of a patient
with polyostotic Paget's disease.
71
Young patient with progressive kyphosis. Diagnosis is?
Scheuermann Disease! Because I knew you were all dying to know
what that is. Scheuermann disease (juvenile kyphosis) is a
deformity in the thoracic or thoracolumbar spine in children
secondary to osteochondrosis of the secondary ossification
centers of the vertebral bodies.
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 Disc
Degeneration: chemical changes
associated with aging causes discs to
weaken, but without a herniation.
 Prolapse: the form or position of the
disc changes with some slight
impingement into the spinal canal.
Also called a bulge or protrusion.
 Extrusion: the gel-like nucleus
pulposus breaks through the tire-like
wall (annulus fibrosus) but remains
within the disc.
 Sequestration or Sequestered Disc:
the nucleus pulposus breaks through
the annulus fibrosus and lies outside
the disc in the spinal canal
Disc Degeneration
78
Summary:





Plain Radiography remains the mainstay as the initial test of choice.
CT can help delineate axial pathology, particularly bony fractures impinging
on nerve roots.
Discography has limited utility due to unacceptably high false positive rates.
Bone scans are good for determining the age of fractures, the extent of
neoplastic spread, and metabolic bone disease.
MRI is good for everything else, particularly infections (most), disc
herniations, and ellucidation of spinal and neural root pathology.
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