LOW BACK PAIN

Dr.dr.THOMASEKOP.SpS(K).
Bagian/SMFNeurologiFKUNUD/RS.SANGLAH
DENPASAR
 LectureTopic
1.OverviewLowBackPain
2.HNP
 Course Objectives

KnowtheREDFLAGSinhistorytaking.
KnowthePainGeneratorsoftheLumbar
spine
KnowtheGuidelinesforImagingofthe
spinewithlowbackpain.
Knowthegeneralguidelinesto
rehabilitation.
 BACKGROUND
LBP:
-Imhotep:Egypt,3000BC
-HippocratesandGalen:Lumbago&Sciatica

Prevalence:
USA:15-20%
CopcordIndonesia:14-18%
POKDINYERIPERDOSSI(2002):18%
 AncientHistory:
TheEgyptianphysician,
Imhotep,wascreditedthe
earliest(3,0002,500BC)
knownreportofwork-
inducedbackpaincases.
Heprovidedmedicalcare
totheworkerswhobuilt
thegreatpyramids...!
15thCenturyTurkishTreatment-
Cauterization
 Epidemiology of Back Pain

Whogetsit?
60-90%lifetimeprevalence.
80-90%haverecurrentepisode.
WhatistheNaturalhistory?
80-90%resolvesin1month.
20-30%remainschronic
5-10%disabling
BackPainaHugeProblem:Newsweek-April
26,2004
 AlfNachemson
Whatsthecauseofbackpain?
Inmostcases
Idontknow!
 ETIOLOGY
Etiology
~97%oflowbackpainismechanical
Despitethemanypossiblecauses,makinga
specificdiagnosisisusuallyimpossible(~85%
ofthetime)
Nonspecific Mechanical Low Back Pain

AHCPR publication 95-0643

Deyo RA et al JAMA 268:760, 1992
Deyo RA et al NEJM 344:363, 2001
Atlas JA et al J Gen Intern Med 16:120, 2001
 Etiology (Contd)
Etiology
Manypatientsandphysiciansfeartheserious,
systemiccauses
~2%willpresentpredominantlywithsciatica
~2%havepainreferredfromvisceraldisease
~1%havepaincausedbyserious
nonmechanicalspinalconditions
<1%presentwiththecaudaequinasyndrome

AHCPR publication 95-0643

Deyo RA et al JAMA 268:760, 1992
Deyo RA et al NEJM 344:363, 2001
Atlas JA et al J Gen Intern Med 16:120, 2001
 DIAGNOSISTRIAGE
(RCGP1996,A Joint Clinical Practice
Guideline from the ACP and APS2007)

1.NonspecificLBP:85%

2.Radiculopathy(Nerverootpain)

3.Seriousspinalpathologic:4%
 Ad.1.NonSpecificLBP
Age:20-55tahun
Goodgeneralcondition
Paininbuttock,thighandlumbosacral
aboveknee
Mechanical

donotrefertospecialist
 Mechanical NSLBP
pain is worsened with movement
pain is improved with rest

KathrynRefshauge 14
Non-specific pain distribution
 Ad.2.Nerverootpain
(Radiculopathy)
unilateral,worsethannonspecificLBP
Spreadingtolowerlimbortoe
Parasthesia+
Lasegue(SLR)tes+
Localizednerverootcompression

Usuallydonotrefertoneurologistbefore4weeks.
 Ad.3. Serious spinal pathology
Cancer
Infection eg osteomyelitis
Cauda equina syndrome
Cord compression
Fracture (osteoporotic)
Inflammatory diseases/arthritides
Abdominal or cardio-thoracic pathology
 Eliminate serious pathology
(red flags)
unexplained weight loss
night pain
poor general health/systemic symptoms
fever
previous history of cancer
no relief with bedrest
failure to improve with therapy

KathrynRefshauge 21
RED FLAG : Signs and symptoms indicating
serious spinal pathology e.g. : fracture, cancer,
infectionandcaudaequinasyndrome

Red flags (contd)

history of trauma
steroid use (osteoporosis)
very severe pain/muscle spasm
bowel/bladder frequency (cauda equina
syndrome)
widespread neurological symptoms
non-mechanical behaviour of symptoms
KathrynRefshauge 23
Red Flags (contd)
Age > 50 years
Constant progressive non-mechanical
pain
Thoracic pain
Persisting severe restriction of lumbar
flexion
Pain that worsens in supine
Yellow flags
Previous history of LBP
Radiating leg pain, NR involvement
Poor fitness
Poor extensor endurance
Poor general health
Psychological distress (fear avoidance
behaviour, depressed)
KathrynRefshauge 25
Yellow flags (contd)
Much time lost from work
Disproportionate illness behaviour
Low job satisfaction
Personal problems (alcohol, marital,
financial)
Adversarial medico-legal proceedings

KathrynRefshauge 26
 DIAGNOSE

1. Anamnesis
2. PhysicalandNeurologicalExamination
3. SpecificExamination

 Ad.1.ANAMNESIS(Sacredseven)
Onset
Duration
Location-radiation
Property
Quality
Whatmakespainbetter/worse.
RedFlag?
NeurologicSymptoms:
Paresthesias.
Bladder/Bowelretentionorincontinence.
Weakness.
 Ad.2.PhysicalandNeurological
Examination

RangeofMotion(documentrangeand
pain)
Flexion-40
Extension-15
Lateralbending-30
Rotation-45
Scoliosis
Motoric Examination

Clinical symposia-ciba, vol 32, no.6, 1980

 Strengthtests

L1,L2-Hipflexion(Psoas,rectusfemoris)
L2,3,4Kneeextension(Quads)
L2,3,4--Hipadductors(adductorsandgracilis)
L5ankle/toedorsiflexion(ant.Tibialis,EHL)
L5Hipabductors(gluteusmedius,TFL)
S1-ankleplantarflexion(gastroc/soleus)
S1Hipextensors(Gluteusmax.,Hamstrings)
 SensoricTesting
Ifthereisnerverootcompression,
sensationcanbedisrupted
Sensoric Examination

L4
L5
 Reflexes
L2,3,4-Quads

L5-Medialhamstring
S1-Achilles
 Sensation

Pinprick-primarilyspinothalamictract
Vibration/positionsense-dorsalcolumns
Vibrationtestedwith256cpsfork!
Positionon3-4thdigit
 Provocative Maneuvers
StraightLegRaise(supineorseated)
ForL5-S2radicularsymptoms
FemoralStretch
ForL2-4radicularsymptoms
FABERstest
ForSIjoint,hipjoint,lumbarz-joint
symptoms
Lasegue ( SLR ) TEST
Testing for lumbar nerve root
compromise
TheHappyCouple
3. Specific
EXAMINATION
A. NEUROPHYSIOLOGY
- ENMG and H reflex :

neuro/radiculopathy.
- SSEP.

B. RADIOLOGY
- Caudo/myelography
- CT caudo/myelography
- Discography
- MRI
Deyo RA Sci Am 279:48, 1998
 PlainRadiographs
Lumbarfilmscorrelatepoorlywith
thepresenceoflowbackproblems
Manypatientswithoutbackpain
willhavedegenerativechanges
Manypatientswithbackpainwill
nothaveradiographicabnormalities
Therefore,whendegenerative
changesarepresent,itisvery
difficulttoknowiftheyare
causative
van Tulder MW et al Spine 22:427, 1997
Deyo RA et al J Gen Intern Med 1:20, 1986
Scavone JG et al Am J Roentgenol 136:715, 1981
 PlainRadiographs
Cannotdetectdiskherniation,spinal
stenosis,ornerverootimpingement
Maynotnecessarilyseetumororinfection
Therefore,theycannotruleoutsuspected
malignancyorinfection
Rarelydetectsomethingthatwasnot
alreadysuspectedfromtheH&P
Mostfilmswillbenon-diagnostic
Sowhenshouldtheybedone?
van Tulder MW et al Spine 22:427, 1997
Deyo RA et al J Gen Intern Med 1:20, 1986
Scavone JG et al Am J Roentgenol 136:715, 1981
 Imaging or Not?
LowyieldwithoutREDFLAGSpresent.
AbnormalfindingsinAsymptomatic.
Psychological.
Anxiety,fear-avoidance-possiblyhelp?
Depression-theremustbesomething
wrong
 Guidelines for Imaging

NOREDFLAGS!
Acutepain-symptomatictreatmentfor4
weeks,re-evaluate.Imageifpaincontinues.
(AHCPRGuidelinesforAcuteLBP).
Subacutepain-Painfor>4wks.Failed
symptomatictreatment.Image.
Chronicpain-none,unlesschangesinsxs
Chronicintermittent-TXasacutepatients
MYTH#2:Newerimagingtests(CTand
MRI)canalwaysidentifythecauseof
pain
 MRI
Therearesimilarfindingsinasymptomaticindividuals
withMRI*:
52%hadbulgingofatleastonedisk
27%hadadiskprotrusion
1%hadadiskextrusion
64%hadadiskabnormalityatonelevel
38%hadadiskabnormalityatmorethanonelevel

*Jensen MC et al NEJM 331:69, 1994

**Jarvik JJ Spine 26:1158, 2001
 SowhenareCTandMRI
Indicated?
Tumor,infection,fracture,orotherspace-
occupyinglesionisstronglysuggestedbythe
clinicalfindings
Symptomsofthecaudaequinasyndrome
Therearesevereorprogressiveneurologic
symptoms
Sciaticasymptoms>1monthandthepatientisan
appropriateandwillingpotentialsurgical
candidate
AHCPR publication 95-0643
Deyo RA et al NEJM 344:363, 2001
Atlas JA et al J Gen Intern Med 16:120, 2001
 MANAGEMENTLBP
1.CONSERVATIVE
2.OPERATIVE
A Joint Clinical Practice Guideline from
the American College Physicians and
Americans Pain Society(2007)

Source
MEDLINE:1966-November2006
CochraneDatabaseofSystematicReview
(2006Issue4)

(Chou,R.AnnInternMed.2007;147:505-514)
Deyo RA Sci Am 279:48, 1998
Deyo RA Sci Am 279:48, 1998
Back Injury Risk Factors - Acute
Acute (traumatic) back injury
may occur due to:
slips, trips and falls;
auto accidents;
sedentary lifestyle (with
occasional lifting);
heavy and/or awkward loads;
improper lifting technique.
 Back Injury Risk Factors -
Chronic
Chronic back injury may result
from poor posture and/or
improper lifting technique
combined with repetitive lifting.
Additionally, genetics and
overall physical fitness may
affect spine health.
 Benar Salah
Mengemudi
Benar Salah
Berdiri

Benar Salah
Memasukkan/mengeluarkan
Benar Salah barang dalam mobil
Duduk

Salah Benar Bekerja Salah

Benar Tidur
Pengaturan postur saat membawa barang

Mengangkat barang

Benar Salah

Membawa barang
didepan tubuh

Benar Salah

Membawa barang
di punggung
Benar Salah
Sit-up parsial untuk memperkuat Latihan untuk mengurangi
otot-otot abdomen peregangan otot punggung

Latihan untuk memperkuat Latihan untuk memperkuat

otot punggung dan panggul otot perut dan panggul

Beberapa variasi latihan ekstensi, mulai dari yang paling ringan ditingkatkan
disesuaikan dengan kekuatan otot-otot ekstensor lumbal
Back Pain Exercise
HERNIATION NUKLEUS
PULPOSUS (HNP)
LUMBALIS
 HNP
-Synonime:herniated/slipped/rupturedlumbardisc
-Prevalence:1-2%population
-MostofHNPimprovewithin4-6weeks
DEFINITION :
HNP occurswhenthenucleuspulposus(gel-
likesubstance)breaksthroughtheanulus
fibrosus(tire-likestructure)ofanintervertebral
disc.
 PATHOPHYSIOLOGY
- IntervertebraledisclinksCVasshock
absorber
-discus:anulusfibrosusandnukleuspulposus
 PATHOPHYSIOLOGY
- Degenerationofdisc:decreasevascularisation
andelasticity,
- watercontentofthenucleusdecreases
progresivewithage.
 Herniated Disc
Peoplebetweentheagesof30-50appeartobe
vulnerablebecausetheelasticityandwatercontent
ofthenucleusdecreaseswithage.

TheprogressiontoanactualHNPvariesfromslow
tosuddenonsetofsymptoms.
 Pathophysiology
Disc Degeneration

NarrowDiscspace NucleusPulposusdrying

Microinstability Stresscapabilitydecrease

NucleusPulposusProtusion
Vertebralendplate
irritation
Dorsomedialprotusion Dorsolateral
Spurformation protusion

Spinalcord Nerverootcompression
Nerveroot
compression
compression
 Disc Herniation
Painresultingfromherniationmaybecombined
witharadiculopathy.
causedbynervecompression
Thedeficitmayincludesensorychanges(i.e.
tingling,numbness)and/ormotorchanges(i.e.
weakness,reflexloss).
 Herniated Disc
Therearefourstages:
(1)discprotrusion
(2)prolapseddisc
(3)discextrusion
(4)sequestereddisc.
Stages1and2arereferredtoasincomplete
(bulgingdisc)
where3and4arecompleteherniations.
 RISK FACTOR
- Smoking
- Cough
- Longtime sitting/standing
- Driving.
- Lifting weight material.
- Sudden movement
 Location HNP
Aherniateddiscoccursmostofteninthe
lumbarregionofthespineMost
Commonly at the L4-L5 and L5-S1
levels
Thisisbecausethelumbarspinecarries
mostofthebody'sweight.
Highly mobility : flexion and extention.
- Posterior Longitudinale ligamentum : 1/2
CLINICAL MANIFESTATION
- Sciatic usually sudden onset.
-Depend nerve root compression :
- Sensorik : paresthesia, burning,
numbness,pain,
dermatom distribusion.
- Motoric: muscle weakness.
- Otonom : urination and bowel disturbances.
- Pain worse when increased of intrathecal /
intradiscus pressure
 Diagnose
Thespineisexaminedwiththepatient
layingdownandstanding.
Duetomusclespasm,alossofnormal
spinalcurvaturemaybenoted.
Radicularpainmayincreasewhen
pressureisappliedtotheaffectedspinal
level.
 Diagnose (contd)
ALaseguetest,alsoknownasStraight-leg
Raise Test,isperformed.
Thepatientliesdown,thekneeisextended,
andthehipisflexed.
Ifpainisaggravatedorproduced,itisan
indicationthelowerlumbosacralnerveroots
areinflamed.
IfthecontralateralSLRalsoproducespain,
itismorelikelytobefromaherniateddisc
 DIAGNOSE (CONTD)
Otherneurologicaltestsareperformedtodetermine
lossofsensationand/ormotorfunction.
Abnormalreflexesarenoted;changesmayindicatethe
locationoftheherniation.
Radiographsarehelpful,buttheMRI is the best
method for evaluation
 MRI
Therearesimilarfindingsinasymptomaticindividuals
withMRI*:
52%hadbulgingofatleastonedisc
27%hadadiscprotrusion
1%hadadiscextrusion
64%hadadiscabnormalityatonelevel
38%hadadiscabnormalityatmorethanonelevel

*Jensen MC et al NEJM 1994:331:69

 DiscDegeneration:Findings?

Narrowing
Osteophytosis
Vacuum Disc
Endplate sclerosis
Myelography
Extrusion
Extrusion
CLINICAL
EVALUATION
1. ANAMNESIS : same as LBP
CLINICAL
EVALUATION
2. PHYSICAL /NEUROLOGICAL EXAMINATION.
INSPEKSI, PALPASI
De yo dan Rainville : ( LBP + radicular pain ).
- Laseque (SLR) Test
- Strength of dorsoflexion ankles and
toes muscles
( L4-L5)
- Achilles reflexes ( S1).
- Sensory Test of medial (L4), dorsal (L5)
and
lateral (S1) foot.
- Contra lateral Laseque test : very
specific, but
not always positive.
- 90% HNP L4-L5 and L5-S1 can be
detected
3. Specific
EXAMINATION
A. NEUROPHYSIOLOGY
- ENMG and H reflex :

neuro/radiculopathy.
- SSEP.

B. RADIOLOGY
- Caudo/myelography
- CT caudo/myelography
- Discography
- MRI
MANAGEMENT (1)
A. CONSERVATIVE
B. OPERATIVE
 MANAGEMENT
(2)
A. KONSERVATIVE
Most of HNP (90%) px improve in 4-6 weeks.
1. Bed rest : 2-4 days , muscle weakness
when too long bed rest, gradual
mobilisation
2. Medikamentosa.
- Analgesic : Aspirin, Acetaminophen,
Tramadol.
- NSAID : Ibuprofen, Natrium Diclofenac,
Etorolac etc
- Corticosteroid : severe case and
controversy.
- Muscle relaxant : esperisone, tizanidine
etc.
- Opioids : severe case
- Anti depressant : amitriptilin.
MANAGEMENT
(3)
-Steroid epidural INJECTION : Controversy
- Chymopapain Injection : succesfull rate
40%,
complication >
- Radiofrequency
3. Physical Therapy
- Pelvic Traction : controversy.
- USW diatermi , Hot/cold pack usefull

- TENS : con troversy.

- Korset lumbal : prevention.
- Exercise : Mild exercise.
4. Accupuncture : controversy
5. Education : back school.
MANAGEMENT
(4)
B. OPERATIVE
- Goal : release irritation and compression
nerve root
-Can not relieve muscle strength but
prevent
worse.
- Effective for radicular pain ( > 90% ) than
back pain.
Operative
-Indication :
-Notimproveafter1month
consevativetreatment
-Severesciatica.
-Caudaequinasyndrome
-Muscleweaknessinlowerlimb.
OPERATIVE
TECHNICH:
-standarddiscectomy
-microscopicdiscectomy
-percutaneousdiscectomy
-laminectomy
HNPCERVICAL