LOW BACK PAIN :

MANAGEMENT UPDATE
DR DEWANTA SEMBIRING,SPS
LOW BACK PAIN
 Annual US Prevalence is 15-20%
 2nd most common symptomatic reason for visits to
primary care physicians.
 60-80% of population will have lower back pain at some
time in their lives
 90% of all episodes will resolve within 6 weeks regardless
of treatment
 90% of all persons disabled for more than 1 year will never
work again without intense intervention
LOW BACK PAIN
 Most common cause of disability in people younger than
45.
 1% of U.S. population is chronically disabled due to back
problems.
 1% of U.S. population is temporarily disabled due to back
problems.
 DEFINITIONS
 Acute LBP: Back pain <6 weeks duration
 Subacute LBP: back pain >6 weeks but <3 months
duration
 Chronic LBP: Back pain disabling the patient from some
life activity >3 months
 FOUR SPINE REGIONS
 1. NECK 7 Cervical vertebrae : C1 – C7
 2. BACK: UPPER BACK 12 thoracic vertebrae :
T1 – T12 ,LOWER BACK 5 lumbar vertebrae :
L1 - L5
 3. SACRUM 5 fused sacral vertebrae: S1 – S5
 4. COCCYX 5 coccygeal vertebrae

 LOWER BACK supports the weight of the upper

body where most back pain is felt Low Back
Pain
 ETIOLOGY OF LOW BACK PAIN
 Muscle : 70%
 Facet : 15-52%
 Disc : 30-50%
 SI : 13-30%
 Red flags, fracture, tumor, spondy, etc. 15%
 MAKING A DIAGNOSIS
 MUSCULAR OR LIGAMENTOUS  FACET SYNDROME
 HERNIATED DISC  SPONDYLOSYS
 SPINAL STENOSIS  SACROILIAC JOINT PAIN
 INFECTION  ANKYLOSING SPONDYLITIS
 COCCYGEAL INJURIES
 TUMORS
 SACROILIAC JOINT PAIN
 Unilateral or bilateral
 Worse : when sitting for long periods of time
 When performing twisting/rotary motions
 Morning stiffness
 Mimics and may be radicular pain.
 Dull Ache, sharp, or stabbing
 Distribution to the buttocks, back of thigh,
and lower back
 Sacroiliac Joint (Management)
 Ice and rest
 NSAIDs
 Modalities to reduce pain
 Supportive brace to correct asymetry
 Strengthening exercises
 IA injection (corticosteroid)
 Denervation ( RF neurotomy)
 MUSCULOLIGAMENTOUS INJURY
 Acute Soft Tissue Injuries.
 No Fracture or Neuro deficits.
 Muscle Pain and Spasm
 RX: NSAIDs, stretch and strengthen (like a hamstring
injury
 HERNIATED DISC
 Radicular Pain with flexion or sitting.
 Varying degrees of back pain to leg pain.
 Rx: Pain control, activity modification,
regular follow up, PT, ESI, Surgery rarely
needed.
 HERNIATED NUCLEUS PULPOSUS
 Symptoms
 –Back pain
 –Leg pain
 –Dysthesias
 –Anesthesias
 SPINAL STENOSIS
 Radicular Pain worsened by walking or running
and improved by sitting.
 Degeneration of facets
 Posterior Longitudinal ligament or ligamentum
flavum can also get thickened and cause spinal
stenosis
 Disc degeneration
 Spondylolisthesis
 Post surgical.
 INFECTIONS
DISCITIS
 Young Children <10 yrs old
 Stiff Back or Abdominal pain and
often refuse to walk.
 Spine tenderness and loss of
motion.
 Elevated ESR, CRP. CBC often
normal.
 X-rays may take 2 weeks for
abnormalities. Bone scan or MRI if
suspicious
OSTEOMYELITIS
 Follow blunt trauma 1/3 of the
time.
 Fever in 58%.
 Neurologic complications
 Elevated ESR 73%, WBC elevated
35%.
 X-rays may take 4 -8 weeks for
erosive changes. Bone scan or MRI
when suspicious
 FACET JOINT SYNDROME
 Pain is usually felt directly over the
affected joint, but may also be felt in the
buttocks, hips, groin and back of the
thighs depending on which facet joint is
injured
 Age 30s-40s
 Pain with hyperextension or running
 Mostly remains undiagnosed with CT/MRI
 X-ray: Facet hypertrophy
 Therapeutic facet joint injection with
steroid/RF ablation of medial branch of
dorsal rami gives long-term relief
 SPONDYLOLYSIS/SPONDYLOLYSTHESIS
 Pain with hyperextension.
 Single Leg hyperextension test.
 X-ray
 Avoid hyperextension, fusion is rarely
needed.
 COCCYGEAL INJURIES

 Fall on buttocks
 Pain with sitting
 Localized tenderness
 Manual Reduction shown
 SPINAL TUMORS
 Osteoid Osteoma or Osteoblastoma
 Night Pain relieved by NSAIDs.
 Get a fine cut CT scan.
 THE ROLE OF THE MANAGER
 1.Make a diagnosis using a differential diagnosis.
 2.Educate the patient about the plan.
 3.Prescribe appropriate medications.
 4.Make appropriate referrals at appropriate times.
 PATIENT EDUCATION
 1.Tell patients your plan and your expectations.
 2.Set reasonable expectations.
 3.Severity of Acute Pain does not correlate with outcome or duration.
 4.Follow up regularly to check response to treatment.
 5.Reassess for further diagnostic of therapeutic options.
 MINIMIZE RISK FACTORS
JOB RELATED RELATED TO INDIVIDUAL
 Manual handling tasks  •Prior Episode
 •Lifting  •Job Dissatisfaction
 •Twisting
 •Smoking
 •Bending
 •Obesity
 •Falling
 •Genetic factors
 •Reaching
 •Excessive Weights
 •Prolonged Sitting
 •Vibration
TERIMA KASIH