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Understanding Low Backache

& its basis oftreatment

Bhaskar Borgohain

MS ortho, DNB ortho, Fellow (Arthroplasty)

Asst Professor, Department of Orthopaedics.NEIGRIHMS

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MOVEMENT IS LIFE

LIFE IS MOVEMENT

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PAINLESS MOVEMENTMEANS

ENJOYING A QUALITY OF LIFE

PAINFUL MOVEMENTS

MEANS

JUST HAVING A LIFE

OR EVEN WORSE

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Biomechanics is nothing but the scientific

study of the movements of the spine;

in health & disease

Movements are so essential or at times so

bizarre

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Low back: Lumbo-sacral Spine

Anatomically Multisegmental column:

Connects upper torso to the pelvis

Function: Maintains upright position (stability)

Yet allow great flexibility for actions: 5 Discs

During all ROMs provide a protective conduit

for neurological structures within Practically No rotation possible: Facets

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Functional components of lumbar

spine

Each Lumbar vertebrahas 3 Components

Body : To bear weight

The Neural Arches:To protect the neural

elements

Bony Processes: To

increase efficacy ofspinal muscle actions

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SPINAL STABILITY SYSTEM

3 Interrelated subsystem

Active: Actively contracting muscles

(Erectors / Abdominals)

Passive: Bone, Joints, Ligaments,

Passively elongated muscles

Neural (Control): Neural elements withinthe active & passive subsystem giving

Dynamic stability

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LIMITATIONS

Cadaveric:

Muscle contarctions

Neural controlDynamic balancing

Translating lab finding to real time

situationsClinical implications

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Components of Lumbar Spine

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Normal biomechanics of spine

Photo of a gymnast

Endless potential

Elastic limits: Youngs modulus Pathobiomechanics: LBA

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Pain sensitive structures of the

spine

Ligaments: PLL

Nerves: sinuvertebral nerve

Facet joint capsule Periosteum

Meningeal coverings

Muscles

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LBA: The grey zone

Biological enigma

Exact cause: 12-15%

Evolutional paradox

Proud spine in Health

Terrible back in Disease

Back Abuse/ Overuse

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Epidemiology & Natural history

Over 80% of population experience some back

pain in their lifetime

(Quebec task force study on spinal disorders)

Overall Prevalence 18%, Annual incidence 15-20%(USA)

Good news: 50% recover in 2 weeks; 90% in 6

wks Bad news: Only 1% chronically disabled

Ugly truth: 80% Hospital resources drained

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Simple Mechanical Backache

Vs

Sinister Backache

Green flag

Noninflammatory

backache

No constitutionalsymptoms

No obvious spinal

deformity

No neurological deficits ortension signs

Not in Extremes of age

Red flag

Inflammatory

Constitutional symptoms

Spinal deformity

Neurological deficits or

tension signs

Extremes of age

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MECHANICAL BACKACHE

Nothing is gravely

wrong except the

backache itself

Non-inflammatory, non-infective & non-

neoplastic pathology

Lumbar Disc disease:

included

Dull backache

aggravated by activity

Physical signs often

slight Neurological deficit nil

Extensive radiating

pain to lower limbsabsent

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IMPORTANCE OF

BIOMECHANICS OF SPINE

Stability Vs Mobility

Spinal motion

segments

Disc & Facet jointsclose to nerve roots

Compressible gel

Mobile Ball bearingaction

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BIOMECHANICAL ANATOMY

Hourglass connection

Dynamic balance

Abdominal muscle Vs

erector spinae groupof muscle

Intrathoracic pressure

and intrabdominalpressure

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Dynamic balance

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INTRADISCAL PRESSURE

IDP changes with

position

Sitting worse,

Standing better ,lyingsupine best

After 6 hours

statistically significant

reduction of normal

disc height

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DDD (Degenerative Disc disease)

Pathobiomechanics

Loss of water content

Abnormal stresses /

biomechanics

Further degeneration

Facet degeneration

Disc prolapse: Weak

PLL Discogenic back pain

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Poor blood supply: poor healing

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WHOOP STRESS

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DISC SPACE LOSS: SEQUEL

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Sequel of Collapse of disc space:

Distorted attempt to stability Segmental spinal instability: Motion segment

abnormality- All column disturbances

Facetopathy: Abnormal stress on facet joints

Vertebral end plate sclerosis

Ligamentum flavum hypertrophy

Secondary canal stenosis LBA: Final common pathway

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DISC DESSICATION

Poor vascularity: Poor healing

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Discogenic back pain

Axial low back pain Sinuvertebral nerve arise from dorsal root

ganglion: non-segmental innervations

S.V.N. Innervates posterior annulus closeto PLL is irritated

Disc bulges on axial compression

Axial pain begins d/t signal carried byparavertebral sympathetic trunk

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Discogenic back pain

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Mangement

Goal: Early return to work

Tailored to each patient

Interdisciplinary approachModify activity in acute phase

Confirming the diagnosis

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Chronic Low Backache

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ABNORMAL POSTURE

Lx lordosis

Infancy Vs adulthood

Muscle weakness

Muscle fatigue

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MODALITIES OF MANGEMENT

Touching the back!

Counseling: Back Schooling

Posture care: Do & Dont listUse of firm mattress

Avoiding cumulative microtrauma to

spineDeveloping positive attitude: Depression

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Bed rest: Contradictory to the goal

Bed rest of > 2days has serious implications 3% of muscle bulk/ mass is lost daily

6% of bone demineralized in 2 weeks

Restriction of social activity & inability to carryout responsibilities PPT depression, illness

behavior & lack of motivation

Adequate sleep: of course yes, endorphin/

melatonin

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MAN Vs SUPERMAN?

Man is a social animal

Anatomically & Physiologically we are nothing

butAnimals

We are probably the only Animals that sit for 5

hours in the computer when the body is askingfor rest & sleep!

Man cannot run faster than a cheetah but he can

drive at 100km/hour and stop in less than asecond

Brunt is taken by the Spine,Discs and Ligaments

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BACK SCHOOL - I

Don't try to be superman

Anatomically & Physiologically we are man

Maintain good posture Take frequent break at work

Use your back but don't abuse it

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BACK SCHOOL - II

Smoke at your own peril

Modify your activity to give rest to the tired

back

Never flog a tired horse

Single footstep of a man a giant leap for

the mans back

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Medications

NSAIDs: 1ST Line

Narcotics: Not beyond

2 weeks

Muscle relaxant: Norole

Antidepressant :Only

if >3 months

Trigger point

injections: No role

Spinal manipualation:Controversial OR

contraindicated if disc

herniation

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SIMPLE BACKACHE IS NOT

SIMPLE

Functional restoration program involv.

interdisciplinary approach if no narcotics or

surgery needed

Psychological evaluation or Psychiatric

analysis whenever possible

Treat co morbid condition that may

aggravate LBA

SIMPLE BACKACHE IS NOT SIMPLE

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SIMPLE BACKACHE IS NOT SIMPLEMalingerers backache:

CompensationHoovers Test

Simulation Rotation Test

Pelvic Compression Test

Sitting SLR Test

Adams anterior bending test Sickness absenteeism

SIMPLE BACKACHE IS NOT SIMPLE

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SIMPLE BACKACHE IS NOT SIMPLEReferred pain: High index of

suspicionHips: Compensatory pain

Pelvic organs

S.I. Joints or pelvis

Renal & Retroperitoneal tumor

Vascular: aneurysm

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Cure Vs Curiosity in Backache

Can we cure backache :yes

Can we cure spondylosis: no

Does all disc prolapse need operation: no Is it possible to have a normallife after a

disc prolapse: yes

Can physiotherapy improve spinalbiomechanics: yes

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Physical therapy

Exercises : once acute phase is overHeat/Infrared/ US Therapy

Electric Stimulation

IFT: only if acute phase is over

TENS: only if acute phase is over

C fibre & Gate theory

Endorphin?

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Thermal therapy

Heat : Superficial

Infrared: Deep

US Therapy: Deep

Increase circulation

Wash off cytokines

Promote healing

Relieve spasm

Counterirritant

Touch

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Pregnancy

Pregnancy aggravates LBA

Weight Gain & Pull Of Abdomen

Address LBA appropriately First Surgery if indicated: Do First

Ligament Laxity

Osteomalacia PhysioTh: Impractical (3rd Trimester)

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Facet injections

Limited Indications: Not a common source

of pain

Pain in spinal extension & radiation to

back of thigh that ends above knee level

Multiple Joints and Peculiar nerve supply

Doesnt Change the Pathology: Adjunct

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Epidural steroids/block

Controversial indications

Decreases sciatic pain

Unpredictability: Inoperable patient

Undermines the actual disease

Complications & Wrong diagnosis

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Surgery: Laminectomy:

Cauda equina syndrome: Hemilaminectomy

Single Laminectomy : 14% overall instability

Cadaver study (Punjabi):

Unilat. Or B/L facetectomy increased

63% Flexion,

78% extension,

15% lateral bending &126% axial rotation

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Surgery: Spinal fusion

Rigid stabilization:

Spinal fusion +

Facetal Fusion

Halts abnormalbiomechanics at

fused level

ALIF or PLIF

Post. or Postlateral

Intertransverse fusion

Posterior: Rods &

pedicular Screws

Anterior: Rods &

ScrewsAddress secondary

causes:

3600 Fusion

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Surgery: Spinal fusion

Persistent disabling Discogenic axial low

back pain in absence of other organic or

psychological component: 70-80%

Multilevel discectomy

Documented instability

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DISC PROLAPSE: SURGICAL

INDICATIONS

Acute neurological complications

Gradual but progressive neurological

deterioration

Persistent radiating pain despite strict bed

rest and medication for 3- 4 weeks

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Why 3 - 4 Wks: TNF,Cytokines

CONTAINED DISCS UNCONTAINED DISCS

BULGE PROTRUSION EXTRUTION SEQUESTRATION

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DISC: TYPES OF INTERVENTIONS

Chymopapain Injection

(Europe): Anaphylaxis

Microdiscectomy: Good

option

Open discectomy:

Objectivity + CompleteNeural decompression

Laser discectomy:

Contained disc

Endoscopic discectomy:

Intradiscal electrothermal

therapy: Thermally ablate

the sinuvertebral nervefibre of posterior annulus

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Endoscopic discectomy:Transperitoneal video-assisted

Technically

demanding:

Complications

Overall: 4.7% cf2.3%

Vascular injury: 2.1%

to 25%

Retrograde

ejaculation: < 9.4%

DVT

Visceral injury, Paralytic ileus

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Dynamic stabilization

Fusion may fail to relieve

pain

Preserve movements of

motion segment

Instruments or artificial

ligaments to control

movements

Load sharing during

movements

Dont remove or disturb

normal anatomy

Augmenting weak

ligaments and muscles

without fusion

Graf ligament

recontruction: mimic

normal biomechanics

Interspinous Spacer(DIAM): no osteoporosis

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Disc replacement

Aim: Painless, Mobile and Stable Spine,

Replaces anatomical structures

Correct Soft tissue tensioning crucial for

maintaining spinal stability

Pain causing structures are physically

removed at surgery

Long term Safety: FDA ( MoM / MoP)

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Gene transfer

Biochemical changes in nucleus

Adenovirus as vector: rat model

IRAP (interleukin receptor antagonist) or

Lac Z gene

Increase synthesis of PG

Immune privileged cells of nucleus Prophylactic injections?

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ALTERNATIVE THERAPY

Too many options means too little known

The exact cause found in only 12-15%

Biofeedback: No role after 2 weeks of trial

Acupuncture: No role after 2 weeks of trial

Massage: breakdown adhesions

Yoga Endorphin!

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Summary

LBA In man is a biologicalenigma

Mobility leads to repetitivecumulative microtrauma

Microtrauma PPTdegenerative changes

Microtauma progressesto macrotrauma inprolonged back abuse

Degeneration reducesmobility Decreasemobility causes muscleatrophy

Abnormal segmentalmotion starts

Abnormal biomechanicsevolves

& encroaches neuralelements

Secondarily encroachesneural elements

Low back Pain begins

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Thank you