by robert h. belding md orthopedic surgeon columbia, sc, usa

By

ROBERT H. BELDING MD

Orthopedic Surgeon

Columbia, SC, USA

2nd most common cause for office visit 60-80% of population will have lower back

pain at some time in their lives Each year, 15-20% of people will have back

pain Most common cause of disability for

persons < 45 years Costs to society: $20-50 billion/year 80% to 90% Resolve in one month 20% to 30% Become chronic 5% to 10% Become disabling

“One would have thought by now that the problem of diagnosis and treatment would have been solved, but the issue remains mysterious and clouded with uncertainty.”

Rosomoff HL, Rosomoff RS. Low back pain: Evaluation and management in the primary care setting. Med Clin North Am 1999;83:643-62.

ANATOMY

ANATOMY

ANATOMY

ANATOMY

ANATOMY

ANATOMY

ANATOMY

DEEP LUMBARMUSCLES

ANATOMY

SUPERFICIALLUMBARMUSCLES

ANATOMY

ANATOMY

SPINAL NERVES, ARTERIESAND VEINS

ANATOMY

Lumbar “strain” or “sprain” – 70% Degenerative changes – 10% Herniated disk – 4% Osteoporosis compression fractures –

4% Spinal stenosis – 3% Spondylolisthesis – 2%

Spondylolysis, other spinal instability – 2%

Fracture - <1% Congenital disease - <1% Cancer (primary, metastatic)– 0.7% Inflammatory arthritis (RA, lupus, etc.)

0.3% Infections – 0.01%

1. HISTORY2. PHYSICAL EXAM3. PLAIN X-RAYS4. DIFFERENTIAL DIAGNOSIS5. SPECIAL STUDIES

HOW DID IT BEGINWHAT AGGRIVATES ITWHEN IS IT WORSEWHERE IS THE PAIN LOCATEDDOES IT RADIATE TO THE LEGARE THERE ASSOCIATED NEUROLOGICAL SIGNSWHAT TREATMENT HAVE YOU HADWHAT OTHER CONDITIONS HAVE YOU HADIS THERE A FAMILY HISTORY OF BACK PAINHAVE YOU MISSED WORKIS IT WORK RELATEDIS CLAUDICATION PRESENT

HISTORY

History of cancer Unexplained

weight loss Intravenous drug

use Prolonged use of

corticosteroids Older age

Major Trauma Osteoporosis Fever Back pain at rest

or at night Bowel or bladder

dysfunction

HISTORY

RANGE OF MOTION TENDERNESS MUSCLE SPASM STRAIGHT LEG RAISING TEST SI JOINT STRESS TEST TRENDELENBURG SIGN LEG LENGTH SPINE DEFORMITIES ERYTHEMA OR HEAT BIRTH MARKS

Waddell's signs are a group of physical signs, first described by Waddell et al in 1980, that may indicate non-organic or psychological component to chronic low back pain. Historically they have been used to detect "malingering" patients with back pain.

One or two Waddell's signs can often be found even when there is not a strong non-organic component to pain. Three or more are positively correlated with high scores for depression, hysteria and hypochondriasis on the Minnesota Multiphasic Personality Inventory.

Superficial tenderness – skin discomfort on light palpation. Nonanatomic tenderness – tenderness crossing multiple

anatomic boundaries. Axial loading – eliciting pain when pressing down on the top

of the patient’s head. Pain on simulated rotation - rotating the shoulders and

pelvis together should not be painful as it does not stretch the structures of the back.

Distracted straight leg raise - if a patient complains of pain on straight leg raise, but not if the examiner extends the knee with the patient seated (e.g. when checking the Babinski reflex).

Regional sensory change - Stocking sensory loss, or sensory loss in an entire extremity or side of the body.

Regional weakness - Weakness that is jerky, with intermittent resistance (such as cogwheeling, or catching). Organic weakness can be overpowered smoothly.

Overreaction - Exaggerated painful response to a stimulus, that is not reproduced when the same stimulus is given later.

RADIOLOGY

RADIOLOGY

AP LATERAL

SPOT LATERAL L-5

RADIOLOGY

RADIOLOGY

RADIOLOGY

RADIOLOGY

RADIOLOGY

DIFFRENTIAL

1.Back exercise for strengthening and flexibility2.Education about sitting, lifting, bending3.Proper surface for sleeping4.Weight reduction5.Smoking cessation6.Good mental health7.Back school

PREVENTION

Treat the underlying cause first:Tumor, Fracture, Arthritis, Infection, Osteoporosis ,

Congenital deformity, etc.

Treatment of Lumbar strain , spinal stenosis, diskogenic pain, spinal instability, degenerative disease symptomatically as long as there

are no progressive neurologic findings

TREATMENT

1.MEDICATION2.REST3.BRACES & SUPPORTS4.PHYSICAL THERAPY6. STEROID INJECTIONS7. ACCUPUNCTURE

TREATMENT

TREATMENT

TREATMENT

LUMBOSACRALCORSETTE

EXTENTION BACKBRACE

PREVENTIVE WORKBRACE

1.BACK EXERCISE2.MESSAGUE3.ELECTRIC STIMULATION4.HEAT/COLD5.PELVIC TRACTION6.ULTRASOUND7.MANIPULATION

TREATMENT

1.EPIDURAL2.FACET JOINT3.TRIGGERPOINT4.INTRAMUSCULAR

TREATMENT

1.Progressive Neurologic Findings2.Unstable Spine 3.Some Congenital Deformities4.Infection With Abscess Or

Osteomylitis5.Symptoms That Are Unresponsive

To Conservative Treatment6.Tumors7.Fractures

TREATMENT

THANK YOU