presented by mostafa kamal abdellatif lecturer of anesthesia department ain shams university
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Low back pain
Presented byMostafa kamal Abdellatif
Lecturer of Anesthesia departmentAin Shams University
Pain that occurs in an area with boundaries between the
lowest rib and the crease of the buttocks
Types of back pain
Acute back pain
Pain with acut onset and rapid progressive course.
Chronic back pain
Pain that persists longer than the expected time period for healing
greater than 3 months.
What is back pain?
EpidemiologyLow back pain that lasts at least one day and limits activity is a very common and widespread complaint. Over a lifetime, 80% of people have lower back pain,with the difficulty most often begin-ning between 20 and 40 years old.It is most common among women, and among people aged 40–80 years, with the overall number of individuals affected expected to increase as the population ages. Women may be more prone to raise the complaint due to pain related to osteoporosis, menstrua-tion or pregnancy.
Classification
There are many different methods for classi-fication:1) According to origin: Mechanical and Non mechanical2) According to signs and symptoms: Non specific, Radicular and Specific.3) According to chronicity: Acute, Subacute and chronic.
Etiology of back painAcute back pain Acute low back pain is most often caused by a sudden injury to the muscles and ligaments supporting the back. It lasts for six weeks
Subacute back pain
It is from six to tweleve weeks
Chronic back pain :
It prersists more than tweleve weeks
Mechanical Endocrinologic
Rheumatologic Hematologic
Infection Neurologic. Referred
Neoplastic Psychiatric Miscella-neous
Mechanical 85% of all low back pain Muscle, ligament, tendon strain.Discogenic disorders including herniated disc.Apophyseal joint arthritis.Spinal stenosis.Spondylolysis, spondylolisthesis.Scoliosis.
Sources of low back painSuperficial somatic - skinDeep somatic - muscle, joint, tendon, bursa, fasciaRadicular - nerve rootVisceral referred - sympathetic afferentsNeurogenic - mixed motor sensory nervesPsychogenic - cerebral cortex
Pain intensityMinimal - mentioned in passing, normal functionMild - component of symptoms, mild dysfunctionModerate - major component of symp-toms, alters functionSevere - the disease symptom, incapaci-tating function
Diagnosis of low back pain1) History Red flags as cancer, cauda equina syndrome, fracture and infection.
2) ExaminationInspection: No obvious deformities, No erythema or Skin lesions (Zoster)
Palpation:Soft Tissue: we examine 3 clinical zones (Paraspinal muscles, Gluteal muscles, Sciatic area)Bones Primarily palpating spinous processes and facets
Range of movement:Flexion - 80º, Extension - 35º, Side bending - 40º each side
Twisting - 3-18ºStrengthNeurovascularSpecial Tests
3) Radiology
Special testsStraigth leg raising testRaising of stretched limb in supine position, positive test detected by pain in the limb.
Sciatic stretch testIn case of positive SLR, lowering the stretched leg 10 degrees detect pain in foot.
FADIR test:Flexion. AdductionInternal rotation
FABER test:Flexion Abduction External rotation
Hoover testHelps to determine whether pt is malingering, Should be per-formed in conjunction with SLRWhen pt is genuinely attempting to raise leg, he exerts pres-sure on opposite calcaneus to gain leverage
Neurological TestingSensationStrengthReflexes
Choice to do imaging based on:Trauma, chronic steroid use = XRaySuspect abscess, cauda equina = MRIExaminationNew/severe sensory or strength loss = consider MRI
Treatment of back pain
Mild to Moderate single drug v. placebo (active comparator).
Moderate to Severe stable multidrug regimen - flare with withdrawal.
Bed rest for 1-2 weeksMultimodalityBack exercises - flexion and/or extensionAerobic exerciseMedicationsCounterirritant topical therapiesStress management
MedicationsNSAIDsMuscle relaxantsAnalgesicsAntidepressantsAnticonvulsantsAlpha-2 adrenergic agonistsMiscellaneous
NSAIDSImprove pain vs. placebo in controlled trialShort half-lifeacute exacerbations, quick onset
Long half-lifeSustained effectCox - 2 inhibitors
Muscle relaxants Most beneficial in the first week, Shown effective in trials.Similar efficacy,Work best when combined w/ NSAIDs.CyclobenzaprineOrphenadrineMetaxoloneChlorzoxazoneMethocarbamol
AnalgesicsNonnarcoticAcetaminophenTramadolNarcoticShort actingLong acting
AntidepressentsTricyclic and tetracyclic antidepressents as. ami-titriptylline, maprotiline.
AnticonvulsantsGabapentinPregabalin
Interventional therapySimple injections of plain local anaesthetic without adrenalin or cortisone. Specific management includes medial branch and sacroiliac joint blocks, and radiofrequency neurotomy. Patients with long term pain may be referred to a psy-chologist for cognitive behavioural therapy.
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