approach to low backache

8/20/2019 Approach to Low Backache

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APPROACH

TO LOW

BACKACHE


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BASICS


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The back is composed

of : Vertebrae. Muscles.

Ligaments. Intervertebral disc. Nerves.


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DEFINITIONS


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Between the lowestribrease of thebuttocks


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RISK FACTORS


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Modifable risk a!ors"

Improper lifting techni!ues or liftinge"cessivel# heav# loads.

$oor posture while sitting or standing%twisting% vibration.

&trenuous ph#sical activit#.

$s#chological causes like an"iet# ordepression.


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&itting or standing for long periods oftime.

'riving long distances.

(besit#.

&moking.

No# $odifable risk a!ors"

)emale gender.


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CLASSIFICATION


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CLASSIFICATION OF LOW BACK PAIN%%%%D&RATION

*cute +,- months duration &ub acute +,- months duration hronic - months duration

/ecurrent /ecurring after a pain,freeinterval


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LASSIFICATION OF LOW BACK PAIN

Mechanical Low Back $ain:

*natomical deformit#. )unctional *bnormalit#.

Non Mechanical Low Back $ain:

In0ammator#

Infectious. In1ltrating. Traumatic.


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Ca'ses o Lo( Bak A)e

&pinal causes

ongenital

In0ammator# Infectious In1ltrating Traumatic.

Non &pinal auses

Metabolic auses


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ASSESSMENTTAKIN* THE

HISTOR+


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2I&T(/3:

Location of s#mptom The duration of s#mptom Mechanism or onset of s#mptom The character or description of the

pain: mechanical% radicular% claudicant%non,speci1c./elieving or e"acerbating factors.


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RED FLA* SI*NS

Indicate need for earl# diagnostic

testing.

Less than 4+ or older than 5+% with

back pain for the 1rst time. Trauma. The pain is constant and gettingworse. $ain is worse at ni ht or when su ine.


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RED FLA* SI*NS,Co#!

&teroid use)ever and weight loss. Neurological signs such asweakness% numbness% saddleanesthesia or bowel6bladderincontinence.


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S-i#al ra!'re&igni1cant trauma$rolonged glucocorticoiduse*ge 5+ #ears

I#e!io# or a#er2istor# of cancer

7ne"plained weight lossImmunosuppressionIn8ection drug useNocturnal pain*ge 5+ #ears


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Ca'da e.'i#a s/#dro$e7rinar# retention(ver0ow incontinence)ecal incontinenceBilateral or progressive motor de1cit

&addle anesthesia

S-o#d/loar!)ri!isMarked morning sti9ness in the back that

lasts -+ minLow back pain that improves with activit#but not rest*lternating buttock pain

*ge ;+ #ears


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$23&I*L


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Look for scoliosis% k#phosis% 0attening of thelumbar curve or e"aggeration of lumbar

lordosis.

$alpate the spinous processes for tendernessIf present% this is suggestive of spinal fracture

or infection.

$alpate the paravertebral muscles for spasm%hardening% trigger points. This helps to rule

out root levels of d#sfunction.

(N &T*N'IN@:


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The patient is made to e"tend and 0e"their back% side bend% and rotate to assesstheir range of motion.

Increased discomfort with h#pere"tensionis noted with facet 8oint involvement.&pinal stenosis relieved with forward

0e"ion.

>ith 'isc disease lateral 0e"ion is oftenpreserved%

whereas forward 0e"ion is not.


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A+ toe raises or toe walking will test plantar0e"ion and calf muscles innervated b# &A.

2eel walking or heel raises test ankle andtoe dorsi0e"or muscle strength innervated b#L5 and some L; nerve roots.

&ingle s!uat and rise tests the !uadriceps%mostl# innervated b# L; nerve root.


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(N &ITTIN@T)e S!rai0)! Le0 Raise implies signi1cantnerve root irritation when positive.

2ave the patient raise each thigh o9 thetable against #our resistance.2ave the patient e"tend as well as 0e" the

lower legs against resistance


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$atellar re0e" tests L- L;.

*chilles re0e" tests mostl# &A% Babinski orplantar re0e" helps to di9erential aspinal cord lesion upward toe suggests

a lesion above LA.

'orsi0e"ion of the foot tests L5 and someL;.

Cnee e"tensor strength tests L4,L;.

&kin testing for sensation to rule outnumbness and parasthesias should be

performed.


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Modi1ed &chober Test


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In0ammator# vs. MechanicalBack $ain


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DThink (utside the BackE/enal diseasesFp#elonephritis% renal stones% renal

abscessG

$elvic diseases F$I'% endometriosis% prostate

enlargementG

@astrointestinal disease Fcholec#stitis% ulcer%cancerG

/etroperitoneal diseases.

*bdominal *ortic aneur#sm.

2erpes Hoster infection.

'iabetic radiculopath#


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Therap#: Non,speci1c

LB$N&*I'&Muscle rela"ants&pinal manipulation6 $h#siotherap#Fe9ects

limitedG/apid return to normal activities*void heav# lifting% trunk twisting% vibrations


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Therap#: hronic LB$&urger# is often dicult to e"plainIntensive e"ercises help Fhard to maintainG*nti,depressant therap# useful if depressedLong term opioids not recommended/eferral to pain centerMassage therap# is promising

Therapeutic goals optimiJe dail# function


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THANK +O&

approach to low backache

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