By Adrian Khu,SpOT

Low back pain

Introduction

• Low Back Pain is a symptom• The pathologic basis for the pain may something

within the spine or lesion outside of the spine• Classified as :

– Causes within the spine :• Spondylogenic• Neurogenic

– Causes outside the spine :• Viscerogenic• Vascular• Psychogenic

Spondylogenic Back Pain

Derived from lesions involving

• Bony components spinal column

• Changes in the sacroiliac joints

• Changes in the soft tissues– Discs– Ligaments – muscles

Neurogenic Pain

• This pain can causes by :

– Tension, irritation or compression of lumbar

nerve root

– Lesion of central nerve system such as thalamic

tumors, arachnoid irritation

– Tumors involving the roots, like neurofibroma,

neurilemmoma, ependymoma and others cyste

Viscerogenic Back Pain

• Can cause by disorders of the kidneys,

pelvic viscera, lesions of lesser sac and

retroperitoneal tumors

• The pain is not aggravated by activity nor

its relieved by rest

Vascular Back Pain

• Abdominal aortic aneurysms, peripheral

vascular disease give rise to backache

• Insuff. A sup gluteal buttock pain, that

can ↑ by walking and ↓ by standing still

• Pure psychogenic back pain is rarely

seen in clinical

• Caused by emotional breakdown

Psychogenic Back Pain

Spondylogenic Back Pain : Osseous Lesions

• Pathological processes involving the vertebrae and intervertebral joints

• The pain will minor ↑ by activity, and it is not relieved by rest

• Divided into :– Trauma– Infection– Tumors– Metabolic bone disease (osteoporosis)

INFECTION• Relative rare, but potential source of back

pain

• Divide into :– Vertebral osteomyelitis :

• Pyogenic• Granulomatous (TB)• Miscellaneous

– Epidural abscess– Intervertebral disc infection– Intervertebral disc inflammation

TUMOR• Benign tumors and primary malignancies in the

vertebral column are rare, secondary lesions are common

• Primary tumors of spine can be seen on plain radiographs

• Older patient, more likely primary tumoris malignant

• Most benign tumor are in the posterior elements, except GCT, eosinophilic granuloma and hemangioma

• Most primary malignant tumors will be found in

the vertebral body

• The incidence of neurogical compromise is 75%

in malignant tumors and 40-50% in benign

tumors, due to direct tumor extension,

pathological fractures or skeletal deformity

• The prognosis for malignant tumors is not very

good

• Benign tumors :

– chordoma, osteoid osteoma, osteoblastoma, ABC, GCT,

osteochondroma, hemangioma, eosinophilic granuloma

• Malignant tumors :

– Primary : myeloma, chondrosarcoma, osteosarcoma,

Ewing’s sarcoma, fibrosarcoma and lymphoma

– Secondary : hypernephroma, thyroid, bowel ca (lytic

lesion), breast, prostate and lung tumor (blastic

lesion)

Spondylogenic Back Pain : Soft Tissue Lesions

• Lesions :

– Fibrositis

– Myofascial pain syndromes

– Sacralization of lumbar vertebra

– Disc degeneration

– Disc ruptures

Fibrositis (Fibromyalgia)

• Nonspecific inflammatory changes in fibrous tissue that felt for clinical syndromes of lumbago

• Chronic, widespread, nonarticular, musculoskeletal pain

Myofascial Pain Syndromes• If fibrositis is localized to one area of the

body, such as the low back

Sacralization

• Attachment between the transverse process

of L5 with the sacrum and associated with

back pain

Disc Degeneration

• The natural aging process, with or without

repeated minor episode of trauma, results

in :

– loss of nuclear jelly (because of failure to

reproduce the degradated proteoglycan)

– weakening of annulare support (because of

failure of collagen linking)

• The cascade process :

1. Fibroblasts fail to reproduce new collagen to replace

degradated collagen in the annulus

2. Chondrocytes fail to reproduce new proteoglycan to

replace degradated proteoglycan in the nucleus

3. Nutritional flow of glucose, O2 and sulfates to the

discs is decrease

4. These factors (number 3) change disc metabolism

negatively and likely decrease the pH within the disc

5. Decrease in pH gives upper hand to degrading

enzymes (protease), which further increases disc

degeneration

Disc Ruptures

• Divided into :– Contained :

• Protrusion

• Subannulare extrusions

– Noncontained :• Transligamentous extrusion

• Sequestered

Changes of the Sacroiliac Joints

Sacroiliac Joint syndrome

• Pain over SI joint

• Locally tenderness to palpation

• Referred to groin, trochanter and buttock

• ↑ by provocation test

• ↑ movement of asymmetry of the SI joint

OA degeneration post traumatic SI joint

• Tenderness over lower third SI joint

• Tenderness of pubic symphisis on palpation

• Symptoms reproduced by stressing the SI joint

• Accompanying degenerative changes in symphisis pubis

Treatment• Conservative

– Rest limited activity program, mattress, bedrest– Traction pelvic traction– Acute LBP therapeutic cold,superficial heat(infrared,whirlpool

bath,ultrasound)– Chronic LBP ultrasound, transcutaneous electrical nerve

stimulation (TENS) – Medication morphine, analgesic,AIDS,steroid– Occupational change– Activity of daily living and faulty posture– Low back exercise – Low back support and braces

Treatment • Surgery

– Interlaminar surgery– Microlumbar discectomy– Bonegrafts – Interbody fusion