back pain is a very widespread pathology in the world. There are health and socioeconomic consequences. widespread both in the young and in the old. The causes are different. The overwhelming majority is mechanical pain without a specific cause, while the others are pain from disc, infections, tumors, fractures, metabolic.

1. LOW BACK PAIN

2. 1980-
2009

6. Second most commen symptom
Affect all age groups / all economic groups
Globally 54% increase in the last 25 yrs
12 – 33% of adult population have low back pain

9. LOW BACK PAIN

10. History

11. Natural history of low back pain
 80%-90% resolves in 1 months how back pain develops
 20%-30% remains chronic
 5%-10% disabling Muscle imbalances
dysfunction
Condutions -
herniated disc
Pain
Successful
treatment
needs to
begin here
Most
treatments
fail

12. obesity, smoking,
gender
lifting, vibration,
prolonged sitting
job
dissatisfaction

13. low back pain

14. Cause of lower back pain

15. Mechanical 80%
- Lumbar sprain , strain
- Facet joint arthritis
- proplased intervertebral disc
- spondylosis
- Disc anular tears
Infection
- Osteomyelitis
- Discitis
Traumatic
- Spondylolysis
- spondylolisthesis
- Sprain, stain
- spinal/ foraminal stenosis
- vertebral fracture
Metabolic
- osteoporosis
- osteomalacia
- Paget disease

16. • Viscerogenic ( refered)
- Genitourinary disease
-Gynaecological disease
• Vasculogenic
- Aortic aneurysem
• Psychogen
-Somatization disorder
- Myofascial pain
- Fibromyalgia

17. Mechanical low back pain

19. No clearly defined pathology
No significant clinical or radiological findings
Diagnosis of exclusion

20. • Aggrevated with movement and relited by rest
• Patients may complain of symptoms on standing up from supine or
seated positions , and pain on turning over bed .

21. Clinical features
• dull pain
• Aggrevated by
- physicial activity
- stooping
- lifting
- turning and coughing
• No neurological signs and symptoms
• it is not possible to clinically distinguish the source of pain between disc,
facet joint , muscle , ligaments and SI joint .
• Pain on flexion may be related to discogenic pain and facetogenic pain
may be aggrevated by hyperextension.

22. Features of pain
• Location : upper , middle or lower back. Disck prolaps and degenerative
spondylitis occur in the lower lumbar spine, infection and trauma occur in
the dorso lumbar spine.
• Onset : it has a history of trauma or disc prolapse. Pain resulting from a
routine activity such as twisting to pull something out of a drawer.
• Location of pain: pain arising from tend or musle injury is localized,
whereas that originating from deeper structure is diffuse. Pain referred to a
dermatome of the lower limb with neurological signs menas nerve root
entrapment.

23. • Progres of pain: in traumatic condition and acut disc prolaps pain is
maximum at the onset, and then gradually subside over days or weeks.
Back pain to disc prolaps has remission and exacerbation. Arthrotic and
spondylotic pain are more constant and aggrevated by activity. Pain to
infection and tumors take progressive cours ,with nothing causig relief.
• Releiving and aggravitating factors: most back pains are worsended by
activity and relieved by rest. Pain due to ankylosing spondylitis and
seronegative arthritis SSA is typically worse after rest and improves with
activity. Sever back pain at night ant relieved by aspirin indicate to bening
tumor. Pain initiated on walking or standing and relieved by rest is a
feature of spial stenosis. An increase of pain due menstruaction may
indicate a gynaecological pathology.

29. Physical examination
• Position- inspection

30. palpation

32. SLRT

33. Straight Leg Test Variant

35. Femoral Stretch Test (L2-4)

37. • L4 Motor Exam
• To test L4 strength, have the patient
slightly bend the knee and kick out
as you keep pressure against the leg.
Be sure to compare both sides to
see if one side has weakness relative
to the other.

38. L5 Motor Exam
• L5 Motor Exam
• To test L5 strength, hold pressure over the large
toes and ask the patient to dorsiflex the big toes
and foot towards up. Compare both sides for
relative weakness.

39. Test for L5 weakness with walking on heels in normal patient.
If one foot is unable to lift toes off ground, could suggest L5
weakness on that side.

40. Test for S1 weakness with walking on toes in
normal patient. If one foot is unable to lift
heal off ground, could suggest S1 weakness
on that side.

41. S 1 Motor exam

42. Sensory Exam
• In the sensory exam, again
focusing on L4, L5 & S1, we will
look at specific dermatomal
regions as noted in the image.
If possible, use a
monofilament. If not present,
you can use your fingers or the
tip of a tongue depressor to
test for sensation.

43. L4 Sensory Exam
Focus on the anterior/lateral aspect of the thigh.

44. L5 Sensory Exam

45. S1- sensory exam

46. Reflex Exam
• L4 is tested by the patellar reflex.

47. L5 Reflex Exam
L5 is tested by the medial hamstring reflex.

48. S1 Reflex Exam

50. Investigation
• X ray – spondylolisthesis and retrolisthesis AP. Lateral , oblique
• CT And MRI- disc degeneration- Modic , anular teat, facet
arthropaty
• Blood tests - WBC, ESR, CRP infection and inflammatory,
Neoplastic
• Bone scan –facet joint uptake, SI, Metastatic neo, Vertebral fr.

51. Sydney
19 mil
consulti
ons
45 study
1995-2017 4.3 mil
Imaging
1: 4 primary care 1:3
emergency

52. When to consider imaging?
• Neurological deficit
• Significant of trauma
• Signs of infection
• Ca
• Osteoporosis
• Age >50
• Congenital spine problems
• History of a previous spine injury or back surgery
• History of long term steroid use or drug abuse
• Back pain > 4 wks
• Several episodes of severe pain.

57. Treatment
Rest
Analgesic
Physiotherapy
Education
Surgery

58. 50 Obese-
gastroplasty
50 non-
obese
another
OP
LBP 29
obese
pre OP
58%
After OP- 10
patient LWP,-
reduce dose
of medication
19 no LBP
12 (24%),
LWB pre
OP.

66. Management of low back pain
• Surgery
1. desctectomy
2. decompresion ( laminectomy )
3. spinal stabilization
4. verteboplasty / Kyphoplasty
5. Foraminotomy
6. Nuncleoplasty
7. Artificial disc replacement
• Implanted nerve stimulator
1. Spinal cord stimulation
2. dorsal root ganglion stimulation
3. peripheral nerve stimulation

67. Who needs Surgery
unstabile spine
acute fracture with neurological deficit
severe stenosis
after failure of aggressive non operative treatmet
Tu
progessive neurological deficite
sy Cauda equinea

71. Lumbar Disc Herniation is
a very common cause of
low back pain and
radicular leg pain, most
commonly affecting the
L4-L5 and L5-S1 levels.
Diagnosis is made with
MRI studies of the
lumbar spine.
Treatment is a trial of
nonoperative
management with
NSAIDs and physical
therapy. Surgical
laminotomy and
discectomy is indicated
for progressive disabling
pain that has failed
nonoperative
management, progressive
neurological deficits, or
cauda equina syndrome.

72. Epidemiology
peak
incidence is
4th and 5th
decades
lifetime
prevalence
of 10%
only ~5%
become
symptomatic
3:1
male:female
ratio

73. recurrent torsional strain leads to tears of outer annulus which leads to
herniation of nucleus pulposis
location
L5/S1 most common level
95% involve L4/5 or L5/S1 levels

74. • Annulus fibrous
- typ I collagen , water and proteoglycan
- characterized by extensibility and tensile strength
high collagen / low proteoglycan ratio (low % dry
weight of
proteoglycans)
• nucleus pulposus
- composed of type II collagen, water, and proteoglycans
- characterized by compressibility
- low collagen / high proteoglycan ratio (high % dry
weight of proteoglycans)
- proteoglycans interact with water and resist
compression
- a hydrated gel due to high polysacharide content and
high water content (88%)

76. Classification
Central : cauda equinea Sy CSE
• back pain(mostcommon)
• unilateralor bilateralleg pain(2ndmost
• common)
• saddleanesthesia
• bladderdysfunction
• unilateralor bilateralsensory changesin
legs
• unilateral orbilateralmotor weaknessin
• legs
• sexual dysfunction (impotencein men)
• bowel dysfunction

77. posterolateral (paracentral)
most common (90-95%)
PLL is weakest here
affects the traversing/descending/lower
nerve root
at L4/5 affects L5 nerve root

78. classification
Foraminal (far lateral, extraforaminal)
less common (5-10%)
affects exiting/upper nerve root
at L4/5 affects L4 nerve root
herniated disc material directly compresses dorsal root
ganglion
can manifest with more severe pain than traditional
posterolateral
disc herniation

79. Stage of disc herniation

81. RADICULOPATHY
Radiculopathy typically present with symptoms of radicular pain.
the absolute diagnose of radiculopathy is cinclusively made by
electrodiagnostic studies ( EMG/ NCV)
Postive neurological finding also make e strong working diagnosis.
Postive neurological findings include
•Deep tendon reflex change
•Motor weakness
•Sensory change
•Should NOT be use to describe lower extremity pain.
•It is a diagnois , pathology .
RADICULAR PAIN

82. • Lumbar Spinal Stenosis is a degenerative spinal condition
characterized by the narrowing of the lumbar spinal canal due
to a variety of bony or soft tissues structures.
• indence
most common reason for lumbar spine surgery in patients > 65
years
old
seen in 20-25%

84. Classification
• Acquired
• degenerative/spondylotic changes
(most common)
• post-surgical
• post-traumatic (vertebral fractures)
• inflammatory (ankylosing
spondylitis)
• secondary to systemic diseases
(Paget disease, acromegaly,
fluorosis)
• short pedicles with medially placed
facets
• can be subdivided into
• idiopathic
• developmental (achondroplasia)

85. Central stenosis < 10 mm AP axial CT/ MRI
Paracentral stenosis( lateral recesus )- descending nerve root compresion
foraminal stenosis - exiting nereve root compression
Extraforaminal stenosis- exiting nerve root compresion

86. • back pain
referred buttock pain
• leg pain
often unilateral
• neurogenic claudication
pain worse with extension (walking, standing upright)
pain relieved with flexion (sitting, leaning over shopping cart, sleeping in fetal
position)
• weakness
• bladder disturbances
recurrent UTI present in up to 10% due to autonomic sphincter dysfunction
• cauda equina syndrome (rare)

88. Spondylolisthesis
Spondylolisthesis
is the displacement
of one spinal
vertebra compared
to another

89. Cause
Degenerative
Traumatic
Dysplastic
Isthmic
Pathologic
Post-surgical/iatrogenic

90. • mechanical/ back pain
• most common presenting
symptom
• usually relieved with rest
and sitting
• defined as buttock and leg
pain/discomfort caused by upright
walking
• relieved by sitting
• not relieved by standing in one
place (as is vascular claudication)
• may be unilateral or bilateral

91. Classification-