By ROBERT H. BELDING MD Orthopedic Surgeon Columbia, SC, USA

 2 nd 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

Epidemiology of Back Pain 60-90% lifetime prevalence % have recurrent episode. What is the Natural History? 80-90% resolves in 1 month % remains “chronic” 5-10% “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:

ANATOMYANATOMY

ANATOMYANATOMY

ANATOMYANATOMY

DISCOGRAMDISCOGRAM

ANATOMYANATOMY

ANATOMYANATOMY

ANATOMYANATOMY

ANATOMYANATOMY DEEP LUMBAR MUSCLES

ANATOMYANATOMY SUPERFICIAL LUMBAR MUSCLES

ANATOMYANATOMY

ANATOMYANATOMY SPINAL NERVES, ARTERIES AND VEINS

ANATOMYANATOMY

 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.Be able to recognize the difference between routine lower back pain and dangerous forms of lower back pain. 2.Provide information, advice, and a plan of action.

1.HISTORY 2.PHYSICAL EXAM 3.PLAIN X-RAYS 4.DIFFERENTIAL DIAGNOSIS 5.SPECIAL STUDIES

HOW DID IT BEGIN WHAT AGGRIVATES IT WHEN IS IT WORSE WHERE IS THE PAIN LOCATED DOES IT RADIATE TO THE LEG ARE THERE ASSOCIATED NEUROLOGICAL SIGNS WHAT TREATMENT HAVE YOU HAD WHAT OTHER CONDITIONS HAVE YOU HAD IS THERE A FAMILY HISTORY OF BACK PAIN HAVE YOU MISSED WORK IS IT WORK RELATED IS CLAUDICATION PRESENT HISTORYHISTORY

 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 HISTORYHISTORY

 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.psychologicallow back painmalingering 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.depression hysteriahypochondriasisMinnesota 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).Babinski  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.

RADIOLOGYRADIOLOGY

RADIOLOGYRADIOLOGY APLATERAL SPOT LATERAL L-5

RADIOLOGYRADIOLOGY

RADIOLOGYRADIOLOGY

RADIOLOGYRADIOLOGY

RADIOLOGYRADIOLOGY

RADIOLOGYRADIOLOGY

DIFFRENTIALDIFFRENTIAL

1.Back exercise for strengthening and flexibility 2.Education about sitting, lifting, bending 3.Proper surface for sleeping 4.Weight reduction 5.Smoking cessation 6.Good mental health 7.Back school PREVENTIONPREVENTION

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 TREATMENTTREATMENT

1.MEDICATION 2.REST 3.BRACES & SUPPORTS 4.PHYSICAL THERAPY 6. STEROID INJECTIONS 7. ACCUPUNCTURE TREATMENTTREATMENT

TREATMENTTREATMENT

TREATMENTTREATMENT LUMBOSACRAL CORSETTE EXTENTION BACK BRACE PREVENTIVE WORK BRACE

1.BACK EXERCISE 2.MESSAGUE 3.ELECTRIC STIMULATION 4.HEAT/COLD 5.PELVIC TRACTION 6.ULTRASOUND 7.MANIPULATION TREATMENTTREATMENT

1.EPIDURAL 2.FACET JOINT 3.TRIGGERPOINT 4.INTRAMUSCULAR TREATMENTTREATMENT

1.Progressive Neurologic Findings 2.Unstable Spine 3.Some Congenital Deformities 4.Infection With Abscess Or Osteomylitis 5.Symptoms That Are Unresponsive To Conservative Treatment 6.Tumors 7.Fractures TREATMENTTREATMENT

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