2. Low Back Pain Second cause of pain in body Leading cause of sick leave Is a symptom not disease 50-80% of adult will have LBP during their life M=F but after 60 yrs F>M Only 1% of acute LBP is due to lumbar radiculopathy Lumbar radiculopathy often occur during 4 th &5 th decades

3. Risk Factors Occupational factors Lifting, pulling, pushing, twisting, sitting Patient-Related factors Age, Gender, Anthropometric, postural, spine mobility, Muscles strength, Physical fittness, Smoking, Psychological

4. Etiology Degenerative Inflammatory Infection Metabolic Neoplastic Traumatic Congenital/Developmental Musculoskeletal Viserogenic Vascular Psychologic Post op.

7. Normal posture Line of gravity passes from C1 to C7 to T10 & lumbosacral junc. To hip joint

9. Clinical Evaluation Hx P.E: Inspection Palpation ROM(tape, inclinometers) Neurological Exam Gait MSR MMT Sensory Imaging EMG/NCS Bone Scan

10. Mechanical LBP Nondiscogenic LBP, provoked by activity & relieved by rest Often due to stress or strain on back muscles, tendon, lig. Chronic, dull aching pain spreed to buttock No assosiated with neurologic symp. Not increased with cough or sneeze Deconditioning & decompensation

11. Osteoarthritis O.A of vertebral body O.A of facet joint

12. Localized pain Epizodic Usually abrupt onset Limited extension Pain increased with activity & relieved by rest

13. O.A of facet joint(cont.) Treatment: Weight control Rest Analgesic or NSAIDs Manipulation Exercise(Q.L ex., pelvic tilt, flexibility ex., avoid ext.) Avoid prone sleeping

14. Radiculitis & Radiculopathy Common cause of acute, chronic or recurrent LBP particularly in young to middle aged mens Mean age: early 40s

15. Radiculitis & Radiculopathy Bulging disk Prolopsed disk Extruded disk Sequestered disk

16. L5,S1: radiated pain often to buttock, post. Thigh, lateral culf, med. Or lat. Maleoli L3,4: radiated pain to ant. Thigh When disk extrude LBP is decrised & leg symptoms are more prominent In upper lumbar radiculopathy: other cause (eg: neoplastic) should be R/O. Provocative maneuver P.E Lab test

18. Treatment Conservative Surgery if: Progressive neurological deficit Sphicter compromised Large midline disk protrusion with cauda equina syndrome Unresponce to 4-6 weeks comprehensive conservative treatment

19. Spondylolysis & Spondylolisthesis Spondylolysis: bony defect in pars interarticularis Spondylolisthesis : Bilateral lysis lead to ant. Slipping Listhesis: Dysplastic Isthmic ( lytic, elongated, acute Fx) Degenerative Traumatic Pathologic

20. LBP(+/- radicular symptome) Increased lumbar lordosis Hamstring tightness(standing with flex knee)

21. Imaging study L.S x-ray(lat, oblique) Flexion/extension view for segmental instability MRI, CTS, EMG/NCV if: Root symptoms Neurological defect pseudoclaudication

22. Treatment post traumatic: 10-12 weeks immobilization Chronic LBP: strengthening ex. In persistant pain: L.S corset Grade1&2 & in older patient: non surgical Modality Massage Stretching ex. Flexion ex. Abdominal binder

23. Surgury : Advance listhesis beyound grade 2 Young patient with heavy sport or physical job Severe symptomatic slip