Back care

1. Advanced Neuro-Care Institute

2. Spine- care Dr Manish Vaish DNB (Neurosurgery) Fellow of American Association of Neurological Surgeons Member AO spine Society Senior Consultant MAX Healthcare and GBH-American Hospital

3. A little bit of ANATOMY

4. The Spinal Column

5. Low Back Pain Second most common cause of missed work days Leading cause of disability between ages of 19-45 Number one impairment in occupational injuries

6. Low Back Pain Most episodes of LBP are self limited These episodes become frequent with age LBP is usually due to repeated stress on the lumbar spine over many years (“degeneration”) , although an acute injury may cause the initiation of pain

7. Why it is common? The lumber spine has lordotic curve –Last in the evolutionary process, though made perfect-every spine degenerates! WHY!!! From four legged mammal to two legged human being, only due to lumber curve

8. Forces Acting on the Spine Compressive forces push bones and discs together. Tensile forces act (pull) on ligaments, tendons and muscles. Typically these forces occur simultaneously, for example, when lifting objects , or when “ SLOUCHING .”

9. Back Injury Risk Factors - Acute slips, trips and falls; auto accidents; sedentary lifestyle (with occasional lifting); heavy and/or awkward loads; improper lifting technique. Acute (traumatic) back injury :

10. Back Injury Risk Factors - Chronic Chronic back injury may result from poor posture and/or improper lifting technique combined with repetitive lifting. Additionally, genetics and overall physical fitness may affect spine health.

11. Maintaining a neutral spinal posture is important when seated as well as during lifting tasks. If sitting without back support, rotate the hips forward until a neutral posture is achieved. If using the backrest, sit back in the chair to allow the backrest to help maintain a neutral posture and reduce muscle loading . “Flat” Neutral Back Injury Risk Factors - Chronic

12. Risk Reduction - Engineering/Design Design a safer lifting environment by: avoiding very high and very low object placement; reducing object weight and size ; providing handles ; eliminating the need for twisting motions; eliminating bending and stooped postures; and by providing mechanical assistance .

13. Risk Reduction - Lifting Tips When lifting, you can substantially reduce your risk of low back injury and pain by: keeping the object close to you; bending your knees; maintaining your lumbar curve (bend knees and stick buttocks out); not twisting or bending sideways; avoiding rapid, jerky movements; and asking for assistance with heavy and/or bulky loads.

14. Slipped Disc/ Disc Herniation

15. Disc Degeneration With age and repeated efforts, the lower lumbar discs lose their height and water content (“bone on bone”) Abnormal motion between the bones leads to pain

16. Most Common Problems Disc herniation – leads to leg (or arm) pain Disc degeneration – leads to low back (or neck) pain

17. Risk Reduction at Home Maintaining a neutral spinal posture when stooped (e.g., when shaving, brushing teeth, bathing children, repairing cars, shoveling, etc.) may reduce your risk of back injury and discomfort. Planning your lifts , getting assistance, and using mechanical advantage are examples of risk reduction strategies.

18. Back Pain - When to Seek Help For common back sprain , give home remedies a try for 72 hours . In rare cases, back pain can indicate a serious problem - seek medical attention if: you have weakness or numbness in either leg; you have a fever along with back pain ; you notice bladder or bowel control problems; your pain increases with lying down ; or you have a history of significant chronic disease, such as osteoporosis, cancer or diabetes .

19. Diagnostic Modalities X-ray : 40% of the destruction of destruction occurs before it appears on X-ray Normal asymptomatic patient will have same changes on X ray MRI: All answers for backache always has to read in light of patients symptoms CT : Some times your surgeon might ask for it as well

20. Neck pain Use of pillow Neck roll Chin tuck and stretch Neck side tilt Neck turn

21. Take home message Know the warning signs of back pain caused by poor ergonomics and posture Get up and move Keep the body in alignment while sitting in an office chair and while standing Use posture-friendly props and ergonomic office chairs when sitting Increase awareness of posture and ergonomics in everyday settings Use exercise to help prevent injury and promote good posture Wear supportive footwear when standing Remember good posture and ergonomics when in motion Create ergonomic physical environments and workspaces, such as for sitting in an office chair at a computer Avoid overprotecting posture.

22. THANKS VERY MUCH

23. Disc Degeneration – MRI

24. Management REST IN BED Manipulation Medications Epidural injections Facet blocks Physiotherapy

25. Indications for Surgical Treatment Low back pain for at least 2 years Incapacitating Resistant to physical therapy and medication Positive MRI findings (degenerative changes) at L4-5 and/or L5-S1 For selected cases: Concordant pain on discography Psychological evaluation

26. Results of Surgical Treatment Fritzell et al., Spine 2001 Dec 1;26(23):2521-32 Prospective randomized multicentric study (class I evidence) In the surgical group, 63% of patients rated themselves as “much better” or “better”, compared to 29% in the nonsurgical group Surgical treatment is superior to nonsurgical therapy in a well selected group of patients

27. Management Surgery-disc prolapse Direct addressing pathology Myths No surgical procedure Permanent backache Loss of bladder control Lack of stability Loss of motor power Paralysis Removal of whole disc Longer stay in bed Fact Specific Indications for specific surgery Refinement of surgical technique-microscopic Preservation of the facets and protection of dura Removal of disc which has prolapsed, otherwise intact

28. Management Surgery-disc prolapse Hemi Laminectomy – Fenestration technique Endoscopic discectomy –few indication Thermal ablation no statistical data Laser ablation Micro-ENDOscopic discectomy – Gold standard