Management of Low Back Pain - Segun Oniyide.pptx

This presentation outlines the management of low back pain

1. Management of Low Back Pain Department of Orthopaedic Surgery, BUTH Ogbomoso By Dr. ONIYIDE, S. A. 11/05/2023

2. Content Introduction Anatomy & Pathophysiology Epidemiology Classification Aetiology Approach to Management History Presentation & Red flags Examination Imaging Management Prevention Prognosis Conclusion References

3. Introduction Low back pain (LBP) also known as lumbago is a common disorder involving the ligaments, muscles, nerves, and bones of the back in the lumbosacral region. It can vary from a sudden sharp feeling to a dull constant ache.

4. Anatomy & Pathophysiology The lumbar (or lower back) region is the area between the lower ribs and gluteal fold which includes five lumbar vertebrae (L1–L5) and the sacrum. In between these vertebrae are fibrocartilaginous discs, which act as cushions, preventing the vertebrae from rubbing together while at the same time protecting the spinal cord.

5. Anatomy & Pathophysiology Nerves come from and go to the spinal cord through the intervertebral foramen, providing the skin with sensations and sending messages to muscles. Stability of the spine is provided by the ligaments and muscles of the back and abdomen. The facet joints limit and direct the motion of the spine. The multifidus muscles run up and down along the back of the spine, and are important for keeping the spine straight and stable during many common movements such as sitting, walking and lifting.

6. Anatomy & Pathophysiology The intervertebral discs have a gelatinous core, nucleus pulposus, surrounded by a fibrous ring, anulus fibrosus. When in its normal, uninjured state, most of the disc is not served by either the circulatory or nervous systems – blood and nerves only run to the outside of the disc. Specialized cells that can survive without direct blood supply are in the inside of the disc. Over time, the discs lose flexibility and the ability to absorb physical forces. This decreased ability to handle physical forces increases stresses on other parts of the spine, causing the ligaments of the spine to thicken and bony growths to develop on the vertebrae. As a result, there is less space through which the spinal cord and nerve roots may pass. When a disc degenerates as a result of injury or disease, the makeup of a disc changes: blood vessels and nerves may grow into its interior and/or herniated disc material can push directly on a nerve root. Any of these changes may result in back pain.

7. Epidemiology Low back pain that lasts at least one day and limits activity is a common complaint. It is more common among people aged 40–80 years, with the overall number of individuals affected expected to increase as the population ages (Hoy D et. al., 2012). Globally, about 40% of people have LBP at some point in their lives (Hoy D et. al., 2012) with estimates as high as 80% of people in the developed world. (Vinod Malhotra et. al., 2011). Approximately 9–12% of people have LBP at any given point in time, and nearly 25% report having it at some point over any one-month period (Vos T et. al., 2012). Yet even these statistics may underestimate the problem.

8. Epidemiology Gender preponderance for low back pain has not been established as it is not clear whether men or women have higher rates of low back pain. Although an estimated 70% of women experience back pain during pregnancy with the rate being higher the further along in pregnancy (Cunningham F, 2009).

9. Classification Low back pain may be classified by duration as acute (pain lasting less than 6 weeks), sub-acute (6 to 12 weeks), or chronic (more than 12 weeks). The condition may be further classified by the underlying cause.

10. Aetiology Low back pain is not a specific disease but rather a complaint that may be caused by a large number of underlying problems of varying levels of seriousness. The origin of pain can be broadly classified as mechanical, neuropathic, or secondary to another cause. Mechanical back pain implies that the source of pain is in the spine or its supporting structures. Neuropathic back pain denotes the presence of symptoms that stem from irritation of a nerve root(s).

11. Aetiology Mechanical (80-90%) Unknown cause—usually attributed to muscle strain or ligamentous injury (65%-70%) Degenerative disc or joint disease Vertebral fracture Congenital deformity (such as scoliosis, kyphosis, transitional vertebrae) Spondylolysis Instability

12. Aetiology Neurogenic (5-15%) Herniated disc Spinal stenosis Osteophytic nerve root composition Annular fissure with chemical irritation of nerve root Failed back surgery syndrome (such as arachnoiditis, epidural adhesions, recurrent herniation); may cause mechanical back pain as well Infection (such as herpes zoster)

13. Aetiology Non-mechanical spinal conditions (1-2%) Neoplastic (such as primary or metastatic) disease from lung, breast, prostate, thyroid among others Infection (such as osteomyelitis, discitis, abscess) Inflammatory arthritis (such as rheumatoid arthritis and spondyloarthropathies, including ankylosing spondylitis, reactive arthritis, enteropathic arthritis) Paget’s disease Others (such as Scheuermann’s disease, Baastrup’s disease)

14. Aetiology Referred visceral pain (1-2%) Gastrointestinal disease (such as inflammatory bowel disease, pancreatitis, diverticulitis) Renal disease (such as nephrolithiasis, pyelonephritis) Abdominal aortic aneurysm

15. Aetiology Other (2-4%) Fibromyalgia Somatoform disorder (such as somatisation disorder, pain disorder) Malingering

16. Approach to Management As the structure of the lumbago back is complex and the reporting of pain is subjective and affected by social factors, the diagnosis of low back pain is not straightforward. While most low back pain is caused by muscle and joint problems, this cause must be separated from other causes as earlier outlined.

17. Approach to Management - History Demographic risks: age, occupation, geographic location, socioeconomic status, educational attainment, marital status,, racial or ethnic group. History of presenting complaints. Past Medical & Surgical History. Psychosocial History. Complementary and alternative therapy use.

18. Approach to Management - Presentation Pain assessment - Site, onset, duration, character, radiation, aggravating factors, alleviating factors, intensity, associations. In the common presentation of acute low back pain, pain develops after movements that involve lifting, twisting, or forward-bending. The symptoms may start soon after the movements or upon waking up the following morning. The description of the symptoms may range from tenderness at a particular point to diffuse pain. It may or may not worsen with certain movements, such as raising a leg, or positions, such as sitting or standing. Pain radiating down the legs (known as sciatica) may be present.

19. Approach to Management - Presentation Chronic low back pain is associated with sleep problems, including a greater amount of time needed to fall asleep, disturbances during sleep, a shorter duration of sleep, and less satisfaction with sleep. In addition, a majority of those with chronic low back pain show symptoms of depression or anxiety.

20. Approach to Management - Red flags

21. Approach to Management - Examination General examination - including weight of the patient. Musculoskeletal examination. Neurologic - Gait, Motor, Sensory and Reflexes, Sciatic and femoral nerve stretching tests.

22. Approach to Management - Examination Signs of nerve root irritation Leg pain greater than back pain Radiation into foot or lower leg Numbness and paraesthesias in dermatomal distribution Diminished leg reflexes Positive straight leg raising test (L4 - S1 nerve roots) Positive femoral stretch test (L2 - L4 nerve roots) Leg pain exacerbated by coughing, sneezing, or Valsalva manoeuvre

23. Approach to Management - Imaging For pain that has lasted only a few weeks, the pain is likely to subside on its own. Thus, if a person's medical history and physical examination do not suggest a specific disease as the cause, medical societies advise against imaging tests such as X-rays, CT scans, and MRIs. Imaging is indicated when there are red flags, ongoing neurological symptoms that do not resolve, or ongoing or worsening pain. In particular, early use of imaging (either MRI or CT) is recommended for suspected cancer, infection, or cauda equina syndrome and also useful for diagnosis spinal stenosis.

24. Approach to Management - Management General considerations Primary therapy related to etiology Patient expectations Patient education related to pain treatment Pain treatment cost-effectiveness Prevention of back pain exacerbations Prevention of unnecessary surgery and suffering (failed-back-surgery syndrome)

25. Approach to Management - Management Pharmacologic agents Opioid analgesics Anti-inflammatory drugs Muscle relaxants Adjuvants and non-opioid analgesics The management of low back pain often includes medications for the duration that they are beneficial. The medication typically recommended first are acetaminophen (paracetamol), NSAIDs or skeletal muscle relaxants and these are enough for most people. Antidepressants may be effective for treating chronic pain associated with symptoms of depression, but they have a risk of side effects. Although the antiseizure drugs gabapentin, pregabalin, and topiramate are sometimes used for chronic low back pain evidence does not support a benefit (Enke O et. al, 2018).

26. Approach to Management - Management Non-pharmacologic agents Rehabilitative Interventional / Surgical Complementary and alternative medicine

27. Approach to Management - Surgery Surgical interventions for low back pain secondary to major pathologies such as tumours, and fractures are often effective in protecting neurological structures, preventing deformity, and relieving pain. In patients with persistent radiculopathy resulting from common degenerative conditions, surgery can reduce pain and improve function.

28. Approach to Management - Surgery For disc herniations without severe neurological deficits, the main benefit of surgery may be a more rapid return of function compared with the natural course. Compared with non-operative therapy, surgical intervention for spinal stenosis and spondylolisthesis results in superior outcomes, which persist for at least two years after surgery (Weinstein JN, et. al., 2008) In patients with chronic low back pain who present with common degenerative changes seen on imaging, surgical interventions (fusion or disc arthroplasty) are less effective.

29. Approach to Management - Prevention Exercise is useful for preventing low back pain and is also effective in preventing recurrences in those with pain that has lasted more than six weeks (Steffens D et. al., 2015). Exercise helps to strengthen the back and abdominal muscles and this has improved outcomes in both the prevention and management of low back pain. Meditation and relaxation techniques also help to relax some muscles which also help to relieve low back pain.

30. Prognosis Overall, the outcome for acute low back pain is positive. Pain and disability usually improve a great deal in the first six weeks, with complete recovery reported by 40 to 90% (Luciola da C . Menezes Costa , et. al, 2019). Prognosis may be influenced by expectations, with those having positive expectations of recovery related to higher likelihood of returning to work and overall outcomes (Hayden JA et. al., 2019). For persistent low back pain, the short-term outcome is also positive, with improvement in the first six weeks but very little improvement after that. At one year, those with chronic low back pain usually continue to have moderate pain and disability. Factors shown to be associated with development and persistence of low back pain include: Poor job satisfaction or low pay Inadequate coping skills

31. Prognosis Fear avoidance behaviour Manual labour or physically stressful job Obesity Somatisation Smoking Low baseline activity levels Ongoing litigation Older age Low educational level Higher pain intensity or disability Neurological symptoms Anxiety Depressed mood Emotional distress

32. Conclusion Most people will at some time experience an episode of serious low back pain, but most cases resolve with minimal intervention. The main value of a history and physical examination is to determine which patients should be referred for imaging and interventions. Comprehensive assessment of patients is essential for an appropriate treatment plan.

33. References Cunningham F (2009). Williams Obstetrics (23 ed.). McGraw Hill Professional. p. 210. ISBN 9780071702850. Enke O, New HA, New CH, Mathieson S, McLachlan AJ, Latimer J, et al. (July 2018). "Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis". CMAJ . 190 (26): E786–E793. doi:10.1503/cmaj.171333. PMC 6028270. PMID 29970367. Hughes SP, Freemont AJ, Hukins DW, McGregor AH, Roberts S (October 2012). "The pathogenesis of degeneration of the intervertebral disc and emerging therapies in the management of back pain" (PDF). The Journal of Bone and Joint Surgery. British Volume . 94 (10): 1298–1304. doi:10.1302/0301-620X.94B10.28986. PMID 23015552. Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al. (June 2012). "A systematic review of the global prevalence of low back pain". Arthritis and Rheumatism . 64 (6): 2028–2037. doi:10.1002/art.34347. PMID 22231424.

34. References Low Back Pain Fact Sheet. National Institute of Neurological Disorders and Stroke . National Institute of Health. 19 July 2013 Luciola da C Menezes Costa L, Maher CG, Hancock MJ, McAuley JH, Herbert RD, Costa LO (August 2012). "The prognosis of acute and persistent low-back pain: a meta-analysis". CMAJ. 184 (11): E613–E624. doi:10.1503/cmaj.111271. PMC 3414626. PMID 22586331. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Denberg TD, Barry MJ, et al. (April 2017). "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians". Annals of Internal Medicine. 166 (7): 514–530. doi:10.7326/M16-2367. PMID 28192789. Steffens D, Maher CG, Pereira LS, Stevens ML, Oliveira VC, Chapple M, et al. (February 2016). "Prevention of Low Back Pain: A Systematic Review and Meta-analysis". JAMA Internal Medicine. 176 (2): 199–208. doi:10.1001/jamainternmed.2015.7431. PMID 26752509.

35. References Vinod Malhotra; Yao, Fun-Sun F.; Fontes, Manuel da Costa (2011). Yao and Artusio's Anesthesiology: Problem-Oriented Patient Management. Hagerstwon, MD: Lippincott Williams & Wilkins. pp. Chapter 49. ISBN 978-1-4511-0265-9. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. (December 2012). "Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010". Lancet . 380 (9859): 2163–2196. doi:10.1016/S0140-6736(12)61729-2. PMC 6350784. PMID 23245607. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood E, Hanscom B, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008;358:794-810.