Sherif Elwatidy MD, FRCS(SN)

Professor of NeurosurgeryCollege of Medicine, KSU

BACK PAIN

HOW DO YOU MAINTAIN A HEALTHY BACK

(AVOIDANCE OF BACK PAIN)

How many of you had back

pain ?

Epidemiology

60 – 90% of adults experience back pain at

some point in their life.

- incidence age 35- 55 y.o.

- 90% resolve in 6 weeks

- 7% become chronic

- M/ F equally affected

Most episodes of LBP are self limited

85% never given precise pathoanatomical diagn.

Low Back Pain (FACTS)

Second most common cause of

missed work days

Leading cause of disability between

ages of 19-45

Number one impairment in

occupational injuries

Healthcare expenditures $90

Billion (1998) , $26.3 Billion

attributable to back pain

How do you know your back is

Healthy ?

Anatomy (origin of Back pain)

Common Pathoanatomical Conditions of the Lumbar Spine

Disc Degeneration – PathoPhysiology

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

Pathogenesis of Deg. Spondylosis

Factors accelerating spinal Degeneration

Genetic

Smoking

Occupational factors include:

- accident‐related trauma

- heavy physical loading and materials

handling

- lifting, bending, and twisting; prolonged

sitting;

- sustained non-neutral work postures and

vehicular

driving

Overweight

Lack of exercises

Plan ahead, don’t hurry

Spread feet shoulder distance apart

Bend knees

Lift with leg muscles

Tighten stomach muscles

Move in close when

placing object on high shelf

Don’t twist

14

Take Healthy Postures

What Does The Research Show?

% Load Compression On L3 During the Upright Standing, Lying Down, and Sitting.

Compression Increases More with Spinal Flexion, and Increases Still Further with a Slouched Sitting Position.

Differential Diagnosis of Low Back Pain

Diagnoses we don’t want to

miss

Tumor (of bone or viscera)

Infection

Fracture

Any process resulting in severe compromise of

nervous tissue

Systemic illnesses affecting joints

Leaking abdominal aortic aneurysm

History: the nine red pain

flags

Prominent neurological symptoms of weakness, numbness, loss of bowel or bladder control, difficulty walking

Pain is much worse at night

Fever

Other constitutional symptoms that always worry us

Patient cannot sit or stand due to pain

Pain following a fall in the elderly or in a patient at risk for osteoporosis

Leg pain is much worse than back pain

History of cancer in the last five years, particularly breast, lung, prostate,thyroid, renal

Polyarthralgias

Historical aspects that increased

suspicion for infection

Recent IV drug abuse

Immunosuppression

Diabetes

Things we don't want to miss in physical

exam

Neurological signs such as:

loss of reflex in the area of pain

profound focal weakness

profound diffuse proximal weakness

upgoing Plantars

clonus at the ankle

hyperreflexia

Loss of sphincter tone

Things we don’t want to miss

physical exam 2

The patient can’t walk or sit due to back or leg pain.

Severe pain with movement when it has lasted for more than one week history

Severe muscle spasm when it has lasted more than one week on history

Extreme and localized tenderness to percussion over the spinous processes or other bony prominences

Joint effusions, redness, synovial bogginess, tenderness

Predominantly back pain

1. Discogenic pain (annular tear)

2. Painful osteoarthritis of the facet joints

3. Structural pathology

(Congenital or degenerative kyphosis/scoliosis)

4. Compression fracture

5. Spondylolysis/spondylolisthesis

6. Inflammatory spondylitis

7. Visceral pathology

Predominantly leg pain

1. Herniated nucleus pulposus

2. Spinal stenosis

Less common “benign” causes of chronic back and leg pain

Sacroiliac joint pain

Coccydynia

Polymyalgia rheumatica

Stiff man syndrome

Multiple sclerosis

Parkinson’s disease

Sciatic nerve entrapment

Post viral and other autoimmune radiculitis/plexitis

Benign Mechanical Back pain

Usually worse in the morning then improves

with activity, varies with posture/activity

Usually lower lumbar pain, also buttocks and

thighs

Dull poorly localised pain

Cause cannot be attributed to any specific

pathology.

Nerve root pain

Due to nerve root irritation eg from a prolapsed

disc

Shooting pain and paraesthesia down back of

thigh sometimes as far as the heel.

May also affect anterolateral thigh if femoral

nerve roots are affected.

Cauda Equina

Syndrome

Bladder dysfunction, usually retention.

Sphincter disturbance

Saddle anaesthesia

Lower limb weakness

Gait disturbance

Urgent referral is mandatory

Take Home Message

Stop Smoking

Healthy habits of sitting , bending, lifting, driving

Reduce weight

Exercises / walking

Healthy Food rich in (Vit. C, Vit. E, Mg)