1. BACKACHE
DR MANOJ KUMAR
DIRECTOR PROFESSOR
DEPT OF ORTHOPAEDICS
MAMC,NEW DELHI

6. Mechanics of the Back
• Vertebral column is pillar like structure
supported in all directions by musculature,
• Anteriorly – the recti and abdominal muscles
• Posteriorly- erector spine and quadratus
• If any of these supports give way, vertebral
column will move to the other side, and most
of the times its anterior musculature that
gives way,

7. Homo Sapiens- we have erect spine, bearing weight of trunk
against gravity. Rest of the vertebrates do not suffer
backache

8. Causes
Mechanical (affecting
spine only)
• Muscle strain
• Osteoarthritis
• Spinal stenosis
• Discogenic
• Spondylolisthesis
• Vertebral fracture
• congenital
Non mechanical (systemic diseases)
• Ankylosing spondylitis
• Neoplasms
• Infections( TB, Herpes,
osteomyelitis)
• Atherosclerosis
• Visceral pain
Biomechanical causes
• Poor posture
• Sedentary lifestyle
• Poor furnitre
Pyschological causes
• Depression
• stress
ENDLESS PRACTICALLY

9. Causes of Low Back Ache
• Prolapsed intervertebral disc
• Spondylolisthesis
• Lumbar canal stenosis
• Tuberculosis
• Tumors

11. Risk Factors
• Occupational
• Age
• Alcohol and Drug Abuse
• Family History
• Gender
• Level of Activity (Physical Fitness)
• Obesity
• Poor Posture and Alignment
• Previous Back Injury
• Psychological, Social and Spiritual Factors
• Smoking - Studies have shown that smokers have a 1.5 to 2.5 times
greater risk of developing low back pain than nonsmokers. It is
thought this may be due to reduced oxygen supply to disks and
decreased blood oxygen from the effects of nicotine on constriction
of the arteries.
• Sports
• Other factors

12. Prolapsed Intervertebral Disc
• It’s a hydrostatic load
bearing structure from C2-
C3 to L5-S1
• Nucleus pulposus + annulus
fibrosus
• Relatively avascular
• L4-L5 disc, largest avascular
structure in body
• Cervical disc much less
common.

14. PIVD-clinical featues
• History of trivial trauma or lifting weight
• Shooting pain with spasm
• Pain radiating down the leg below the knee
• Aggravated by coughing/sneezing
• Usually sudden onset
• May be associated with concurrent neurological
deficit; sensory or motor, paresthesias.
• H/O remissions and excerbations.

15. Cauda equina
syndrome
• Low back pain
• Numbness in the groin or
area of contact if sitting on
a saddle (perineal or saddle
paresthesia)
• Bowel and bladder
disturbances
• Lower extremity muscle
weakness and loss of
sensations
• Reduced or absent lower
extremity reflexes

17. PIVD- Examination
Posture, movements,
tenderness

18. PIVD- Examination
• Straight leg raising (Lasegue’s test)

19. PIVD- Examination
• Kernig’s Test

20. PIVD- Investigations
• Plain x-ray
• Myelography
• Ct- scan
• MRI (preferred)
• EMG

22. PIVD- Treatment
• Conservative management
rest, drugs, physiotherapy
• Operative intervention – failure of conservative measures,
cauda equina syndrome
1. Fenestration
2. laminectomy
3. hemi-laminectomy
4. laminotmy
fenestration

23. Spondylolisthesis
Bilateral defect in the pars interarticularis
which causes forward displacement of
vertebra

24. Spondylolisthesis

25. Spondylolisthesis- clinical features
Symptoms
• Vary from mild to severe. May even have no symptoms.
• Classically a “STEP” may be palpable.
• Can produce increased lordosis (also called swayback),
but in later stages may result in kyphosis (roundback) as
the upper spine falls off the lower spine.
• Lower back pain, tenderness
• Muscle tightness (tight hamstring muscle)
• Pain, numbness, or tingling in the thighs and buttocks
• Weakness in the legs

27. Palpable Step

28. Spondylolisthesis- investigations
Scottish dog sign

30. Spondylolisthesis- Treatment
• Conservative methods
for grade 2 to 3
spondylolisthesis,
including brace and
analgesics
• Spine flexion exercises
• Failure of conservative
and severe listhesis may
require operative
intervention-
intertrasverse fusion or
internal fixaton.

31. Intertransverse fusion
Pedicle screw fixation

32. Lumbar Canal Stenosis
• Due to the common
occurrence of spinal
degeneration that occurs
with aging.
• sometimes caused by
spinal disc herniation,
osteoporosis or a tumor.
• In the cervical and
lumbar region, can be
a congenital condition to
varying degrees.

33. Lumbar Canal Stenosis- features
• Low back ache – dull
aching nature
• Weakness and tingling
sensation in b/l lower
limbs.
• frequently unable to walk
for long distances
• symptoms improved
when bending forward
while walking with the
support of a walker or
shopping cart
• Psuedo-claudication
(neurogenic claudication)
Bicycle test of van Gelderen

34. Claudication

35. Lumbar Canal Stenosis

36. Lumbar Canal Stenosis
Axial cuts

37. Lumbar Canal Stenosis

38. Lumbar Canal Stenosis
• Management mostly conservative on
• Analgesics
• Rest
• Specific drugs like pregabalin and gabapentin
• Epidural injections of steroid- cortisone
• Surgery indicated- no response to conservative
Laminectomy and stablisation

39. Midline decompresion

40. TB Spine- Pott’s
Disease
• Spine most common
extrapulmonary site
• Dorsolumbar region
common
• Paradiscal type most
common

41. Types of TB spine
Paradiscal central anterior posterior

42. TB Spine- Clinical features
• Constitutional symptoms- night cries, low apetite
• Commonest- backache
• Vary from LBA to complete paraplegia.
• Muscle spasm
• Cold abscess
• Deformity of spine- kyphosis
• Upper motor neuron type Para paresis, brisk reflexes, clonus
and increased tone.

43. Neurological complication
• Early onset paraplegia-paraplegia in active phase of disease
(generally within 2 yrs)
• Pathology-
• inflamatory edema
• granulation tissue
• abscess
• caseous material
• Late onset paraplegia-paraplegia many year after the disease
(more than 2 years)
• Pathology-debris,sequestra,internal gibbus,stenosis,deformity

44. Stages of paraplegia
 Stage 1 (negligible)- Patient unaware
Ankle clonus
Plantar extensor
 Stage 2 (mild)- Patient aware of deficit but manage to
walk with support
 Stage 3(moderate)- Nonambulatory
Paralysis in extension
Sensory loss less than 50 %
 Stage 4(severe)- 3 + flexor spasms/paralysis in
flexion/flaccid/sensory loss more
than 50 %
Bladder involvement

45. • Reduction of
disc space
• Fuzziness of
margins

46. MRI Pictures

47. MRI Picture

48. TB Spine - Treatment
• Conservative if no neurological deficit or improving deficit-
ATT and bed rest, followed by ash brace
• Indication for surgery-
• Neurologic deficit –
• Spinal deformity with instability or pain
• No response to medical therapy
• Continuing progression of kyphosis or instability
• Large paraspinal abscess

49. Operative interventions
• Costotransversectomy, anterolateral decompression

50. Anterolateral Decompression

51. Tumors
• Most common tumors
in spine- seconadaries
• Primary spine tumors
less common
• Most common
primary- multiple
myeloma

52. Multiple myleoma

53. Secondaries

55. Metastasis MRI Imaging

56. Lesions in spine