2. Spinal pain is multifaceted- involving
Structural
Biomechanical
Biochemical
Medical
Psychosocial influences
Treatment is often difficult/ineffective
3. LBA is defined as chronic (cLBA) after 3
months because most connective tissues
heal within 6-12 weeks, unless
pathoanatomic instability persists.
cLBA is the most common cause of
disability in adults younger than 45 years.
LBA is the most expensive benign
condition in industrialized countries.
4. SCIATICA- leg pain that is localised in the
distribution of one or more lumbosacral
nerve roots, typically L4-S2, with or without
neurological deficit.
Non specific radicular pattern- when
dermatomal distribution is unclear
5. RISK FACTORS
Men=women
(>60 years: women> men)
Sciatica –fourth and fifth decades of life
Extreme height
Cigarette smoking
Morbid obesity
Weakness of trunk extensor muscles compared with
flexor strength– sciatica
Occupational risk factors- heavy physical work,
lifting, prolonged static work postures, simultaneous
bending and twisting, exposure to vibration
6. CLINICAL EVALUATION
HISTORY
-characterization of pain as mechanical-
most often aggravated by static loading of
the spine, long- lever activities and levered
postures. Pain relieved by rest.
Non mechanical pain- r/o serious causes like
infection and cancer.
7. PHYSICAL EXAMINATION
Complete inspection- limb length
discrepancy and pelvic obliquity,scoliosis,
postural dysfunction with forward leaning
head and shoulders, accentuated kyphosis.
Any soft tissue abnormalities and tenderness
to palpation should be noted.
palpation of lumbar paraspinal, buttock and
other regional muscles- note areas with
superficial and deep muscle spasms.
8. SLRT with patient supine-ipsilateral leg pain
between 10 and 60 degrees- positive
SLRT that produces pain in the opposite leg
carries a high probability of disc herniation-
investigate
Reverse SLRT
Neurological evaluation is performed to
determine the presence or absence of and
levels(if present ) of radiculopathy or
myelopathy.
9. Mechanical/activity- related
causes of LBP
Discal and segmental degeneration- may include
facet arthropathy from osteoarthritis
Myofascial, muscle spasm or other soft tissue
injuries and/or disorders
Radiographic spinal instability with possible
fracture or spondylolisthesis- may be due to
trauma or degeneration
Fracture of bony vertebral body or trijoint
complex- may not reveal overt radiographic
instability
Spinal canal or lateral recess stenosis
Arachnoiditis, including postoperative scarring
10. Disorders associated with non
mechanical LBA
Neurological syndromes
myelopathy from intrinsic or extrinsic
processes
Lumbosacral plexopathy esp from diabetes
Neuropathy including the inflammatory,
demyelinating type- eg. Guillan Barre
syndrome
Myopathy
Dystonia
12. DIAGNOSTIC STRATEGIES
PLAIN XRAYS(AP/LATERAL) OF LUMBAR SPINE-
indicated for patients older than 50 years
CT SCANNING- effective when the spinal and
neurological levels are clear and bony
pathology is suspected.
MRI- useful when the spinal and neurological
levels are unclear and a pathological
condition of disc or spinal cord is suspected.
MYELOGRAPHY –useful in elucidating nerve
root pathology
EMG/SSEP
14. 3 phases depending upon the duration of
symptoms:
PRIMARY
Passively applied physical therapy during the
acute phase of soft tissue healing(<6 week)
SECONDARY
Spine care education
Active exercise programs during the subacute
phase between 6-12 weeks with physical
therapy-driven goals to achieve preinjury levels
of physical and psychological deconditioning
and disability.
15. TERTIARY
When spinal pain persists into the chronic
phase, therapeutic interventions shift from
rest and applied therapies to active exercise
and physical restoration.
Therapeutic injections, manual therapy and
other externally applied therapies should be
used adjunctively to reduce pain so that
strength and flexibility can continue.
16. Elimination of activity of positive
biomechanical loading can only be
achieved by BEDREST.
Bedrest is usually considered an
appropriate treatment for acute
backpain.
17. Topical treatment is drug delivery over or
onto the painful site.
The medication is deivered through the
skin to a shallow depth <2cm and acts
locally without producing systemic side
effects.
Bisphosponates (palmidronate) have
recently attracted attention as a
potential new treatment for mechanical
spinal pain involving discal and radicular
structures.
18. SPINAL INTERVENTIONAL
PROCEDURES
Local anaesthetics, corticosteroids or other
substances may be directly injected into
painful soft tissuess, facet joints or epidural
spaces.
Local injections into paravertebral soft
tissues, specifically into myofascial trigger
points are widely advocated.
Intra-articular facet blocks are also
advocated.
Medial branch blocks have been used for
both diagnostic and therapeutic purposes.
19. Epidural injections, epidural adhesiolysis are
also other methods
Intradiscal ElectroThermal Therapy (IDET)
Is a minimally invasive technique in which the
annulus is subjected to thermo-modulation,
thereby reducing the nociception reduced by
mechanical loading of a painful disc.
20. SURGERY
The benefit of lumbar spine surgery is not
controversial in many clinical circumstances
like major trauma, chronic or complicated
spinal infection etc
Moden suregery for LDD and sciatica are
characterised by small incisions, minimal
blood loss and early hospital discharge with
post- operative convalescence lasting only a
few weeks.
21. PHYSICAL THERAPY FOR THE SPINE CAN BE
DIVIDED INTO PASSIVE AND ACTIVE THERAPIES:
Passive therapy includes ultrasound, electric
muscle stimulation, traction, heat and ice and
manual therapy, were appropriate for short
term treatment for acute backpain or acute
exacerbation of a chronic backpain,
Corsets and braces are long used adjuncts for
treatment.
22. Traction is a long endured medical
prescription for LBP and is incorporated
into a variety of methods to treat
conditions of the spine.
Education/ cognitive behavioural
therapy.
Exercise
