Low back ache and sciatica

LOW BACK ACHE AND SCIATICA

Spinal pain is multifaceted- involving Structural Biomechanical Biochemical Medical Psychosocial influences

Treatment is often difficult/ineffective

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.

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

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

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.

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.

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.

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

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

Systemic disorders Neoplasms Infections Metabolic bone diseases Vascular disorders Referred pain Gastro intestinal disorders Genitourinary disorders Gynaecological disorders

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

NON OPERATIVE TREATMENT NSAIDS Muscle spasmolytics Neuropathic pain analgesics Antidepressants(TCA) Opiod analgesics

3 phases depending upon the duration of symptoms:

PRIMARYPassively applied physical therapy during the acute phase of soft tissue healing(<6 week) SECONDARYSpine care educationActive 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.

TERTIARYWhen 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.

Elimination of activity of positive biomechanical loading can only be achieved by BEDREST.

Bedrest is usually considered an appropriate treatment for acute backpain.

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.

SPINAL INTERVENTIONAL PROCEDURESLocal 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.

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.

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.

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.

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

THANK YOU!