باشـيـخ. مــازن د

• 1-Lower back pain (less than 12 weeks)

Etiology. Diagnosis. management.

• 2-Chronic lower back pain (more than 12 weeks)

• 3-cervical pain.

• 1-Disc herniation (Spondylosis)

• 2-Spondylolisthesis

• 3-Musculo-ligamintous pain

• 4-Spinal stenosis

• 5-Degenrative Changes in the vertebrae, joints or intervertebral discs (osteoarthritis).

• 6-Systimic diseases:

Infection.

Rheumatological diseases.

• 8-Visceral diseases. e.g.:

Kidney diseases.

Aortic aneurism.

• 9-Trauma.

• 10-Psychogenic.

History

Physical examination

Investigation

History

• Personal data : - Age : serious condition are found most

frequently > 50 years .

• Pain- Onset : suddenly trauma or disk lesions

gradually other D.D.

- Duration : acute < 12 weeks

chronic >12 weeks

- Nature and severity : how it affect functional life of the patient

- Site : low or high

unilateral low back pain with buttock pain which get worse with standing SI joint derangement

• Radiation : below knee with paresthesias and weakness of lower limbs disk herniation

• Progression of pain• Aggravating and precipitating

factors: lifting heavy objects or walking

• Reliving factors : bed rest , NSAID, or leaning forward

• Previous episode

• History of trauma ,weight loss ,loss of appetite , fever, saddle anesthesia ,loss of sphincter control , lower limbs weakness , history of immune suppression , arthalgia.

• Systemic review to detect systemic causes• Past history: especially of cancers (bronchus , breast ,

thyroid ,prostate , or kidney )

• Social history • Family history• Psychological history is important

Physical examination

• Inspection : posture , deformity , and walking

• Palpation : of spinal processes ,iliac crest ,iliolumbar ligament ,and sacroiliac joint

• Rang of motion : asymmetrical or limitation

• Flip test disc lesion• Neurological examination : for lower

limbs especially L4 ,L5 ,S1

Investigation

• NB : this list of most of investigation to most common cause of back pain but you don’t have to do all of it .

• Laboratory

• Radiological

Laboratory

• Alkaline phosphatase paget’s disease ,osteomalcia, secondary deposit in bones

• Serum calcium high in cancers , myloma• CBC• U&E

Radiological

• Spine X-ray : fracture , erosion ,destruction of bones and intervertebral discs ,osteolytic or osteosclerotic lesions

• CT scan and MRI : location of disc lesion , spinal tumor ,spinal compression

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Management of back pain Management of back pain divided into :divided into :

• Management of Acute Management of Acute

back painback pain

• Management of ChronicManagement of Chronic

back painback pain

• Management of Cervical painManagement of Cervical pain

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What is a management of acute back What is a management of acute back pain ?pain ?

- A management involve :- A management involve :

• Patient educationPatient education

• Exercise and physical treatmentExercise and physical treatment

• Medication & injectionMedication & injection

• SurgerySurgery

• Psychosocial factorsPsychosocial factors

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1- Patient education :1- Patient education :

• It's an important aspect of a It's an important aspect of a successful outcome as a successful outcome as a 90 %90 % of of patients recover within 4 weeks patients recover within 4 weeks despite method of treatment . The despite method of treatment . The education should be about :education should be about :

A - Activity level :A - Activity level : • bed rest should be avoided except in bed rest should be avoided except in

the most severe cases ( for 1-2 days the most severe cases ( for 1-2 days only )only )

• and usual activity should be initiated and usual activity should be initiated as soon as possible (as soon as possible (except for except for bending & lifting should be avoidedbending & lifting should be avoided ) . ) .

• exercise classes ( exercise classes ( physical treatmentphysical treatment )

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b- Prevention of b- Prevention of recurrence :recurrence :

• Back Pain can be Back Pain can be prevented by: prevented by: practicing safe practicing safe bendingbending and and liftinglifting techniques, techniques, strengthening and strengthening and stretching stretching exercises for the exercises for the muscles support muscles support the back, the back, good good postureposture, and , and weight controlweight control

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2-exercise & physical 2-exercise & physical therapytherapy :

• should be started during the first month of symptom with physical therapists .

the aim :the aim :• strengthening the back and

relieving pain

what kind of exercises should what kind of exercises should the patient do ?the patient do ?

• two kinds of exercises :

• first ,first , the patient should start by stretching of the back ( increase circulation and increase a process of healing )

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• second ,second , then he continue with strengthen type of exercises to make the muscles of his back, stomach, hips and thighs strong and flexible and this can be done by Low Back Exercise Guide for 10 -30 minutes / day and it's divided into 3 levels :

• initial exercisesinitial exercises

• IntermediateIntermediate

• advancedadvanced (also involve aerobic conditioning such as also involve aerobic conditioning such as

walking, swimming, or joggingwalking, swimming, or jogging) http://www.back.com/articles-exercises.html

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3- Medication & 3- Medication & Injection :Injection :

• NSAIDs ( commonly use )

• Muscle relaxant (not effective as NSAIDS )

InjectionInjection :e.g. :• Epidural

injection ( after surgery , spinal stenosis to relieve the pain )

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4- Surgery :4- Surgery :

• Only 5 -10% of a symptomatic disc hernia require surgery .

Types of surgery :Types of surgery :• decompression and stabilization.

Decompression may be used on a patient with a disc pressing on a nerve or a nerve being impinged by bone, both of which can have neurological effects( Usually these types of problems are caused by a bulging disc or a herniation of the disc which is pressing on a nerve).

Stabilization is performed to eliminate spinal weakness.

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5- Psychosocial factors :5- Psychosocial factors :

Social factorSocial factor is very important as a poor situation can alter a patient's reaction to pain .

PsychologistPsychologist – addresses

symptoms of depression, anxiety and stress, supporting patient and family with education

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