Orthopedics | Approach to low back pain | Made Easy by Dr. Pramod Baral | DIP Medical Video | Part 1

A video by:
Dr. Bharat Kc

Approach to Low Back Pain
Dr Pramod Baral
Assistant Professor
Department of Orthopedics
B.P. Koirala Institute of Health Sciences, Dharan, Nepal.

Introduction
The leading cause of Disability
The only illness occurring more frequently than LBP is the common cold (since 1980s).

75-85% of all individuals will experience LBP at some point in their lifetime (life time prevalence).

-Acute (less than 6wks) & Subacute (6-12 wks)
transitory
90% resolving in 2 months.
-Chronic LBP lasts mmore than 12wks
significant physical, psychological and social disabilities.

Risk factors: several clusters

Individual Factors: Genetics, Age, Gender (higher in females)
-Incidence of LBP highest in 3rd decade, overall prevalence increase with age until 60-65yrs and then declines.

b. Morphological Factors

c. Psychosocial factors: depression, anxiety- transition from acute to chronic pain and disability.

d. Occupational physical factors: heavy physical work- overextension, repetitive motion, twisting and bending, lifting, vibrations.

Clinical Evaluation
History:
Onset of symptoms (acute less than 12 weeks vs. chronic more than 12 weeks)
Location, Quality and Intensity of pain (VAS)
Aggravating and alleviating factors
Radiation to leg
Neurogenic Claudication
Any red flag symptoms (B/B involvement, fever, night sweat, wt. loss, weakness).
Co-morbidities, past surgeries, medications, psychological status, employment status.
VAS/ODI

Physical Examination
Skin

Gait

Contour: sagittal and coronal

Tenderness – Spinous process, SI joint

ROM (pain- discogenic vs facet arthropathy)

Neurologic Examination: Sensory, Motor and Reflexes

Straight Leg Raise test
Lasegue sign
Bowstring test
Femoral Stretch test

Adam’s forward bending test

Gaenslen’s test, FABER, Schober’s, Modified Schober’s

Classification of LBP:

Spondylogenic back pain: Bony spinal column, SI Joint, Soft tissues (discs, ligaments, muscles).

Neurogenic pain

Viscerogenic back pain: Kidneys or pelvic viscera, lesser sac or retroperitoneal tumors.

Vascular back pain: Abdominal aortic aneurysm, Peripheral vascular disease, Superior gluteal artery insufficiency.

Psychogenic back pain

Typical Pain Patterns of Spondylogenic LBP:
Structural Spinal Disorders
Inflammatory Spine Pain
Tumors
Infections
Trauma
Osteoporotic Compression Fractures

Flags in assessment of LBP

Red flags: Major conditions investigated by red flags can be summarized in five areas- Fractures, Tumor, Infection, Inflammatory disease, Cauda Equina syndrome.
Yellow flags and Orange flags:

Yellow: Risk factors for long term disability- Psychosocial- attitudes and beliefs.

Orange: Signs of more serious mental disorder that requires referral to a psychiatric treatment. Back problem reassessed later.

*Blue and Black Flags- at risk of poor work-related outcome.


Back pain in children and adolescents

10-30% of normal pediatric population will experience back pain at some point by the time they reach adolescence.

Detailed history (with red flags) and physical examination ( along with deformity, Adam’s forward bending test) of spine important.

Examine foot (eg cavus), hip, pelvic obliquity, LLD


D/D:

Nonspecific/mechanical LBP
Spondylolysis and Spondylolisthesis
Scheuermann kyphosis
Scoliosis
Disc herniation
Trauma

Infection,
Neoplasms
Benign: ABC, Osteoblastoma, histiocytosis, osteoid osteoma
Malignant: Ewing’s sarcoma, Osteosarcoma, Leukemia Chondrosarcoma


Back pain in Adults

Problems of Aging spine: Osteoporotic Compression Fractures and Degeneration of Spinal Structures.


Disorders associated with aging producing back pain
Disc degeneration, Osteochondrosis, PIVD
Facet degeneration
Degen. Spondylolisthesis
Spinal Stenosis
Spinal Deformities
Osteoporosis with VCFs
Pathological fractures- Mets
Infections

Music credit:
Aakash Gandhi - lifting dreams

@DIP - Medical Videos | 2020
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