Low Back Pain ( LBP )

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1 LOWER BACK PAIN

2 Low Back Pain ( LBP ) Most common musculoskeletal problem world wide 85% of all people exp. LBP in lifetime Impacts Life style Quality of life Work

3 UNITED STATES $$$$ 100 BILLION PER YEAR SPINALCORD FUSION SURGERY Medicare $343 million in 1997 to $2.24 billion in Adjusted for inflation, that's nearly a 400% increase. (Wall Street Journal., Dec 2010)

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5 Cross Section of the Lumbar Spine

6 Cross Section of Cord

7 Spinal Column

8 Dermatomes

9 Nerve Roots

10 Dermatomes

11 Upper Extremity Nerve Roots

12 Low Back Pain LOW BACK PAIN Acute Low Back Pain Chronic Low Back Pain Degenerative Conditions Injuries Infections and Tumors Scoliosis Back Pain and Emotional Distress

13 BACK PAIN Acute Low Back Pain Last 4 12 weeks Chronic Low Back Pain Last > 12 weeks

14 Degenerative Conditions Herniated Lumbar Disc Spondylolisthesis Lumbar Spinal Stenosis Osteoporosis

15 MRI LS SPINE

16 Herniated Lumbar Disc

17 Osteophyte L3

18 Degenerative Conditions Spondylolisthesis

19 Spondylolisthesis Dotted line follows posterior vertebral margins of L5 and the sacrum.

20 Spondylolysis Spondylolysis refers to a defect in the pars interarticularis (a bone connecting one facet joint to another).

21 Degenerative Conditions Lumbar Spinal Stenosis

22 Normal Anatomy

23 Spinal Stenosis

24 Symtoms of stenosis Back pain. People with spinal stenosis may or may not have back pain Burning pain in buttocks or legs (sciatica). Numbness or tingling in buttocks or legs. Weakness in the legs or "foot drop." Less pain with leaning forward or sitting.

25 Low Back Pain LOW BACK PAIN Acute Low Back Pain Chronic Low Back Pain Degenerative Conditions Injuries Infections and Tumors Scoliosis Back Pain and Emotional Distress

26 INJURIES Spinal Cord Injuries Occupational and Sports Injuries Whiplash & Whiplash Associated Disorder

27 "Red flags" for a potentially serious underlying cause for low back pain Recent significant trauma, or milder trauma age >50 Unexplained weight loss Unexplained fever Immunosuppressant History of cancer Intravenous (IV) drug use Osteoporosis, prolonged use of glucocorticoids Age >70Focal neurologic deficit progressive or disabling symptoms Duration greater than 6 weeks

28 Treatment Exercise therapy Back schools Spinal manipulation Acupuncture massage therapy

29 Medications Acetaminophen and nonsteroidals Opioids Antidepressants Skeletal muscle relaxants Benzodiazepines Antiepileptic medications

30 PSYCHOLOGICAL AND MULTIDISCIPLINARY INTERVENTIONS Cognitive behavioral therapy Functional restoration Interdisciplinary rehabilitation

31 INJECTIONS Epidural Steroid Injections Lumbar Zygapophysical (Facet) Joint Injections

32 INDICATIONS FOR SPINAL SURGERY Neoplastic epidural spinal cord compression Symptoms of cauda equina syndrome Lumbar disc prolapse Spinal Stenosis Degenerative Spondylolithesis

33 INTRACTABLE LOW BACK PAIN Patients may have persistent disabling low back pain despite use of several standard therapies following back surgery (ie, failed back surgery syndrome). Treatment spinal cord stimulation

34 Self-care maintain activity bed rest does not improve either function or pain

35 Sleeping A medium-firm mattress sleeping on your back puts 55 lbs. of pressure on your back. Putting a couple of pillows under your knees cuts the pressure in half Lying on your side with a pillow between your knees also reduces the pressure.

36 Lumbar Supports Bracing Studies support not effective Poor compliance

37 Back Pain Prevention Lifestyle Choices Exercise Back Pack Safety Pregnancy and Back Pain Preventing Osteoporosis Back Pain Basics Book

38 Lifestyle Choices Don't Smoke Restricts blood flow to the disc ^ Degenerative changes Reduces calcium absorbtion Compression fractures

39 Blood Supply

40 Preventing Osteoporosis The best prevention begins in childhood. However, it is never too late to make small but effective changes that can stave off or even reverse bone loss. Your risk of developing osteoporosis depends on how much bone mass you build between ages 25 and 35 (peak bone mass) and how quickly you lose it as you grow older. The higher your peak bone mass, the more bone you have in the bank and the less likely you are to develop osteoporosis during normal aging. Getting enough calcium and vitamin D (which is essential for absorbing calcium) and exercising regularly can help ensure that your bones stay strong.

41 Preventing Osteoporosis Calcium. The skeleton contains 99% of the body s calcium. Calcium is necessary for proper functioning of the heart, nerves and muscles and is involved in vital functions from blood clotting to muscle contraction. As profoundly important as calcium is to these essential body functions, your skeleton s health is so dependent on this mineral that it uses all but 1% of your body s calcium. A diet low in calcium contributes to your risk for osteoporosis. Milk and dairy products as well as leafy green vegetables provide the calcium bones need. Vitamin D Necessary for the body to absorb calcium. Not getting enough vitamin D can cause your body to use the calcium stored in your bones. Sources of vitamin D include fortified milk, cod liver oil, egg yolks, liver and fatty fish such as salmon.

42 Preventing Osteoporosis Exercise Crucial to good bone health Weight-bearing exercises increases bone strength. SEE YOUR DR BEFORE BEGINNING EXERCISE PROGRAM Life style Stop smoking. Limit alcohol. Avoid fad diets. SEE YOUR DR FOR ADVICE REGARDING WEIGHT LOSS

43 Weight Control Shifts gravity Increase strain on muscles Stay within 10 lbs of ideal weight Maintain a balanced diet Avoid extreme fluctuations of weight and diet. ( Contributes to loss bone density)

44 Exercise Strengthening Stretching/Flexibility Aerobic Exercise

45 Strengthening Core Strengthening Transverse (rotational) Sagittal (front to back) Abdominal Crunch Abdominal Exercise Resistance Training Neck Press Side Plank Prone Bridge/Plank

46 Core Strengthening Targets Abdominal Paraspinal Gluteal Diaphrgmatic Pelvic floor Hip girdle

47 Strengthening Pilates, yoga martial arts

48 Stretching/Flexibility Neck Stretches Shoulder Rolls Frontal Core Stretch Backward Bending Press Up Inner Thigh Stretch Hamstring Stretch Standing Thread the Needle Doorway Chest Stretch Wall Wash

49 Aerobic Exercise 3-5 times per week 20 minutes. Walking is the best place to start Bicycling and jogging Swimming water provides resistance, cardiovascular benefits less damaging to joints than higher impact aerobic exercises.

50 10 Tips for a Healthy Back 1. Standing keeping one foot forward of the other, with knees slightly bent, takes the pressure off your low back 2. Sitting sitting with your knees slightly higher than your hips provides good low back support. 3. Reaching stand on a stool to reach things that are above your shoulder level. 4. Moving Heavy Items pushing is easier on your back than pulling. Use your arms and legs to start the push. If you must lift a heavy item, get someone to help you.

51 10 Tips for a Healthy Back 5. Lifting kneel down on one knee with the other foot flat on the floor as near as possible to the item you are lifting. Lift with your legs, not your back, keeping the object close to your body at all times. 6. Carrying two small objects (one in either hand) may be easier to handle than one large one. If you must carry one large object, keep it close to your body. 7. Sleeping sleeping on your back puts 55 lbs. of pressure on your back. Putting a couple of pillows under your knees cuts the pressure in half. Lying on your side with a pillow between your knees also reduces the pressure.

52 10 Tips for a Healthy Back 8. Weight Control additional weight puts a strain on your back. Keep within 10 lbs. of your ideal weight for a healthier back. 9. Quit Smoking smokers are more prone to back pain than nonsmokers because nicotine restricts the flow of blood to the discs that cushion your vertebrae. 10. Minor Back Pain treat minor back pain with anti-inflammatories and gentle stretching, followed by an ice pack.

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54 BURST FRACTURE

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58 MRI LS SPINE

59 MRI LS SPINE

60 Sagittal (left panel) and axial (right panel) gadolinium-enhanced spinal MR scan of a 69- year-old women with a remote history of breast cancer, interscapular back pain for one month, and a normal neurologic examination. The scans demonstrate a large epidural lesion compressing the spinal cord (arrows).

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