DR.MUHAMMAD HAMID ALI MBBS,FCPS ASSISTANT PROFESSOR SAAQ, DEPT. OF NEUROSURGERY

1. DR.MUHAMMAD HAMID ALI MBBS,FCPS ASSISTANT PROFESSOR SAAQ, DEPT. OF NEUROSURGERY LUMHS/ JAMSHORO SINDH

7. LOW BACK • Five lumbar vertebrae • Fibrocartilaginous discs b/w the • (cushions, protection) ligaments and muscles (stability) facet joints (limits & directs spinal motion) multifidus muscles (keep spine straight & stable in movements)

9. LOW BACK PAIN(LBP) • COMMON PROBLEM → 80% population • NO SPECIFIC CAUSE → 85% cases • SYMPTOM notAN ILLNESS • 2ND MOST COMMON reason to seek medical advise • 15% all sick leave • 1% pt: → nerve root symptoms • 1 – 3% pt: → lumbar disc herniation • 90% pt: improve in one month • 80% pt: of sciatica improve with or without surgery

11. CLASSIFICATION ACUTE LBP SUB-ACUTE LBP CHRONIC LBP

12. CLASSIFICATION Majority has DEGENERATIVE Degenerative disc Spinal osteoarthritis Spinal stenosis MECHANICAL(MUSCULOSKELETAL/NON-SPECIFIC) disorders Myofascial disease Fibromyalgia

13. DEGENERATIVE TYPE

14. CLSSIFICATION • Minority has NON-DEGENERATIVE LBP • Metabolic • Inflammatory • Infectious • Neoplastic

15. REFERRED PAIN • From other parts of body

16. AHCPR classification • Potentially serious spinal condition • Spinal tumors • Spinal infections • Fractures • Cauda equina syndrome • Non-specific back symptoms • Symptoms suggesting neither nerve compression nor a potentially serious condition

17. AHCPR classificationSciaticaBack related lower limb symptoms suggesting nerve root compression

18. ASSESSMENT Initial assessment is geared to detecting “red flags” Pts: with LBP, fever, weight loss, continuous stiffness, acute bone pain &pain at rest needs to investigate for “red flags”

19. INITIAL ASSESSMENT History • Age > 50 years • Previous Ca • Unexplained weight loss →favor neoplastic lesion • Failure to improve after 1 month therapy • Pain more than 1 month • Immunosuppression • Pain worse at night

20. INITIAL ASSESSMENT History • Skin infection • Iv drug abuse →favor spinal osteomyelitis • UTI or other infection -age > 50 or 70 years - trauma - steroids → favor compression fracture - bone pain

21. INITIAL ASSESSMENT History -LBP radiating to legs - numbness in legs → favors herniated lumbar disc(sciatica) - weakness in legs • Age > 50 years • Pain or numbness on walking → favors spinal stenosis

22. INITIAL ASSESSMENT History • Bladder dysfunction • Saddle anesthesia → favors cauda equina syndrome • Unilateral or bilateral leg weakness or pain • Age < 40 years • AM back stiffness → favors ankylosing spondylitis • Pain relieved on motion • Pain > 3 months

23. INITIAL ASSESSMENT History • Other factors • Work status • Typical job task • Educational level • Failed previous treatment • Addiction • depression

24. INITIAL ASSESSMENT Physical examination • More helpful in identifying spinal infection than spinal cancer • Following findings favors spinal infection but may be common in pts: without infection • Fever (common in epidural abscess & in osteomyelitis but less common in discitis • Vertebral tenderness • Very limited range of spinal motion

25. INITIAL ASSESSMENT Physical examination • Finding favoring neurologic compromise Weak dorsiflexion of ankle & big toe Weak planter flexion Diminished achilles reflex Diminished light touch sensation over medial malleolus & medial foot Diminished light touch sensation over dorsum of foot Diminished light touch sensation over lateral malleolus &lateral foot Scoliosis SLR & crossed SLR

27. FURTHER EVALUATION • Over 95% of cases of LBP • In the initial 4 weeks of symptoms • In the absence of any “red flags” conditions ↓ NO FURTHER TESTING RECOMMENDED Simple tests such as CBC and ESR along with x-ray of back should be obtained if any doubt exist relating to back tumor or infection

28. FURTHER EVALUATION special tests are performed to evaluate non-degenerative and “red flags” conditions. They are divided into 2 groups 1:-Tests to detect physiological dysfunction A. to detect neurologic dysfunction: EMG, NCV, SEP… B. to detect non-neurologic diseases: CBC, ESR, UCE, U/S, CAL,VIT.D, phosphate, magnessium, parathyroid hormone level , alkaline phosphatase, acid phosphatase, BONE SCAN… 2:- Tests to demonstrate anatomy X-rays, CT, MRI, bone density, Myelography…

32. CONSERVATIVE TREATMENT • Indicated where there is no urgency for surgery or diagnosis is non-specific or in the absence of “red flags”. • Based on recommendation by AHCPR panel and include the following ① BED REST:- Bed rest not more than 4 days by reducing movements and reducing pressure on the nerve roots. ② AVTIVITY MODIFICATION:- Tolerable physical activity to minimize disruption of daily activity. Avoid lifting heavy weight, prolonged bending & sitting or twisting of the back.

33. COSERVATIVE TREATMENT ③ EXERCISE:- low stress aerobic exercise, increase gradually for few weeks ④ ANALGESICS:- NSIAD, opioids in severe pain ⑤ MUSCLE RELAXANTS:- Reduce pain by relieving spasm

34. ⑥ EDUCATION:- Reassurance proper posture, lifting techniques

35. COSERVATIVE TREATMENT ⑦ SPINAL MANIPULATION THERAPY (SMT):- In acute LBP without radiculopathy ⑧ EPIDURAL INJECTIONS:- Short term relief of radicular pain no t useful without radiculopathy

36. MEDICAL MANAGEMENT • Besides of above discussed measured one must see the basic cause of disease that may be treatable medically like in OSTEOMALACIA Oral ergocalciferol 0.05mg(2000 iu) U/ Violet rays if H/O malabsorption then 5mg(200000iu) or 40 to 80 thousands iu iv RT acidosis corrected with sodium bicarbonate

37. MEDICAL MANAGEMENT OSTEOPOROSIS Ca supplement 1 to 2 gm/day Estrogen 0.625 mg/day for 3 to 4 weeks Progesterone 5-10 mg/day for last 10 days of estrogen Sodium fluoride 5 mg increases healing T/L braces Decrease alcohol and tobacco Increase exercise

38. MEDICAL MANAGEMENT PAGET’ DISEASE Calcitonin 100 microgram/day with biophosphonate & mithramycin in resistant cases decompressive laminectomy in severe stenosis

39. MEDICAL MANAGEMENT PYOGENIC INFECTION 6 weeks of intravenous antibiotics along with rest & immobilization GRANULOMATOUS DISEASES Anti-fungal Anti-tuberculous Antibiotics MISALLENIOUS Steroids and chemotherapeutic agents in tumors

40. Interventional Treatment Options • Neural blockade • selective nerve root blocks • facet joint blocks, medial branch blocks • Neurolytic techniques • radiofrequency neurotomies • pulse radio frequency • Stimulatory techniques • spinal cord stimulation • peripheral nerve stimulation • Intrathecal medication pumps • delivery into spinal cord and brain via CSF

41. Physical Treatment Options • Exercise (stabilization training) • Neutral position • Soft tissue mobilization • Transcutaneous electrical nerve stimulation (TENS) • Electrothermal therapy • Complementary measures (acupuncture; relaxation/hypnotic/biofeedback therapy) • Spinal manipulative therapy • Multidisciplinary treatment programs (back schools/education/counseling/pain clinic)

42. SURGICAL TREATMENT • INDICATION for HLD:- Pts: with < 4 – 8 weeks of symptoms (A). those with “RED GLAGS” 0r progressive neurological deficit (B). Intolerable pain refractory to medical management Pts: with > 4 – 8 weeks of symptoms Sciatica that is both severe and disabling

43. SURGICAL TREATMENT Routine HLD Discectomy foraminal or far lateral HLD partial or total facetectomy lumbar spinal stenosis decompressive laminectomy fracture/dislocation/instability lumbar spinal fusion (trauma, tumors, infections, spondylolisthesis)

44. instrumentation and fusion

46. Lumbar disc herniation Outlines • Introduction • Definition • Causes • Types of disc herniation • Typical locations of disc herniation • Clinical manifestations • Diagnostic studies • Management • Nursing intervention

47. Lumbar disc herniationIntroduction

48. Definition of disc herniation • Abnormal rupture of the soft gelatinous central portion of the disc (nucleus pulposus) through the surrounding outer ring (annulus fibrosus). In about 95% of all disc herniation cases, the L4-L5 or L5-S1 disc levels are involved.

50. Causes of lumbar disc herniation • Trauma or injury to the disc • Disc degeneration • Congenital predisposition