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8/18/2019 Presentasi LBP Mitra bestari June 9 2015 LBP.ppt
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LOW BACK PAINLOW BACK PAIN
Susanto, dr, Sp.SSusanto, dr, Sp.S
RSUD Kelas B CianjurRSUD Kelas B Cianjur
June 9, 2015
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PAINPAIN
“An unpleasant sensory andemotional eperien!e asso!iated
"it# a!tual or potential tissuedama$e% or des!ri&ed in terms o'su!# dama$e()
– International Association for the Study of Pain(Merskey, 1979)
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PAINPAIN
•
Pain is al"ays su&je!ti+e(
• ,#e patient-s sel'.report o' pain is
t#e sin$le most relia&le indi!atoro' pain(
• ,#e !lini!ian must a!!ept t#epatient-s sel' report o' pain(
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DI//0R0N, ,1P0S O/ PAIN A!ute pain is de2ned as s#ort.term pain or pain "it# an easily
identi2a&le !ause
C#roni! pain is medi!ally de2ned as pain t#at #as lasted 3 mont#sor lon$er
Cutaneous pain is !aused &y injury to t#e s4in or super2!ial tissues Somati! pain ori$inates 'rom li$aments% tendons% &ones% &lood
+essels% and e+en ner+es t#emsel+es
5is!eral pain ori$inates 'rom &ody or$ans
P#antom lim& pain is t#e sensation o' pain 'rom a lim& t#at one no
lon$er #as Neuropat#i! pain !an o!!ur as a result o' injury or disease to t#e
ner+e tissue itsel'
University of Pécs, e!art"ent of #eurolo$y
Types of PainTypes of Pain
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Types of PainTypes of Pain
No!i!eptors 6 pain 2&er sensiti+e tonoious stimuli
Somati! 7 injury to tissues% "elllo!ali8ed
5is!eral 7 injury to or$ans 9stret!#
re!eptors:% poorly lo!ali8ed Re'erred 7 a;erent +is!eral 2&ers <
somati! to same spinot#alami!pat#"ay
Nociceptive PainNociceptive Pain
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Types of PainTypes of Pain
Neuropathic painNeuropathic pain A&normal neural a!ti+ity se!ondary to disease% injury%
or dys'un!tion
Persists "it#out on$oin$ injury 9tri$eminal neural$ia%D= neuropat#y:
,ypes>
Sympat#eti! 7 'rom perip#eral ner+e injury "it#autonomi! !#an$es
? “Ne") term 7 Comple Re$ional Pain Syndrome 9CRPS:
7 ,ype I 6 RSD ,ype I 6 RSD
7 ,ype II 6 !ausal$ia ,ype II 6 !ausal$ia Perip#eral autonomi! pain 7
? Same &ut "it#out autonomi! !#an$e 9P@N:
Central Pain 9spinal !ord injury:
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Low Back PainLow Back Pain
De2nition %
Pain t#at o!!urs in an area"it# &oundaries &et"een t#elo"est ri& and t#e !rease o'
t#e &utto!4s
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Ba!4 pain is one o' t#e most!ommon ailments o' man4ind(
An estimated o' people
eperien!e &a!4 pain at somepoint in t#eir li+es% and sli$#tlymore men su;er 'rom it t#an
"omen Potent !ause o' a&sen!e 'rom
"or4
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,#e pre+alen!e rates 'or lo" &a!4 pain in t#e $eneralpopulation &y a$e
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Low Back Pain - DisordersLow Back Pain - Disorders
=e!#ani!al 9: Re'erred R#eumatolo$i! @ematolo$i!
In'e!tious Neurolo$i!
Neoplasti! Psy!#iatri!
0ndo!rinolo$i! =is!ellaneous
9N 3:
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& 'orenstein , iesel S, 'oden S% o* 'ack Pain% Medical ia$nosis and +o"!rehensive Mana$e"ent 199-
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S. Matin MD
Vertebra
Body% anteriorly. /unctions to
su!!ort *ei$ht
5erte&ral ar!#%
posteriorly. /or"ed 0y t*o
!edicles and t*ola"inae
. /unctions to!rotect neuralstructures
ANATOMYANATOMY
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ANATOMYANATOMY
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Causes of ack painCauses of ack pain
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S. Matin MD
LBP! "isk #actorsLBP! "isk #actors
@ea+y li'tin$ andt"istin$
O&esity
Poor p#ysi!al2tnessE!onditionin$
@istory o' lo" &a!4trauma
Psy!#iatri!#istory9!#roni! LBP:
ff $ f $$
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Differentia$ Dia%nosis for a$$Differentia$ Dia%nosis for a$$ack painack pain
0tiolo$i!
F( =e!#ani!al Spinal Condition 9GH:
( Non.me!#ani!al Spinal Condition 9F:
J( Non.spinalE5is!eral Disease 9:
,emporal
A!ute 3 "ee4 duration
C#roni! 3 "ee4 duration
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h $ $ d
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Non&echanica$ spina$ conditionsNon&echanica$ spina$ conditions'() O# ALL LO* BAC+ PA,N'() O# ALL LO* BAC+ PA,N
Neoplasia> multiple myeloma% metastati!Ca% lymp#oma% leu4emia% spinal !ordtumors% retroperitoneal tumors% primary+erte&ral tumors 9(H:
Infection> osteomyelitis% septi! dis4itis%paraspinous a&s!ess% epidural a&s!ess%s#in$les 9(F:
Inammatory arthritis> An4ylosin$
spondylitis% psoriati! spondylitis% Reiter-ssyndrome 9(J:
S!#euermann Disease 9osteo!#ondrosis:
Pa$et Disease
.i $ Di.i $ Di
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.iscera$ Disease.iscera$ Disease''/) O# ALL BAC+ PA,N/) O# ALL BAC+ PA,N
1. Disease of pelic or!ans>prostatitis% endometriosis% !#roni!PID
". #enal Disease> nep#rolit#iasis%pyelonep#ritis% perinep#ri! a&s!ess
$. Aortic aneurysm
%. &I disease' pan!reatitis%!#ole!ystitis% penetratin$ ul!er
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0sed ter&ino$o%y in ack pain0sed ter&ino$o%y in ack pain
S!ondylosis S!ondylolysis
S!ondylolisthesis
S!inal stenosis adiculo!athy
Sciatica
+auda 23uina Syndro"e
ordosis, 4y!hosis, Scoliosis
Pirifor"is Syndro"e
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561918
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Mechanica$ LBP Differentia$ Dia%nosisMechanica$ LBP Differentia$ Dia%nosisC$inica$ #eaturesC$inica$ #eatures
erniated disk Usually occurs in adults a$ed :5 to -- years
Sciatica, often associated *ith le$ nu"0ness or!aresthesias, is a
. hi$hly sensitive (9-;) and s!ecific (ed 0y neuro$enic claudication
. radiatin$ 0ack !ain and lo*er e=tre"ity nu"0ness
. e=acer0ated 0y *alkin$ and s!inal e=tension
. i"!roved 0y sittin$
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Steven Stoltz, M.D.
Causes of Low Back Pain1Causes of Low Back Pain1
Spondylolysis% dis4o$eni! lo"&a!4 pain or ot#er insta&ility 7
,raumati! 'ra!ture . F
Con$enital disease . F
Can!er 7 (H
Inammatory art#ritis 7 (J
In'e!tions 7 (F
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2 Most Co&&on LBP2 Most Co&&on LBPother than "adicu$opathyother than "adicu$opathy
Sa!roilia! Disorder
,ro!#anteri! Bursitis
Pyri'ormis Syndrome
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Pirifor&is syndro&ePirifor&is syndro&e
Pain 'rom piri'ormismus!le 7 irritation o's!iati! ner+e passin$deep or t#rou$# it
Pain on resisted a&du!tion Eeternal rotation o' le$
PAT,3NT 4, TO"YPAT,3NT 4,5TO"Y
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PAT,3NT 4,5TO"YPAT,3NT 4,5TO"Y
Onset
Palliati+eEPro+o!ati+e 'a!tors
uality
Radiation
Se+erityESettin$ in "#i!# it o!!urs
,imin$ o' pain durin$ day
Understandin$ . #o" it a;e!ts t#epatient
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OnsetOnset
A!ute . Li'tEt"ist%'all
Su&a!ute .ina!ti+ity%
o!!upational9sittin$% dri+in$%yin$:
Pain e;e!t on> "or4Eo!!upation
sportEa!ti+ity 9durin$ ora'ter:
ADL-s
h
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Pain CharacterPain Character
S#arp
Burnin$ Dull a!#e
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Pain with1Pain with1
Prone position /a!et% Lat @NP% systemi!
d8
Sittin$ Paramedian @NP%
annular tear
Standin$ Lateral @NP% spinal
stenosis% 'a!et syndrome
Wal4in$ Spinal stenosis
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"adiation"adiation
Up &a!4
,o sa!rum
,o &utto!4s
Do"n le$
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O h 5Oth 5 t
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Other 5y&pto&sOther 5y&pto&s
Cou$#E+alsal+a ea!er&ation
Distal neuro s ."ea4nessEparest#esia
Perianal parest#esia
Bo"elE&ladder s
h 4O h 4i
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Other 4istoryOther 4istory
Prior treatments andresponse
Prior #Eo &a!4 pain
0er!ise #a&its
O!!upationEre!reational
a!ti+ities
$$ #$
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Ye$$ow #$a%s Ye$$ow #$a%s
/a!tors prolon$in$ &a!4 pain Internal 'a!tors.Opioid dependen!y
“0ternal !ontroller) patient.typelearned #elplessness 'a!titious disorder
=ental #ealt#. depression or aniety
Interpersonal 'a!tors QSi!4 role“
Stressors in relations#ips
0n+ironmental E so!ietal 'a!tors.Disa&ility payments E Liti$ation E=alin$erin$
" d #$
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"ed #$a%s"ed #$a%s
A$e H
/e+ers% !#ills% re!ent U,IEs4in in'e!tion% penetratin$ "ound nearspine
Re!ent si$ni2!ant trauma or milder trauma a$e
Unrelentin$ ni$#t pain or pain at rest
Pro$ressi+e motor or sensory de2!it
Saddle anest#esia% &ilateral s!iati!a or le$ "ea4ness% di!ultyurinatin$% 'e!al in!ontinen!e
Uneplained "ei$#t loss
@istory o' !an!er or stron$ suspi!ion o' !an!er
@istory o' osteoporosis
Immunosuppression C#roni! oral steroid use
I5 dru$ use% su&stan!e a&use
/ailure to impro+e a'ter 3 "ee4s o' !onser+ati+e t#erapy
Point tenderness
Physica$ 36a&inationPhysica$ 36a&ination
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Physica$ 36a&inationPhysica$ 36a&ination
O&ser+ation o' "al4in$
Inspe!tion o' &a!4 and posture
Palpation o' t#e spine and so't tissue
Ran$e o' motion
Stren$t# testin$
Strai$#t le$ raisin$ 9'or patients "it# le$ symp:
Neurolo$i! assessment o' L% L% SF roots 9'or
patients "it# le$ symptoms: Spe!ial tests
0+aluation 'or mali$nan!y 9&reast% prostate% LN eam:
Perip#eral pulses in older patients "it# eer!ise.indu!ed !al' pain(
' , i '
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,nspection 'cont7,nspection 'cont7
Posture
S#oulders and pel+is s#ould &e le+el
Bony and so't.tissue stru!turess#ould appear symmetri!al
Normal lum&ar lordosis
0a$$erated lum&ar lordosis is!ommon !#ara!teristi! o' "ea4eneda&dominal "all
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B P $ iB P $ ti
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Bone Pa$pationBone Pa$pation
Palpate LEL jun!tion 9le+el o' ilia!!rests:
Palpate spinous pro!esses superiorly
and in'eriorly S spinous pro!ess at le+el o' posterior
superior ilia! spine
A&sen!e o' any sa!ral andEor lum&ar
pro!esses su$$ests spina &i2da
5isi&le or palpa&le step.o;indi!ati+e o' spondylolist#esis
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5 f Ti P $ i5 ft Ti P $ ti
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5oft Tissue Pa$pation5oft Tissue Pa$pation
6 clinical >ones Midline ra!he
Paras!inal "uscles
@luteal "uscles
Sciatic area
Anterior a0do"inal *all and in$uinalarea
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5t th T ti5t th T ti
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5tren%th Testin%5tren%th Testin%
test hi! fle=ion, hi! e=tension, kneefle=ion, knee e=tension, ankledorsifle=ion, and ankle !lantarfle=ion
Additional testin$ if the *eaknessis in the distri0ution of a s!ecific
nerve or nerve root
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5 i $ T t5 i $ T t
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5pecia$ Tests5pecia$ Tests
,ests to stret!# spinal !ord or s!iati! ner+e Strai$ht e$ aise, +ross e$ S, 4erni$ est
,ests to in!rease intrat#e!al pressure ?alsalva Maneuver % e!roduction of !ainsu$$estive of lesion !ressin$ on thecal sac
,ests to stress t#e sa!roilia! joint /A'2est (PatrickBs est), @aenslen si$n
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Pelvic Compression Test Fabere test
N $ i 3 i iN $ i 36 &in i n
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Neuro$o%ic 36a&inaionNeuro$o%ic 36a&inaion
Includes an e=a" of entire
lo*er e=tre"ity, as Ss!ine !atholo$y isfre3uently "anifested ine=tre"ity as altered
refle=es, sensation and"uscle stren$th
escri0es the clinicalrelationshi! 0et*een
various "uscles, refle=es,and sensory areas in thelo*er e=tre"ity and their!articular cord levels
N " t 5 dN " t 5 d
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Nerve "oot 5yndro&esNerve "oot 5yndro&es
N i Ph i $ 5iNonor%anic Physica$ 5i%ns
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Nonor%anic Physica$ 5i%nsNonor%anic Physica$ 5i%ns
Psy!#olo$i!al distress may ampli'y lo"&a!4 symptoms
Super2!ial tenderness
Distra!ted SLR
Patient o+errea!tion durin$ t#ep#ysi!al eamination
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NNo ""3D #LA853D #LA85 99
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NoNo ""3D #LA853D #LA85 99
CA'ter a #istory and eam eliminates t#epossi&ility o' a dan$erous &a!4!ondition% "e !an mo+e on to
treatment( =ost people "ill 'all intot#is !ate$ory( No radio$rap#s or la&s"ill &e ne!essary(
.One !an reassure patients t#at G o'!ases resol+e in one mont# "it# only!onser+ati+e treatment(
Approach to LBPApproach to LBP
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Approach to LBPApproach to LBP
@istory T p#ysi!al eam
Classi'y into F o' >
BAD> LBP 'rom ot#er serious !auses
? Can!er% in'e!tion% !auda euina% 'ra!ture
LBP 'rom radi!ulopat#y or spinal stenosis
Non.spe!i2! LBP
Non.&a!4 LBP
Wor4up or treatment
BAD $ k i ' $ BAD $ k i ' $
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BAD $ow ack pain 'e6a&p$esBAD $ow ack pain 'e6a&p$es
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5uspected "adicu$opathy or5uspected "adicu$opathy or
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5uspected "adicu$opathy or5uspected "adicu$opathy or5pina$ 5tenosis5pina$ 5tenosis
Re'er to Neurolo$y% P#ysi!al ,#erapy
/ollo" in . "ee4s 'or pro$ress
I' no impro+ement &y 3.F "ee4s
Plain 2lms% =RI%
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5o&e Causes of ;Non-specific LBP
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Non-specific Low Back PainNon specific Low Back Pain
2ducate !atient a0out e=!ected $ood!ro$nosis
Advise to re"ain active as tolerated
Provide anal$esics and selfCcaredirections
/U in DC6 *eeksE adFust t= as needed
onBt do =rays unless it 0eco"eschronic
U if no i"!rove"ent
;;Outside the Back
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Outside the BackOutside the Back
Non.&a!4 LBP
Retroperitoneal d89Pan!reati!% Renal%Duodenal% Vyn%
Prostate: Vyne!olo$i!al d8
AAA
oster
Dia&eti!radi!ulopat#y
SI joint
R#eumatolo$i!disorders
Reiters
An4ylosin$ Spondylitis
LasLas
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LasLas
La&s are $enerally not ne!essary% &ut may &e #elp'uli' !an!er or in'e!tion or +is!eral disease is suspe!ted(
,#e 'ollo"in$ la&oratory studies s#ould &e !onsideredi' t#ere is !on!ern 'or !an!er or in'e!tion
F( CBC
( 0SRECRP
J( PSA
( Al4aline p#osp#atase Serum immunoele!trop#oresis
3( Urine testin$ 'or li$#t !#ains
Dia%nostic 5tudiesDia%nostic 5tudies
http://images.google.com/imgres?imgurl=http://www.eicsd.k12.ny.us/staffweb/vromanchik/images/beaker%2520%26%2520test%2520tube.gif&imgrefurl=http://www.eicsd.k12.ny.us/staffweb/vromanchik/index.htm&h=236&w=239&sz=7&hl=en&start=19&tbnid=hRb8RId_TGGxTM:&tbnh=108&tbnw=109&prev=/images%3Fq%3Dtest%2Btube%26gbv%3D2%26svnum%3D10%26hl%3Den
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Dia%nostic 5tudiesDia%nostic 5tudies
Radio$rap#s 0arly i' R0D /LAVS
Symptoms present
3 "ee4s despitet
#urther studies#urther studies
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#urther studies#urther studies
() and *#I should be considered +hen'
F( I' a serious pro&lem is suspe!ted9!an!erEin'e!tion: and is not +isuali8ed onplain 2lm
( Suspi!ion o' !auda euina or spinalstenosis
J( I' t#ere is a plan 'or sur$ery or ot#erinter+ention
( ,o dia$nose +is!eral disease% i' indi!ated
u"0ar S!ine I"a$in$ Studiesu"0ar S!ine I"a$in$ Studies
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u"0ar S!ine I"a$in$ Studiesu"0ar S!ine I"a$in$ Studies
J3 o' C, s!ans a&normal inasymptomati! persons
o' myelo$rams a&normal inasymptomati! persons
JH positi+e dis!o$rams inasymptomati! persons
PA,N T"3ATM3NT CONT,N00MPA,N T"3ATM3NT CONT,N00M
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PA,N T"3ATM3NT CONT,N00MPA,N T"3ATM3NT CONT,N00M
Dia$nosis
Oral =edi!ationsP,% 0er!ise% Re#a&ilitation
Be#a+ioral =edi!ineCorre!ti+e Sur$ery
,#erapeuti! Ner+e Blo!4sOral Opiates
Implanta&le Pain =ana$ement De+i!es
NeurostimulationIntrat#e!al Pumps
Neuroa&lation
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Mu$ti-Discip$inary Pain Pro%ra& Mode$sMu$ti-Discip$inary Pain Pro%ra& Mode$s
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Mu$ti-Discip$inary Pain Pro%ra& Mode$sMu$ti Discip$inary Pain Pro%ra& Mode$s
Pain Consultation ,eam
=ultidis!iplinary Pro$rams
=ultidis!iplinary Outpatient Pro$rams
=ultidis!iplinary Inpatient Pro$rams
Pain Ser+i!e
Pain Consu$tation Tea&Pain Consu$tation Tea&
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Pain Consu$tation Tea&Pain Consu$tation Tea&
Pain Mana%e&ent Tea& Mu$tidiscip$inary
Anest#esiolo$y
Neurolo$y
P#ysi!al =edi!ine and Re#a&ilitation
Psy!#olo$y
Ort#opaedi! E Neurosur$ery
Pain MedicationsPain Medications
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Pain MedicationsPain Medications
Se!ond most !ommonly pres!ri&ed dru$!lass
Does not eliminate pain
Lon$ term Opiates
? 9J redu!tion:
Anti.Con+ulsi+e E Depressants? 9F>J "ill #a+e redu!tion:
? Rarely &elo" 9.F ratin$:
Turk (2002), CP
,nterventiona$ Treat&ent Options,nterventiona$ Treat&ent Options
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,nterventiona$ Treat&ent Options,nterventiona$ Treat&ent Options
Neural blocade
sele!ti+e ner+e root &lo!4s
'a!et joint &lo!4s% medial &ran!# &lo!4s
Neurolytic techni-ues
radio'reuen!y neurotomies pulse radio 'reuen!y
Stimulatory techni-ues
spinal !ord stimulation
perip#eral ner+e stimulation Intrathecal medication pumps
deli+ery into spinal !ord and &rain +ia CS/
"eferra$ for sur%ery"eferra$ for sur%ery
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"eferra$ for sur%ery"eferra$ for sur%ery
S!iati!a and pro&a&le #erniateddis!s
Cauda euina syndrome
Pro$ressi+e or se+ere neurolo$i!alde2!it
Persistent neuromotor de2!it a'ter .3 "ee4s !onser+ati+e treatment
Persistent s!iati!a "it# !onsistentneurolo$i! and !lini!al 2ndin$s
"eferra$ for sur%ery"eferra$ for sur%ery
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Spinal Stenosis
Pro$ressi+e or se+ere neurolo$i!al de2!it
Persistent &a!4 and le$ pain impro+in$"it# eion and asso!iated "it# spinal
stenosis on ima$in$
Spondylolist#esis
Pro$ressi+e or se+ere neurolo$i!al de2!it
Se+ere &a!4 painE s!iati!a "it# 'un!tionalimpairment t#at persists F year
"eferra$ for sur%ery"eferra$ for sur%ery
5ur%ery5ur%ery
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5ur%ery5ur%ery
5pina$ fusion '=>) sti$$ had pain
"epair for herniated disk
'=?) sti$$ had pain
"epeat sur%ery
'@@) sti$$ had pain
Turk (2002), CP
#ai$ed-Back-5ur%ery 5yndro&e#ai$ed-Back-5ur%ery 5yndro&e
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#ai$ed Back 5ur%ery 5yndro&e#ai$ed Back 5ur%ery 5yndro&e
Reoperations
3 due to post7spinal sur$ery!ompli!ations
due to un!orre!ted or ne"stru!tural a&normalities o' t#espine
#ai$ed-Back-5ur%ery 5yndro&e#ai$ed-Back-5ur%ery 5yndro&e
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#ai$ed Back 5ur%ery 5yndro&e#ai$ed Back 5ur%ery 5yndro&e
Postsur$ical causes of 0ack !ain
ecurrent or retained disk fra$"ent
Posto!erative insta0ility
ural adhesions
oot inFury
Arachnoiditis
Pseudo"enin$ocele
/ailure to relieve the ori$inal !atholo$ic condition
Posto!erative *ound and disk infection
+ey Points aout $ow ack pain+ey Points aout $ow ack pain
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+ey Points aout $ow ack pain+ey Points aout $ow ack pain
G are due to me!#ani!al !auses and"ill resol+e spontaneously "it#in 3 "ee4sto 3 mt#s
Pursue dia$nosti! "or4up i' any red a$s
'ound durin$ initial e+aluation
I' 0SR ele+ated% e+aluate 'or mali$nan!yor in'e!tion
In older patients initial Xray use'ul todia$nose !ompression 'ra!ture or tumor
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