Title: An approach to Backpain

Date:10th-Mar-2009

Lecture Series : Orthopaedics

© reserved to author and Christian Medical College, Vellore

An approach to

BACKPAIN
Upright posture
IMPACT OF BACK PAIN

„ No.1 musculoskeletal condition

„ No.2 overall health condition

that cause us to seek help from

healthcare providers.
IMPACT OF BACK PAIN

„ 80% of adults
experience backpain.
„ 9/10 instances LBA is
transient.
„ LBA increasing
sedentary lifestyle
obesity
IMPACT OF BACK PAIN

Economy 11 Billion USD(1989)

Rs .440,00,00,00,00

Absenteeism

Workman’s compensation
Lecture Plan
„ Anatomy of Spine
„ Normal Biomechanics
„ Causes of LBA
„ Red Flags
„ History
„ Investigations
„ Treatment
Anatomy

Cervical 7
Thoracic 12
Lumbar 5
Sacral 5
Coccyx 4
Anatomy
Pain generators
„ Facet joint
„ Nerve roots
„ Dorsal root ganglion
„ Periosteum
„ Vertebral blood vessel
„ ALL,PLL,SL
Etiology
„ Mechanical postural
acute back strain
obesity

„ Spinal pathology infections, fracture, tumors,

PIVD,degeneration

„ ‘Extra-spinal’ pancreatitis
dissecting aortic aneurysm

„ Psycho-social secondary gain

workers compensation
Normal Biomechanics
„ Balanced curves

Kyphosis x 2
Lordosis x 2
Normal Biomechanics
„ Static erect position spine balances against
gravity using minimum energy

„ In movement energy used economically and

with minimum wear and tear.
Normal Biomechanics
„ To conserve energy muscles play a minimal
role in maintaining erect posture.
„ Main role is played by LIGAMENTS and
CAPSULAR TISSUES.
„ When ligamentous strain exceeds
physiological limits muscle action comes into
play.
Normal Biomechanics

„ Good posture requires a balance between

ligamentous tone and core muscle tone
RED FLAGS

1.Age <20 >50 years

2.Severe unremitting night pain
3.Significant trauma
4.Significant muscle weakness
5.Cauda equina syndrome
RED FLAGS
6.Fever
7.Weight loss
8.High risk behavior (HIV), IV drug abuse,
prolonged steroid use
9.History of cancer
10.Clinical suspicion of ankylosing spondylitis
Yellow flags
1. Belief that pain and activity are harmful
2. Depressed , social withdrawal
3. Claim and compensation
4. Low job satisfaction
5. Heavy work, unsociable hours
6. Over protective family or lack of support
7. Economic problems.
 History
Age
Children : Scoliosis
Adults : Mechanical back pain
Prolapsed intervertebral disc
Spondylolisthesis
Spinal fractures
Elderly : Osteoarthritis
Spinal Metastasis
Pathological fractures
History
„ PAIN
DURATION < 6 weeks (acute) Mechanical
Trauma
PIVD
> 6 weeks (chronic) Postural
Spinal stenosis
Infection
Osteoporosis
ONSET Rapid fracture
backstrain
Slow Spinal stenosis
History
„ PRECIPITATING EVENT FICN
T
N I
trauma SIG ma
trau
sudden twist

„ SITE Upper back Infection

Low Back Mechanical
PIVD

„ LOCALIZED OR DIFFUSE Infection,fractures, Coccydynia

Postural
„ CONTINOUS OR INTERMITTENT Infections,fractures
ht
Mechanical Nig
n
pai
„ NATURE OF PAIN
Excruciating IVDP,Tumors, infections
Moderate Mechanical

„ AGGRAVATING / RELIEVING FACTORS

Movements IVDP,Infection
Stooping Canal stenosis

„ RADIATION OF PAIN
‘Sciatica’
Facet joint disease
„ CLAUDICATION PAIN
Vascular
Neurogenic

„ NEUROLOGICAL INVOLVEMENT
Paraesthesia
Weakness
Bladder/bowel
EXAMINATION
General examination
ƒ Anemia
ƒ Pallor
ƒ Clubbing
ƒ Lymphandenopathy
ƒ Psychological assessment
Local

Inspection:
Alignment
Paraspinal spasm
Deformity
Gibbus
Swelling
Local Examination
„ Feel
Tenderness
Step
„ Movements
Flexion,Extension
„ Nerve tension signs
SLRT
Laesegue
Bowstring
„ Hip joint
„ SI Joint
„ Abdomen
„ Peripheral pulses
Neurological examination

Motor
Sensory
Reflexes
Per rectal exam
Investigations
„ Hb
„ TC DC
„ ESR/CRP
„ RBS
„ Xrays Ap/Lat views
Degenerative
Xray
Infection
 Xray
Fracture
Xray
Spondylolisthesis
Scoilosis
CONCLUSION

„ Mechanical LBA most common

„ Red flags need to be identified .

„ Investigations kept to a minimum.

„ Appropriate management
 Copyright of this educational material rests with the
author and Christian Medical College, Vellore.
Duplication, revision and redistribution are not
permitted. For any further clarification please contact
the concerned author

© reserved to author and Christian Medical College, Vellore