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Low Back Pain PowerPoint Presentation

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On : Mar 14, 2014

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  • Slide 1 - Sciatica/HNP Thomas M. Howard, MD Sports Medicine
  • Slide 2 - HNP-Epidemiology 30-40 yo >95% @ L4-5 and L5-S1 75% resolve in 6 months 5-10% require surgery
  • Slide 3 - Joints zygoapophyseal (facets) synovial joint (cartilage, capsule, synovium) limit extension/flexion Disc nucleus pulposus two end plates annulus fibrosis laminated collagen fibers 65o orientation
  • Slide 4 - L4 Motor- quad and tibialis anterior Sensory- medial foot DTR- patellar
  • Slide 5 - L5 Motor- extensor hallicus longus (EHL) Sensory- dorsal foot DTR- none
  • Slide 6 - S1 Motor- foot plantar flexion and eversion Sensory- lateral foot DTR- achilles
  • Slide 7 - HNP-Pain Torn annular fibers of disc Chemical and mechanical irritation of: spinal root soft tissues (posterior longitudinal ligament)
  • Slide 8 - Annular Tear Lumbar strain Locked in flexion without neuro sx
  • Slide 9 - Sciatic Neuropathy HNP Trauma blunt- fall or contusion penetrating- injection, fracture, stab traction- hip surgery Peripheral Compression wallet sciatica piriformis syndrome (myofacsial)
  • Slide 10 - History
  • Slide 11 - Onset Usually spontaneous and without discrete event Discrete events lift cough/sneeze prolonged drive flexion/flexion with twist
  • Slide 12 - Pain with… Prone position Facet, Lat HNP, systemic Sitting Paramedian HNP, annular tear Standing Lateral HNP, central stenosis, facet syndrome Walking Central stenosis
  • Slide 13 - Other Symptoms Cough/valsalva exacerbation Distal neuro sx - weakness/paresthesia Bowel/bladder sx
  • Slide 14 - Red Flags
  • Slide 15 - Differential Diagnosis
  • Slide 16 - Examination Walk Standing Sitting Supine
  • Slide 17 - Walking Gait length of stride arm swing trunk motion ?pelvic tilt
  • Slide 18 - Standing - Range of Motion FF ~90o (reversal of lumbar lordosis with FF) Ext ~15-20o Side bend ~ 45o Trunk rotation
  • Slide 19 - Standing - Other Tests Single leg extension Gastroc strength Squat Standing single-leg balance (nl 15-30 sec)
  • Slide 20 - Supine SLR (Lasegue Test) Passive hip flexion Modified Thomas Test (Quad & Hip flexor flexibility) FABER (Patrick Test) SI Compression Test
  • Slide 21 - Supine Rectal tone Anal wink Cremasteric reflex
  • Slide 22 - Supine - Palpation Spinous processes Dorsal lumbar fascia/soft tissues Sacral notch tenderness
  • Slide 23 - Radiographs Early if ominous signs - fever, night pain, age >60, h/o Ca, wt loss, trauma Symptoms > 1 month
  • Slide 24 - MRI/CT Not needed to diagnose HNP 30% asx patients will have an abn MRI Order if hx/exam confusing Roadmap for surgeon MRI more costly, increased time to scan, problem with claustrophobic patients
  • Slide 25 - EMG/NCV R/O peripheral neuropathy Localize nerve injury Correlate with radiographic changes Order after 4 weeks of symptoms
  • Slide 26 - Lab Studies Generally not necessary
  • Slide 27 - Acute Management Relative rest no more than 48 hrs bedrest Educate patient body mechanics natural history of the condition Modalities Ice Heat Ultrasound Electric Stimulation
  • Slide 28 - Acute Management Medications Pain control Tylenol/NSAID’s minimize narcotic use Muscle relaxers use Valium for short term (1-2 days) Corticosteroids 2mg/Kg burst for 5-7 days
  • Slide 29 - Acute Management Exercises Extension biased discogenic flexion biased posterior element pain
  • Slide 30 - Physical therapy Bracing Traction Education Modalities Tissue flexibility and segmental motion Strengthening and postural control Home program instruction
  • Slide 31 - Traction May decrease disc pressure 20-30% May allow separation of vertebrae to decrease nerve root compression
  • Slide 32 - Subacute Management Continue patient education Activity & Conditioning walking Stretching - HS, hip extensors, erector spinae Strengthening - abs, erector spinae Mechanics - lifting technique, sport, ... Avoid prolonged sitting/standing recurrent bending twisting
  • Slide 33 - Epidural Steroid Injection (ESI) Local anti-inflammatory Performed by experienced anesthesiologist May buy time for the pt with marginal surgical indications
  • Slide 34 - Referral HNP (> 8 weeks) Ominous signs/sx - fever, weakness, bowel/bladder dysfunction Progressive neuro deficit or flaccid paralysis
  • Slide 35 - Caveats of Management Adequate/complete initial evaluation Follow-up evaluations 1-3 days for acute pain 4-6 weeks for chronic pain Activity as tolerated Survey for Red Flags

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