Presentasi LBP Mitra bestari June 9 2015 LBP.ppt

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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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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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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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



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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


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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Presentasi LBP Mitra bestari June 9 2015 LBP.ppt

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