different causes of low back pain,how to diagnose low back pain ,interventional management for low back pain ,evidence based interventions ,color real photos for different interventions

2. Is it a common disorder?!
-80 % of the population will suffer from LBP at
some time of their lives.
19.6 % in those aged between 20-59 years old are
suffering from CHRONIC LBP

3. Risk factors
• Smoking
• Obesity
• Age
• Sedentary life
• Job (vibrating machine)
• Psychological disorders
• Osteoporosis

4. Pain generators
• Disc
• Bone
• Joints
• Ligaments
• Muscles
• Nerve root

6. Common Disorders of the Spine
• Herniated disc
• Degenerative disc
• Facet arthropathy
• Sacroiliac joint dysfunction
• Lumbar strain
• Fibromyalgia
• Arthritis

7. Diagnosis

8. We must exclude red flags
» Fever
» Motor deficit
» Sensory loss
» Incontinence
» Unexplained weight loss
» Swelling of the back
» Constant progressive, non mechanical pain (no
relief with bed rest)

9. »Diagnosis process History
Examination
Investigations

10. Pain
• Character
• Distribution (Dermatomal) ?
• Radiation (Passing the knee) ?
• Duration
• Rating on a scale
• What
• What
• Course
• Associated symptoms
• Evidence of other systemic disease (Rheumatoid, DM,
or SLE)
(eg, sitting, standing, laying, medications, physical therapy)?

11. Radicular painSomatic pain
 Sharp , shooting , superficial,
dermatomal .
 Always referred to the leg,
common below the knee.
 Aggravated by flexion.
 Relieved by rest , lying down.
 Positive Neurological Signs.
Straight leg raising: Positive.
 Dull , poorly localized , deep ,non-
dermatomal.
 Referred to thigh, hip, uncommon
below the knee.
 Aggravated by extension, rotation
 Relieved by walking.
 Negative Neurological Signs.
 Pain brought by Local pressure.
Somatic pain Vs Radicular pain
Spondylolithesis , FBSS and Spinal canal stenosis constitute a
combined anterior and posterior compartment pain.

12. HISTORY
• Is there a history of a lesion or disease of the nervous
system, either central or peripheral nervous system?
• If comorbidities are present, are they related to
neuropathic pain (e.g., cancer, stroke, diabetes,
herpes zoster, central cervical disc prolapse, or MS)?
• Cancer history

13. Examination
• Inspection: for signs of asymmetry, lesions, scars,
trauma, swelling, or previous surgery.
• Palpation:
• Percussion
• Midline tenderness
• Paramedian tenderness
• Trigger points
• Diffuse tenderness
• Altered sensation

14. Special exam according to your suspicion:
• The neurologic examination.
• Take measurements of the calf circumferences
(at midcalf). Differences <2 cm are considered
normal.
• Measure leg lengths (anterior superior iliac
spine to medial malleolus) if side-to-side
discrepancy is suspected

15. Muscle strength in both lower extremities:
• 0 = absent strength.
• 1 = trace muscle movement.
• 2 = poor muscle strength [less than antigravity].
• 3 = fair muscle strength [antigravity strength
through normal arc of motion].
• 4 = good strength.
• 5 = normal strength.

16. Test for sensation and reflexes:
0-2 ordinal scale for pinprick sensation:
» 0 = no sensation,
» 1 = diminished sensation
» 2 = normal sensation
0-4 ordinal scale to rate reflexes:
» 0 = no reflex,
» 1 = hyporeflexic,
» 2 = normal reflex,
» 3 = hyperreflexic, and
» 4 = hyperreflexic with clonus.

17. Clinical tests for signs of sciatic nerve tension
Passive straight leg raising (SLR) test
Reverse straight leg raising (SLR) test
Slump test

18. LAP
» Infection: CBC, ESR, CRP etc
» Extensive MSK: rheumatologic workup
» Generalized bone ache: Ca, PTH
» Fleeting arthritis: ESR, ASOT titer, uric acid
» Brucella: ELISA
» Coagulation profile before interventional
management

19. Imaging
• X-ray: alignment, density, fractures, disc
height, mets, stability, surgical implants
• CT scan: vertebroplasty
• MRI: soft tissues
• Bone scan
• Discography ??!!

25. Discogenic pain
• Prolonged sitting
• Prolonged standing
• Straining
• Mid line tenderness
• Chemical irritation
• Centralization phenomenon .
• Bony vibration test (BVT)
• HIZ
• Discography

27. Lumbar discography

30. Interventional management:

32. Lumbosacral Radicular Pain
A lumbosacral radicular syndrome (LRS) is characterized
by a radiating pain in one or more lumbar or sacral
dermatomes;it may or may not be accompanied by
other radicular irritation symptoms and/or symptoms
of decreased function.
In the literature, this disorder can also be referred to as
sciatica, ischias, or nerve root pain.

34. Interventional management:

40. Facet joints arthropathy

43. Interventional management:

44. Sacroiliac Joint Dysfunction:
» Trauma, obese, post lumbar fixation
» Ankylosing spondylitis
» Supine: ASIS, Faber test
» Prone: tenderness, thigh extension
» X-ray, CT
» Diagnostic block

46. Interventional management:

47. Thank you