Approach to Backpain PDF

APPROACH TO BACKPAIN Dr. Sanesh Miseer Orthopaedic Spinal Surgery Tygerberg Academic Hospital Stellenbosch University Discussion Points Backpain (BP) is common. Key is identifying sinister pathology. Timing regarding referral. Challenges in excluding potential mimickers. Prevalence...

APPROACH TO BACKPAIN Dr. Sanesh Miseer Orthopaedic Spinal Surgery Tygerberg Academic Hospital Stellenbosch University Discussion Points Backpain (BP) is common. Key is identifying sinister pathology. Timing regarding referral. Challenges in excluding potential mimickers. Prevalence most common: 25-29 years high incidence 20 to 49 years Economic Burden Affecting most productive years 40 workdays lost per year in UK / person 1 000 000 consult their GP’s annually for LBP 300 000 referred to hospital (30%) 30 000 admitted (3%) 5 000 surgery (0.5%) General Practitioner Role details about the onset, duration, and nature of the pain Complete history & examination. evaluate the patient's posture, range of motion, and any visible deformities or asymmetry & check for tenderness, muscle spasms, and any neurological signs like altered reflexes, strength, or sensation that could indicate nerve root involvement Exclude sinister pathologies infection, tumours, non-spinal causes spinal infections abdominal aortic aneurysm, pancreatitis, or kidney stones, which may present with referred pain. Advise on non-surgical management Pain Management: analgesics (e.g., acetaminophen AKA panado etc. or NSAIDs) / short-term muscle relaxants for pain relief Physical Therapy: physical therapy or specific exercises to improve flexibility, strength, and posture. Lifestyle Modifications: Advice on weight management, smoking cessation, and ergonomic adjustments at work or home Patient Education: Educating the patient about the nature of lower back pain, the expected course, and strategies for self-management is crucial & red flags that warrant further medical attention. Follow-Up: Regular follow-ups to monitor the patient's progress and adjust the management plan Back Pain Syndromes Mechanical / axial Nerve compression Pathological process  Back Pain Syndromes *Discs: Degeneration, bulging, or herniation of intervertebral discs = related to structural problems in the spine pain. The discs act as cushions between the vertebrae, and when they are damaged, they can cause pain due to pressure on nearby nerves or from inflammatory processes. *Joints: Facet joints (the joints between the vertebrae) can become Mechanical / axial arthritic or inflamed, leading to back pain = facet joint syndrome. *Ligaments: Overstretching or tears in the ligaments that support the spine can cause pain. localized issues in the musculoskeletal system *Muscles: Strains or spasms in the muscles surrounding the spine can lead to significant discomfort. Muscle-related pain is often due to Structural problem Discs / Joints / Ligaments / Muscle Certain postures or movements can aggravate the pain, others can provide relief Changes with position E.g. bending forward might increase pain if there is a disc problem, while leaning Worse with activity back might worsen pain if the facet joints are affected. Fluctuant Improves with rest  Back Pain Syndromes results from irritation or compression of a spinal nerve root Nerve compression sharp, shooting, or burning pain that travels down the leg Characteristics: (sciatica) or arm, depending on which nerve is affected Radicular pain that radiates from the spine to other areas of the body, following the path of a nerve abnormal sensations such as tingling, Paraesthesia numbness, or "pins and needles." Dermatomal occurs in the muscles innervated by the compressed nerve root - difficulty Weakness with specific movements, depending on which nerve root is affected Neurological deficit loss of reflexes, reduced sensation, or motor weakness in a pattern that corresponds to the affected nerve root imagine a map on your body that shows which areas are connected to different nerves - if a nerve is squished, you’ll feel that funny sensation (tingling or pain) in the specific area that nerve is in charge of. it’s like each nerve has its own neighborhood on your skin! Back Pain Syndromes Pathological process Age some serious conditions can cause back pain more commonly found in older people Progressively worsening pain Thoracic pain pain in the middle of your back Night pain wakes you up at night or gets worse at night Constitutional symptoms fever, weight loss, fatigue Medical history *cancer *osteoporosis (which makes your bones weak) *history of infections might put you at higher risk for serious causes of back pain. *recent surgeries Back Pain Syndromes FEEL LIKE BACK PAIN Examination Pearls  Examination Pearls tenderness, deformities, abnormalities & scoliosis/abnormal curvature Back vs front of the spine. asymmetry or abnormal curvature changes in skin color, temperature, swelling, or abnormalities Feet & pulses. presence, strength, and regularity of pulses Remember the buttocks! tenderness, swelling, or any abnormalities  should improve within 3 months if not = chronic lower back pain sudden onset & severe not harmful/serious - not usually caused by major underlying condition resolves on its own without extensive medical treatment  Yellow Flags indicates severe nerve compression risk of metastatic disease in the spine loss of sensation in the areas that would come into contact with a saddle, including the buttocks, inner thighs, and genital region Diagnostic Imaging not done often X-rays. not always effective in diagnosing back pain Of limited use especially for degenerative conditions Readily available Poor correlation to symptoms (esp. Degen) X-ray findings may not always match the severity or presence of symptoms  patient comes in with back pain Diagnostic Imaging x-ray shows hip is actually the problem severe osteoporosis Treatment Reassurance encouragement and explain that most back pain improves with time & is not serious Short period of rest (no more than 2 days) to avoid muscle weakening and deconditioning Anti-inflammatory medication reduce inflammation and relieve pain Analgesics pain relievers such as acetaminophen can help manage discomfort Physiotherapy improve strength, flexibility, and posture & alleviate pain Exercisestrengthen the back muscles and support recovery Weight loss achieve and maintain a healthy weight to reduce strain on the back and prevent future pain NSAID’s Most frequently prescribed medications for LBP 51 trials (6057 patients) Main results: NSAIDs better than placebo Conclusion: NSAID’s effective for short-term treatment of acute LBP sufficient evidence in chronic LBP still lacking Van Tulder, Scholten, Koes. The Cochrane Library, Issue 2, 2003  My Treatment Regimen Counsel. manage nerve pain and may relieves pain and fever help with neuropathic pain (general pain management) Lyrica, Celebrex, Paracetamol, Baclofen. NSAID that reduces muscle relaxant that helps inflammation and pain relieve muscle spasm and pain Option for re-entering the system. make changes to your treatment if needed  Pain Procedures steroid injections into the epidural space Epidural steroids sciatica not for back pain alone inject anesthetics (and sometimes steroids) into the facet joints of the spine Facet blocks temporary or short-term transient relief relief from pain or symptoms may break pain cycle temporarily reduces pain and allows for improved movement and physical therapy  surgical procedure that involves cutting/destroying Rhizotomies specific nerve roots in the spinal cord to reduce pain Limited evidence for current use. Take Home Messages Careful history taking. 1. history 2. examination 3. x-rays Remember mimickers. Examination techniques. Dankie Thank you Enkosi