Transcript Lower Back Pain

Lower Back Pain
Dr Angela Jenkins
ST3 Anaesthetics
10th September 2008
Introduction
 Epidemiology
 Presentation
 Investigations
 Management
 Conclusions
Epidemiology
 Incidence
- Lifetime prevalence 60-85%
- Peak incidence age 40-60y
- No difference between male and female
- More common in heavy, manual occupations
- Increased incidence in smokers
Epidemiology
 Impact on Society
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Approx 52 million working days lost per annum
500 000 people receive Incapacity Benefit
£481 million pa cost to NHS
£5 billion pa cost to society
50% chance of returning to work after 6 months absence
Impact on NHS
Transition from Acute to
Chronic Pain
 Risk factors:
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Signs of nerve root involvement
Ongoing compensation claim
Long time off work
Psychological distress +/- depression
Poor physical fitness
Heavy smoking
Presentation
 Simple musculoskeletal pain (95%)
 Spinal nerve root pain (4-5%)
 Serious spinal pathology (~1%)
Musculoskeletal Back Pain
 Mechanical in nature
 Age 20 – 55 years
 Pain in lumbosacral area and buttocks
 Referred into upper thighs
 Dull ache, varies with activity
 Otherwise physically well
Musculoskeletal - Causes
 Discogenic pain
 Sacroiliac Joint pain
 Facet Joint pain
 Ligament and Muscle pain
Nerve Root Pain
 Well localised, sharp, electric shock-like
 Dermatomal radiation down leg into foot
 Neuropathic element worse than back pain
 May have paraesthesia +/- loss of reflexes
 Exacerbated by coughing, straining, sneezing
 Nerve root pain with SLR test
Nerve Root - Causes
 Posterior Disc Herniation
 Spinal Stenosis
 Epidural Adhesions
Serious Spinal Pathology
 Differential Diagnosis
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Spinal tumours / myeloma
Infection
Trauma
Inflammatory disease
Cauda Equina Syndrome
AAA
Retroperitoneal fibrosis
Serious Spinal Pathology
 ‘Red flag markers’
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Age <20y or >55y
Constant / progressive pain
Acute onset in the elderly
H/O tumour
Fever / night sweats
Immunosuppression / HIV
Recent bacterial infection
Acute neurological symptoms
Unexplained weight loss
Systemically unwell
Serious Spinal Pathology
 Examination
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Tenderness on SI springing
Multiple nerve root signs
Dissociative signs
Symmetrical limitation of SLR
Signs of lower limb ischaemia
Abdominal mass
Investigations
 Radiology
 X-ray, CT, MRI, isotope bone scan
 Blood tests
 FBC, ESR, Ca, plasma viscosity
 Nerve conduction studies
 Diagnostic nerve blocks
Management
 Aims:
 Improve pain
 Optimise physical, psychological and social functions
Management
 Pharmaclogy
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NSAIDs
Anti-depressants
Anti-convulsants
Opioids
Anti-spasmodics
 Psychology
 CBT
 Pain management programmes
Management
 Physiotherapy
 TENS
 Accupuncture
 Injections
 Radiofrequency Lesioning
 Spinal Cord Stimulation
 Surgery
Conclusions
 Consequences may be more problematic than the pain
itself
 Huge cost to society and NHS
 Multiple presentations / causes
 Must exclude serious pathology
 Multi-disciplinary management
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