NYERI PUNGGUNG BAWAH
dr. Heru Hermantrie, Sp.OT
INTRODUCTION
Low back pain is an extremely common problem that most people
experience at some point in their life.
Low back pain is the leading worldwide cause of years lost to
disability and its burden is growing alongside the increasing and
ageing population.
Most low back pain is unrelated to specific identifiable spinal
abnormalities,
Source : Buchbinder Rachelle et al. Low Back Pain : a call for action.
Lancet 2018; 391: 2384–88
DEFINITION
It is defined as pain and discomfort between the costal margin and
inferior gluteal folds with or without leg pain.
Pain may be acute (less than 6 weeks’ duration),subacute (6−12 weeks)
and chronic (more than 12 weeks).
Source : Apleys 10th Ed, p517-18
RISK FACTOR
Risk factors are variables associated with an increased risk of disease,
including :
1. Age >60 years old
2. Female > male
3. Smoking
4. Obesity or BMI > 30
5. Posture ( scoliosis, kyphosis, leg length discrepancy, hyperlordosis)
6. Occupational factors (manual handling, bending, twisting and whole
body vibration)
Source : Buchbinder Rachelle et al. Low Back Pain : a call for action.
Lancet 2018; 391: 2384–88
Source : Manchikanti Laxmiah. Epidemiology of Low Back Pain. Pain
Physician, Volume 3, Number 2, pp 167-192 2000, Association of
Pain Management Anesthesiologist
CAUSES
The following classification of the causes of low back
pain, developed by Macnab, is most helpful:
Classification Abnormalities
Viscerogenic Lession of genitourinary tract and
pelvic organ, irritation to posteior
peritoneum
Vasculogenic aneurysma/occlusion of
descending aorta and iliac
arteries
Neurogenic Infection/ neoplasm of the spinal
cord or cauda equina
Spondylogenic - Osseus lession
(most common cause) - Soft tissue lession
Psychogenic Emotionally unstable or neurotic
patients
Source : Salter, Textbook of Disorder and Injuries of the
Musculoskeletal System 3rd Ed, p280
CLINICAL FEATURES
Mechanical pain is aggravated with movement and relieved by rest
Pain is described as dull, aching and similar to toothache and does
not radiate down the leg.
Patients with pain radiating down to the buttocks and posterior
thigh may have neurogenic pain such as spinal stenosis
It is usually not possible to clinically distinguish the source of pain
between the disc, facet joints, muscles, ligaments and the
sacroiliac joints.
Source : Apleys 10th Ed, p517-18
LOWER BACK PAIN − RED AND
YELLOW FLAGS
Source : Apleys 10th Ed, p517-18
EXAMINATION
Spine examination may reveal :
1. muscle spasm
2. local tenderness
3. Restriction of back movements
4. Pain on flexion indicate disc pathology
Sacroiliac joints are examined by FABER test
hips should be examined to exclude hip joint pathology
Neurological assessment includes eliciting nerve root irritation with the
straight-leg raise test (L4−S1) and the femoral stretch test (L2−L4 nerve
roots). Motor power, sensation and reflexes should be documented.
Source : Apleys 10th Ed, p519
INVESTIGATION
1. X-RAYS :
It can be normal or there are appearance of flattening of dsic space,
marginal osteophytes.
In the lateral view, there may be slight displacement of one vertebra
upon another (spondylolisthesis, retrolisthesis)
Discography and facetography may reveal disc abnormalities
Source : Apleys 10th Ed, p519
Cont’d
2. BLOOD TEST :
FBC and ESR help screen for non-mechanical causes
of lower back pain such as infections, inflammatory
conditions and neoplasms.
In elderly patients a serum protein electrophoresis
should be checked
prostate-specific antigen in males should be part of
the workup.
Source : Apleys 10th Ed, p519
Cont’d
3. CT AND MRI :
These investigations may reveal signs of disc
degeneration as well as early features of OA in the
facet joints
MRI findings of high intensity zones (annular tear),
disc degeneration and Modic end-plate changes are
suggestive as causes of lower back pain
Source : Apleys 10th Ed, p519
TREATMENT
CONSERVATIVE TREATMENT
Indicated if the symptoms are neither severe nor disabling
1. Reassurance :Patients can be reassured that most cases of acute back
pain are self-limiting and resolve over a few weeks.
2. Activity Modification : avoid heavy work and stop smoking.
3. Physical therapy : Conventional physiotherapy and spinal manipulation
for patients may be of benefit.
4. Spinal support : A simple corset may provide symptomatic relief
5. Psychological support
Source : Apleys 10th Ed, p519
Ergonomic Position
Cont’d
6. Medication Acute : LBP treatment includes paracetamol and NSAIDs,
short courses of opioids, or nonbenzodiazepine muscle relaxants.
Tricyclic antidepressants are more useful for chronic LBP and gabapentin
tends to be used in radiculopathy
Injection therapy : In chronic radiculopathy, nerve root blocks
provide short term symptomatic relief and diagnostic information
Source : Apleys 10th Ed, p519
Source : Koes B W et al. Diagnosis and Treatment of Low Back
Pain. Clinical Review. BMJ Volume 332. June 2006
TREATMENT
SURGICAL TREATMENT
1. Spinal Fusion : its traditionally aimed at stabilizing the painful segment
by anterior fusion, posterior fusion or both. Also, especially for non-
radicular LBP with degenerative disc findings.
2. Discectomy: for herniated disc with radiculopathy
3. Laminectomy : for symptomatic spinal stenosis
Source : Chou et al. Surgery for Low Back Pain A Review of the
Evidence for an American Pain Society Clinical Practice Guideline.
SPINE Volume 34, Number 10, pp 1094–1109. 2009
What are the most important prognostic
indicators for chronicity?
Source : Koes B W et al. Diagnosis and Treatment of Low Back
Pain. Clinical Review. BMJ Volume 332. June 2006
CONCLUSION
It is clear that low back pain is an extremely common problem, which
most people experience at some point in their life
It has a huge impact on individuals, families, communities, governments
and businesses throughout the world
Diagnostic triage focuses on excluding specific pathology and nerve root
pain
Management of patients with persistent and disabling low back pain
remains a clinical challenge
Terimakasi
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