patofisiologilowbackpainms- 2007- orth- islam mohamed

7/31/2019 PatofisiologilowbackpainMS- 2007- Orth- Islam Mohamed

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Pathophysiology of Low Back Pain

and Its Implications on Treatment

Essay

Submitted for Partial Fulfillment of

Master Degree

Of

Ort hopaed ic Surgery

By

Is lam Moh am ed Abdel Aziz Moham ed

M.B.B.Ch.

Under Supervision of

Pro f. Dr. Ezzat M. El-Ha w i

Professor of Orthopaedic Surgery

Faculty of Medicine-Ain Shams University

Dr. Abde lfa t t ah M. F. Sao ud

Assistant Professor of Orthopaedic SurgeryFaculty of Medicine-Ain Shams University

Fac u l ty o f Med ic ine

Ain Sham s Univers i ty

2008


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CONTENTS

I . In t roduc t ion .

I I . Anatom y & B iomec han ics .

I I I . Pat hophysio logy o f Low Bac k Pa in .

IV. Im pl ic a t ions o f Pat hophysio logy on

Trea tmen t

V. Sum m ary

VI . Referenc es.

V I I . Arab ic sum m ary .


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Pat hophys io logy o f Low Bac k Pa in

and I t s Imp l i ca t ions on Trea tm ent

I n t roduc t ion

The international association for the study of pain has expressly defined

low back pain topographically.

is pain perceived as arising from a regionLumbar low back pain:

bound laterally by the lateral borders of the erector spinae and

transversely by imaginary lines through the L1 vertebra above and S1

vertebra below.

acral lowSPain below this level till the tip of coccyx is described as

and within the same lateral confines.back pain

(1, 2).painPain in other regions should not be described as low back

which is less than 3 monthsAcuteLow back pain is classified into:

which is more than 3 months complaint. Some addChroniccomplaint &

where the duration of complaint lies sometimeSubacutethe category of

)(2, 3inbetween.Between 70% and 85% of the population suffer from low back pain at

some time in their lives. The annual incidence of low back pain in adults

in industrialized countries is 15%.Low back pain is the primary cause of

disability in individuals younger than 50 years. Moreover, the lifetime

prevalence for any back pain ever is probably well over 50% of the

(4, 5, 6)countries.trializedinduspopulation in

Sources of low back paininclude:Motionsegmentanditscomponents (Intervertebral disc, Zygoapophysial [Facet]joint,

Ligamentum flavum, Anterior and posterior longitudinal ligaments,

Supraspinous and Interspinous ligaments, Back muscles, Back fascia,

Bony vertebrae and periosteum, Neural structures[Contents of spinal and

(5).jointsSacroiliacandintervertebral canals])


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The relation between intervertebral disc degeneration and low back pain

is not clearly understood. Intervertebral disc degeneration may

contribute to back pain through loss of disc structure and biomechanical

(5)properties and release of mediators that may sensitize nerve endings.

Facet joint changes with age include thinning of the articular cartilage &

decrease of the water content of hyaline cartilage. Facet joint arthritis

may be caused by disturbance in mechanical balance of the joints,

iatrogenic injuries or synovial joint diseases. (7)

Possible causes of sacroiliac joint pathology & pain include mechanical,

degenerative, inflammatory, infective causes, osteopathies, neoplasms,

trauma or dysplasia. (8, 9, 10)

Diseases that cause low back pain of mixed pathology include: Spinal

deformities [scoliosis, kyphosis, lordosis], Spondylolysis&

Spondylolisthesis, Spinal stenosis and Failed back surgery syndrome.

(11, 12, 13)

Possible causes of pain in spinal deformities include muscle imbalance,

tension in some ligaments, degeneration and arthritis of facet joints,

intervertebral disc degeneration, arthritis of sacroiliac joints, spinalstenosis or irritation of intra-spinal pain sensitive structures. (13)

Pain in Spondylolisthesis could be due to spinal stenosis, abnormal

stresses on facet joints, abnormal stresses on the discs, abnormal shear

stresses and stretching of ligaments and muscles. (11)

One of the implications of pathophysiology of low back pain on its

treatment is the role of gene therapy in the treatment of low back pain

which has been extensively evaluated to prevent degenerative disc

disease, regenerate degenerated intervertebral discs and promote spinal

fusion. (14, 15)


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Aim of t he Work

Reviewing literature about the pathophysiology of low back pain

and focussing light upon its implications on different recent

modalities of treatment.

References

1. Bogduk N: Low back pain; Burchiel KJ ed.: Surgical management ofpain. Thieme medical publishers, New York, 2002: pp 327-341.

2. Merskey H, Bogduk N, eds.:Classification of chronic pain:

Descriptions of chronic pain syndromes and definitions of pain terms.2nd

ed.Seattle: IASP Press, 1994:11-36.

3. Van Tulder MW, Koes BW, Bouter LM: Conservative treatment of

acute and chronic non-specific low back pain: a systemic review of

randomized controlled trials of the most common interventions.

Spine.1997; 22:2128-2156.

4. Andersson GBJ: Epidemiological features of chronic low back pain.

Lancet 1999; 354:581-585.

5. Biyani A, Andersson GBJ: Low back pain: Pathophysiology and

management. J Am Acad Orth Surg: Vol. 12, No 2, March/April 2004.

6. Shekelle P:The epidemiology of low back pain: In: Giles LGF, Singer

KP eds.: Clinical anatomy and management of low back pain. 1st

ed.,

Butterhouse-Heinemann Publisher, 1999, pp 18-31.

7. Giles LGF: Zygoapophyseal joints, spinal and intervertebral canals:

In: Giles LGF and Singer KP eds.: The clinical anatomy and

management of low back pain, 1st

ed., Butterworth and Heinemann

publishers, Oxford, 1999, pp 72-113.


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8. Duthie RB: Affections of the spine: In: Duthie RB and Bentley G eds:

Mercer's Orthopaedic surgery, 9th

ed., Arnold publisher, London, 1996,

pp 916-1014.

9. Giles LGF: Introduction: Giles LGF and Singer KP eds: The clinical

anatomy and management of low back pain, 1st

ed., Butterworth andHeinemann publishers, Oxford, 1999, pp 3-17.

10. Rickenbacher J, Landolt AM and Theiler K (1985): Applied anatomy

of the back. Springer Verlag, Berlin.

11. Knolmayar BR, McAlindon R and Wiesel SW: Medical and surgical

management of low back pain of mechanical origin: In: Giles LGF and

Singer KP eds: The clinical anatomy and management of low back pain:Butterworth and Heinemann publishers, Oxford, 1999, pp 334-343.

12.Long DM: Failed back surgery syndrome: Burchiel K ed: Surgical

management of pain, Thieme medical publisher, New York, 2002, pp 354-

364.

13. Weinstein SL: The Thoracolumbar spine: In: Weinstein SL and

Buckwalter JA eds: Turek's Orthopaedics: Principles and their

application, 5th

edition, Philadelphia, J.B.Lippincott company, 1994, pp

447-485.

14. Nishida K, Gilbertson LC, Evans CH, Kang ID: Potential

applications of gene therapy to the treatment of spinal disorders. Spine

2000; 25:1308-1314.

15. Nishida K, Gilbertson LC, Robbins PD, Evans CH, Kang JD:

Potential applications of gene therapy to the treatment of intervertebral

disc disorders. Clin Orthop 2000; 379(suppl):S234-S241.

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