BACK PAIN

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BACK PAIN

• Disc herniation

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History

• Primitive cultures attributed it to the work of
  demons
• Ancient Greeks recognized the symptoms as a
  disease
• Goldthwait in 1911 attributed back pain to
  posterior dislacement of the disc (disc tumor)
• Barr in 1932 attributed sciatica to herniated
  lumbar disc suggested surgical treatment

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epidemiology

• Hult estimates 80 of people are affected by this
  symptom at some time in their lives (Acta Orth
  Scand 1954)
• Dillane,fry and Kalton reported 79 of men 89 of
  women the specific cause was unknown( BMJ 1966)

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epidemiology

• Saal and Saal noted 80 of those reporting
  chronic back pain did not report limitation of
  activity
• Females more frequently than males
• No racial differences

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epidemiology

• Carey et al 1992 incidence 3.9 chronic low back
  pain in 4437 North Carolinians
• 34 of those permanently disabled

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Cost

• Lost work time
• Compensation (2 billion /year in USA)
• Treatment (1/3 total cost)

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Factors affecting..

• Jobs requiring heavy and repetitive lifting,use
  of machine tools,operation of motor vehicles
• Cigarette smokers
• Anxiety, depression, stressful occupations
• Number of pregnancies
• Frymoyer et al JBJS 1983

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.

• Scoliosis
• Jackson,Simmons Spine 1983
• Patients taller than 181cm
• Gyntelberg F Dan Med Bull 1974
• Obesity
• Deyo,Bass Spine 1989

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Disc anatomy
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Nucleus pulposus

• Loose,nonoriented,collagen fibril framework
  supporting a network of cells resembling
  fibrocytes and chondrocytes
• Gelatinous matrix of various glucosaminoglycans,wa
  ter and salts

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Annulus fibrosus

• Concentric rings of fibrocartilaginous tissue
• Rings attach to each other with additional
  diagonal fibers
• Rings are thicker anteriorly

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Neural elements

• Neural fibers exist in the outer rings of the
  annulus
• They are branches of sinu vertebral nerve lying
  dorsally (small filamentous nerve originates from
  ventral ramus)
• Bogduk N Spine 7319 1982

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Natural history

• Stage I Dysfanction
• 15-45 y old,circumferential radial tears in
  disc annulus, localised synovitis of facets
• Stage II Instability
• 35-70y old, internal disc disruption,
  progressive disc resorption, facet
  degenaration,sublaxation, joint erosion

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Natural history

• Stage III Stabilisation
• Osteophytes, stenosis, spondylosis
• Kirkaldy-Willis Spine 4102-109, 1979
• Disc disease one of recurrent episodes of pain
  followed by periods of significant or complete
  relief

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Simple compression of nerve root creates sensory
motor symptoms but no painSmyth MJ, Wright V
JBJS 40A1401-1418 1958
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Chronic irritation by compression tends to be
painfulSmyth,Wright JBJS 1958Howe,Laser,Calvin
Pain 325-41,1977
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Consequences of pressure

• Alteration in intraneural blood flow
• Problems with axoplasmic transport
• Inflamation, edema, demyelination
• Nobuhiro H,Hwan-Mo L,Weinstain JN textbook of
  spinal disorders 1996
• Rydevik BL,Brown MD,Lundberg G Spine 97-15 1984

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Kawakami et alJournal of Orthopaedic Research
vol 18-2, 2000

• Mechanical constriction leads to
  demyelination,alters pain related behavior
• Nucleus pulpususmechanical hyperalgia
• 4-0 silk loop no hyperalgia
• Silk loop nucleus pulpusus thermal hypralgesia

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Park JB,Chang H,Kim YS Spine 128(1)100 2003

• Immune reaction
• Increase interleukin 12,T-helper Type I,
  interferone-gamma(INF-gamma),Th2(IL-4)

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Kawakami et al Spine 21(18)2101-2107 1996

• pH
• Interleukin I
• Phospholipase A2
• Nitric Oxide

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