الفهرس 
Low Back Pain (anatomy, pathogenesis, and investigations) Anatomy of the Lumbar SpineOnly 14 pages are availabe for public view
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Abstract
Low back pain is a common musculoskeletal disorder
affecting ٨٠٪ of people at some point in their lives. It accounts
for more sick leave and disability than any other medical
condition. It can be acute, subacute , or chronic in duration.
Several lines of treatment have been used and there are
recent advances in the tools of management of low back pain.
Various new trends have been proposed; including
intradiscal electro thermal therapy. It works by heating the
outer layer of the disc where pain receptors are located. The
heat theoretically alters the collagen within the disc and also
destroys pain receptors located there. Pain reduction has been
reported within a few days and up to six months following the
procedure.
Recently attention has been given to the use of
mesenchymal stem cells derived from adult bone marrow and
on the feasibility of constructing cells through tissueengineering
.The cells have the ability of self –renewal and
proliferation and the multilineage potential to differentiate .
The intradiscal ozone therapy(Chemonucleolysis) is a
novel technique for management of low back pain due to
compression of nerve roots by the intervertebral disces.It is
based on the use of oxygen atom liberated from breaking
down of oxygen molecule when it is injected into the disc
.The active oxygen atom attaches with proteo-glycan bridges
in the nucleus pulposus which are broken down and become
no longer capable of holding water .As a result the disc shrinks
and becomes mummified and decompression of the nerve root
occurs . It is equivalent to surgical discectomy. It has also anti
inflammatory action and tissue oxygenation is increased.Chemonucleolysis uses an enzyme called chymopapain
(derived from papaya), which is injected into the disc space.
Local anesthesia or general anesthesia may be used to control
pain during the injection. Chymopapain speeds up the
breakdown of the jellylike substance inside the disc (nucleus),
releasing water. As a result, the bulging disc may shrink and
relieve pressure on the nerve root.
Pulsed radiofrequency is a another new technique where
strong electromagnetic field is produced around the nerve .It
acts to stop pain signal transmission .Here the normal function
of nerve is maintained and only abnormal pain is stopped.
Patients with chronic discogenic LBP can also benefit
from injection of methylene blue into painful discs which may
be a very effective alternative for surgical treatment
.Methylene blue neurotropic effect enables it to block nerve
conduction or destroy nerve endings.
Lumbar facet joint injection involves injecting a small
amount of local anesthetic and/or steroid medication, which
can anesthetise the facet joints and block the pain. Facet joint
injections usually have two goals: to help diagnose the cause
and location of pain and also to provide pain relief . The
medial branch nerve block is designed to interrupt the pain
signal being carried by the medial branch nerves that supply a
specific facet joint.
A sacroiliac joint injection - also called a sacroiliac
joint block - is primarily used either to diagnose or treat low
back pain and/or sciatica symptoms associated with sacroiliac
joint dysfunction.
Spinal steroid injection is a low risk and rapid treatment
option. It is more effective in patients with MRI finding of
discogenic inflammation, specifically adjacent inflammatory
end plate changes Steroid injection interrupts the pain spasm cycle and nociceptor transmission by the local analgesic and
reducing inflammation induced by corticosteroids .It is
contraindicated in cases as in diabetes, malignancy and
relatively with allergy to the injected substance ,history of
steroid psychosis ,congestive heart failure, pregnancy.
Prolotherapy is an injection procedure used to treat
connective tissue injuries of the musculoskeletal system that
have not healed by either rest or other conservative therapies
in order to relieve back pain. The injections promote a healing.
It works by causing a temporary, low grade inflammation at
the injection site, activating fibroblasts to the area, which, in
turn, synthesize precursors to mature collagen and thus
reinforce connective tissue. The substance used in
prolotherapy injection is a natural irritant agent as
sugar(dextrose or glucose) alone or in combination with
glycerine and phenol.
Hydroelectrophoresis is a novel method of driving drugs
through the dermal tissue, which has been proposed for muscle
pain treatment.It allows the active agent to penetrate about
٠٫٥-١٠cm in tissue avoiding dispersion and creating a
directional flow allowing local regional therapy .It permits
management of pain with applications lasting for ١٥-
٣٠minutes with a possibility to focus therapy to involved
regions.A treatment protocol based on ٣ hydrofor applications
of water solution containing sodium diclofenac and mesilate
pridinole(added in order to enhance drug molecule transport).
Injection of Botox directly into the target muscles could
have the advantage of reducing muscle spasm without
producing sedation. This is in contrast to systemic muscle
relaxants. This has a benefit in the treatment of muscle spasm
associated with chronic low back pain. Botox® may produce a
prolonged reduction of spasm by producing a partial,
reversible denervation of the muscles. selective weakening of painful muscles in spasm may interrupt the pain-spasm-pain
cycle, and facilitate rehabilitation.
Biochemical treatment options including attempts at
intervertebral disc restoration are desirable for the physiologic
treatment of degenerative disc disease without herniation
Lumbar intervertebral discs can be injected with a solution of
glucosamine and chondroitin sulfate combined with hypertonic
dextrose and dimethlysulfoxide (DMSO) which has
chemoneuromodulatory potential. They contribute to the
biosynthesis of proteoglycans. Proteoglycans and collagens
constitute the two major classes of macromolecules in the
nucleus pulposus and annulus fibrosus .
Degenerative discs are thought to produce nerve root
pain mechanically or chemically. Exposure of irritated nerves
to hypertonic dextrose is thought to have a
chemoneuromodulatory potential and reduce sustained pain .It
involves injection of a combination of dextrose, glucosamine,
chondroitin and dimethylsulfoxid.
Piriformis Syndrome Is a condition in which the
piriformis muscle, spasms and causes buttock pain. The
piriformis muscle can also irritate the nearby sciatic nerve and
cause pain, numbness and tingling along the back of the leg
and into the foot (similar to sciatic pain). There is no simple
diagnostic test for piriformis syndrome.The condition is
diagnosed on basis of the patient’s symptoms and on aphysical
examination, and after excluding other possible causes of the
patient’s pain. Treatment include a combination of ice pack or
heat pack, medications (NSAIDs), injections (eg. Botox) and
electrotherapy.
After an episode of low back pain has lasted between
two to six weeks, or if there are frequent recurrences of low
back pain, it is reasonable to consider physical therapy for
back treatment. In general, the goals of back pain exercises and physical therapy are to decrease back pain, increase range
of motion, and provide education on a maintenance program to
prevent further recurrences .Physical therapy includes Passive
Physical Therapy eg; Heat/ice packs, TENS units,
Iontophoresis and, Ultrasound and Active Physical Therapy eg:
Stretching exercise, Strengthening exercise ,Low-impact
aerobic conditioning , Core strengthening exercises and,
Exercise balls.
Yoga is approximately ٤٬٠٠٠ years old and is a scientific
methodology aimed at uniting the mind, body, and spirit. This
bonding that occurs through yoga is said to bring about not
only physical benefits, but mental benefits as well, taking the
individual to a level that could not be reached by manipulating
one factor alone.