1 / 55

Case of Back Pain

Case of Back Pain. 53 year old, right handed lady, hotelier 3 day history of severe lower back pain and weakness in her legs bending over at work and had noticed a mild back pain, which progressed Night and rest pain, leg radiation, worse with movement. Unable to walk. Case of Back Pain.

stasia
Download Presentation

Case of Back Pain

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Case of Back Pain • 53 year old, right handed lady, hotelier • 3 day history of severe lower back pain and weakness in her legs • bending over at work and had noticed a mild back pain, which progressed • Night and rest pain, leg radiation, worse with movement. Unable to walk

  2. Case of Back Pain • Sep 05Haematologists shoulder pains, lymphadenopathy and rash, fatigue, 7 kg weight loss in 6 months • l-node < 1cm ALP 210 Rheum referral • Subsequently admitted • Ex In pain restricted spine ? leg weakness and altered sensation feet

  3. Case of Back Pain • ALP 320, ALT 89 CRP 96 XR normal • MRI spine normal • Symptoms progressed • Tingling in upper limbs, noted to have reduced reflexes

  4. Case of Back Pain • CSF protein 2.55 g • ?Guillan-Barre • Transferred to neurology • IV Ig, Rehab, FVC, vitals monitoring • Campylobacter IgG and IgA 160 • EBV +ve

  5. GB syndrome • Post-infective acute inflammatory demyelinating polyneuropathy • 1-3 weeks post viral • Distal numbness and weakness – evolves over days to weeks ascending • Back and leg pain can be a feature • 20% severe with autonomic and respiratory complications • Weakness, areflexia, sensory loss

  6. GB syndrome • Rare – ocular and ataxia – Miller-Fisher syndrome • NCS: slowing of conduction or block • CSF: 1-3g/l • IV Ig, supportive, ventilation, plasmapharesis, rehab

  7. BACK PAIN Jaya Ravindran Rheumatologist

  8. Causes • Simple mechanical eg ligamentous strain • Degenerative disease with/without neural, cord or canal compromise • Metabolic – osteoporosis, Pagets • Inflammatory – Ankylosing spondylitis • Infective – bacterial and TB • Neoplastic • Others, (trauma,congenital) • Visceral

  9. Red flags • Age <20 or >50 with back pain for the 1st time • Thoracic pain >50 yrs • Pain following a violent injury/trauma • Unremitting, progressive pain

  10. Red flags • Past or current history of cancer • On Steroids or immunosuppressants • Drug abuser or +ve HIV • Systemic symptoms - fever, appetitie and weight loss, malaise

  11. Red flags • Bilateral leg radiation, sensory/motor/sphincter symptoms • Pain predominantly at night

  12. Inflammatory flags • Morning stiffness and pain >30 mins -1 hr • Better with activity • Peripheral joint involvement • Anterior uveitis • Psoriasis • Inflammatory bowel disease • Recent GI or GU infection • Family history

  13. Myotomes • C5 Deltoid, biceps (biceps jerk) • C6 Wrist extensors, biceps (biceps, brachioradialis jerk) • C7 Wrist flexors, finger extensors, triceps (triceps jerk) • C8 Finger flexor, thumb extensors (triceps jerk) • T1 finger abductors

  14. Myotomes • L2 Hip flexion • L3 Knee extension (knee jerk) • L4 Knee extension, ankle dorsiflexion (knee jerk) • L5 toe dorsiflexion • S1 foot plantar flexion, eversion

  15. DERMATOMES

  16. Examination • LOOK – deformity, muscle wasting, kyphosis, scoliosis • LOOK – normal cervical lordosis, thoracic kyphosis, lumbar lordosis • FEEL – spinal processes and sacroiliac joints

  17. Examination • MOVE – Lumbar flexion • Schober’s test – marks at “dimples of Venus” and 10 cm above. Measure at maximal flexion – usually 5 cm • MOVE – Lumbar lateral flexion • MOVE – Cervical flexion/extension, lateral rotation and flexion, thoracic rotation

  18. Examination • Sciatic stretch (patient supine) - Straight leg raise and dorsiflexion of foot - pain in calf and posterior thigh between 30-70o – low lumbar (L5/S1) lesion or sciatic irritation • Femoral stretch (patient prone) – knee is flexed and then hip extended – pain in anterior thigh – high lumbar (L2-L4) lesion

  19. Imaging • XR – tumour, fracture, infection, inflammation • Bone scan – increased turnover eg infection, metastatic disease, fractures, Pagets • MRI – soft tissue, discs, facet joint, nerve roots, cord, inflammation

  20. Degenerative disease and sciatica • Very common • Facet joint OA, disc disease, osteophyte • Mechanical back pain • Sciatica – most resolve NB persistent, neurology, bilateral, red flags • Analgesia, PT, pain clinics

  21. Degenerative disease and sciatica

  22. Malignancy • Unremittting, progressive and night pain • Systemic symtoms • Past hx Ca • Breast, bronchus, thyroid, kidney, prostate and myeloma/plasmacytoma • Osteolytic (prostate osteoblastic) • XR can be normal in early stages – further imaging if suspicion high • Predilection for vertebral body and pedicles

  23. Malignancy

  24. Malignancy

  25. Infection • discitis, osteomyelitis, and epidural abscess. • hematogenously spread • most often Staphylococcus aureus. • Gram-negative rods in postoperative or immunocompromised patients • normal skin flora is less commonly isolated in postoperative patients. • Postoperative patients develop symptoms 2 to 4 weeks after surgery after an initial improvement in pain.

  26. Infection • Pseudomonas organisms in intravenous drug users. • Mycobacterium tuberculosis in developing nations and immigrant population. Fungal infections are rare. • Only one third have fever and 3% to 15% present with neurologic deficit. • Infections typically involve the intervertebral disc and vertebral body endplate

  27. Infection • Radiographic changes at 2 to 4 weeks • bone scan can be positive as early as 2 days 75% specific. • MRI appearance is decreased T1- and increased T2-weighted signal in the infected disk. Enhancement after gadolinium

  28. Infection • Conservative treatment of antibiotics, rigid bracing to prevent deformity and control pain • Surgery : neurologic deficit, presence of abscess, extensive bone loss with kyphosis and instability, failure of blood work and biopsy to isolate any organism, excision of a sinus tract, or no response to conservative treatment.

  29. Infection

  30. Infection

  31. Osteoporosis

  32. DEXA

  33. T scores

  34. Osteoporosis

  35. Low bone density

  36. Osteoporosis - risks • History of low trauma # - colles, NOF, vertebral, sacral or pelvic insufficiency • Steroids • Maternal history of NOF # • Gonadal hormone deficiency • Ca deficiency • Prolonged immobility • Low BMI • Alcohol and smoking

  37. Causes of low bone density

  38. Vertebral fractures

  39. Osteoporosis

  40. Osteoporosis • Bisphosphonates • SERMs • Strontium • Teriparatide • Calcitonin • Lifestyle factors • Ca and Vit D

  41. 7-dehydrocholesterol sunlight cholecalciferol • (diet) • liver • 25-hydroxycholecalciferol • kidney 1-hydroxylase • 1,25-dihydroxycholecalciferol (-) • increased GI Ca2+ absorptionCa2+ • Bone resorption Thyroid • (-) • Parathyroid Gland PTH  Renal Ca2+(-) Calcitonin • reabsorption

  42. Spinal stenosis • Canal or foraminal narrowing with possible subsequent neural compression • Cause • Ligamanetum flavum hypertrophy, facet joint hypertrophy, vertebral body osteophytes, herniated disc • Rare: Pagets, AS, acromegaly

  43. Spinal stenosis • Symptoms • Age - >50 • Dull aching pain in the lower back and legs • Exertional leg pain/weakness/numbness • Symptoms relieved leaning forward, sitting or lying • Examination • May be normal • Normal sensation and power • Reflexes normal or slightly reduced • Normal foot pulses

  44. Spinal stenosis

  45. Spinal stenosis • Conservative – analgesics, NSAIDs, PT, epidural • Surgery – laminectomy (+arthrodesis)

  46. Cauda Equina Syndrome • Back pain, lower limb weakness, saddle anaesthesia, sphincter disturbance, impotence • Causes – usually disc, rarely tumour, abscess, advanced AS • Diminished sensation L4 to S2 (sacral numbness), weakness ankle and plantar dorsiflexion, loss ankle jerks, urinary retention, loss anal tone • Urgent MRI and surgical decompression

  47. Cauda Equina Syndrome

  48. Pagets

  49. Pagets • Pain, deformity • Skull, long bone, vertebra, pelvis, near hip • Neurologic compromise • Planned surgery • ?ALP 2X ULN • Rare: high output failure

  50. AS

More Related