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Case of Back Pain

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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 ... – PowerPoint PPT presentation

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Title: Case of Back Pain


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 lt 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 lt20 or gt50 with back pain for the 1st time
  • Thoracic pain gt50 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 gt30 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
  • Schobers 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 - gt50
  • 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
51
AS
  • NSAIDs
  • Sulphasalazine peripheral joints
  • PT
  • Anti-TNF

52
AS
53
AS
54
AS
55
THE END
  • THANK-YOU
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