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