Presentation on theme: "DIFFERENTIAL DIAGNOSIS AND TREATMENT OF LOW BACK AND LOWER EXTREMITY PAIN Prof. Dr. Ece Aydoğ PMR."— Presentation transcript:
1 DIFFERENTIAL DIAGNOSIS AND TREATMENT OF LOW BACK AND LOWER EXTREMITY PAIN Prof. Dr. Ece AydoğPMR
2 Learning objectives1. be able to differentiate mechanical and non-mechanical pain2. be able to enumerate the risk factors for low back pain3. be able to define spondylosis, spondylolysis, spondylolisthesis and spondylitis4. be able to describe clinical presentation and treatment for acute muscular strain, lumbar discopathy, spinal stenosis and spondylolisthesis and spondylolysis.5. be able to enumerate non-mechanic causes of low back pain and describe differential diagnosis.
3 Learning objectives6. be able to enumerate the red flags of serious low back pain7. be able to enumerate the reasons which cause pain in the lower extremity and make the differential diagnosis.8. be able to enumerate situations that require emergency surgery for lumbar back pain and surgical indications in lumbar discopathy.9. be able to enumerate diagnostic methods, treatment approaches, pharmacological and non pharmacological methods for low back pain.
4 Who gets back pain ? Almost Everybody Estimates run as high as 80% of the population.Only 1-2 % need surgery.5-10 % develop chronic pain.75 % of patients have relapses.Peak occurrence is between age 30 and 45.
5 The spine has two basic jobs: 1) to protect the spinal cord2) to allow us to moveBack pain usually involves someloss of ability to move easily.
10 SPİNAL SEGMENTEvery level of the spine is composed of a disc in the front and paired facet joints in the back. The disc acts as a shock absorber in between the vertebrae, whereas the paired facet joints restrain motion. They allow the spine to bend forwards (flexion) and backwards (extension) but do not allow for a lot of rotation.
12 ClassificationsTransient—duration is hours to days, only brought to medical attention when episodicAcute—duration is days to weeks; most recover spontaneouslyPersistent—lasts more than 3-6 months; does not improve with time; no psychological co-morbidities (often associated with spondylotic disease)Chronic—lasts more than 6 months; worsens with time, associated with major psychological co-morbidities
13 90% of low back pain is “mechanical” Injury to muscles, ligaments, bones, disksSpontaneous resolution is the ruleNonmechanical causes uncommon but don’t miss them!SpondyloarthropathySpinal infectionOsteoporosisCancerReferred visceral pain
14 Risk FactorsAgeSendentary lifestylePregnancyObesitySmokingInjuryPreexisting back injury due to:Lifting a heavy objectImproper liftingSudden movement, bending, or twistingProlonged sitting or standingBad postureVibration from vehicles or heavy equipmentPrior back surgeryOther factors which may negatively influence back pain include:Psychological factors, such as low job satisfactionFatigue or sleep deficitDrug or alcohol abuseStress
15 Congenital bone conditions Congenital causes (existing from birth) of low back pain include scoliosis and spina bifidaScoliosis is a sideways (lateral) curvature of the spine that can be caused when one lower extremity is shorter than the other (functional scoliosis) or because of an abnormal design of the spine (structural scoliosis)Children who are significantly affected by structural scoliosis may require treatment with bracing and/or surgery to the spineAdults infrequently are treated surgically but often benefit by support bracing
16 Classification of Scoliosis CongenitalFailure of formationFailure of segmentationMixedNeuromuscular- Myopathic- Arthrogryhosis- Muscular dystrophy-NeuropathicUpper motor neuronLower motor neuronDysautonomia (Riley-Day syndrome)nİdiopathicInfantil (0-3 years)Juvenil (3-10 years)Adolescent (10y + years)OthersNeurofibromatosisMesenchymal (Ehler Danlos s, Marfan’s s)TraumaticTumorsOsteochondrodystrophies
19 Common Sources of LBP Somatic dysfunction Muscle in “spasm”Nerve rootIn somatic dysfunction, some muscles become overactive (“spasm”)and other muscles become inactive.
20 There are many more joints in the back than discs. There are many more muscles than joints.The most common cause of low back pain is when one or more muscles “forget” to relax. We call this a somatic dysfunction.
21 Common Sources of LBPAny dysfunction involving the thoracic or lumbarspine, the sacroiliac joint or the hip can create low back pain.
22 Common Sources of LBP Long dorsal si ligament piriformis sacrospinous ligamentsciatic nervesacrotuberous ligament
24 Role of the sacroiliac joint The sacroiliac joint requires muscle activity to keep it stable.If muscles can’t work correctly, perhaps because of a somatic dysfunction, the joint becomes unstable and painful.132
25 The most common causes of low back pain; Injury or overuse of muscles, ligaments, facet joints, and the sacroiliac joints.
26 Lumbar Strainstretching injury to the ligaments, tendons, and/or muscles of the low backmicroscopic tears of varying degrees in these tissuesone of the most common causes of low back painoccur because of overuse, improper use, or trauma"acute" if it has been present for days to weeks"chronic" lasts longer than three months
27 Symptoms Pain, mostly in the back and buttocks Muscle spasms, cramping, and stiffnessIt is aggravated by weight-bearing or specific movements and is relieved by restThe most severe pain usually lasts 48 to 72 hours and may be followed by days or weeks of less severe painThe back is easily reinjured during this time
30 SpondylolysisSpondylolysis (spondylo = spine; lysis=dissolved) refers to the defect (black arrows) present when the pars interarticularis is fractured. This results is the lamina and inferior facet joints being disconnected from the vertebral body.
31 SpondylolysisSpondylolysis isn't something that people are born with, but develop in childhood /adolescenceIt is thought to be a stress fracture that doesn't healIt is seen most often in football linemen and in gymnasts
32 SpondylolisthesisSpondylolisthesis (spondylo=spine; listhesis=to slip) occurs in the presence of a spondylolysis when the intervertebral disc stretches and allows the vertebral body to slide forward on the vertebra below. This results in widening of the pars defect. This is known as an isthmic spondylolisthesis.
33 Spondylolisthesis Displastic (congenital dysplasia between the L5-S1) Degenerative (elderly people)Traumatic (fracture in the posterior stractures except isthmus)Patologic (metabolic bone disease, metastatic Ca..)
35 Spinal StenosisSpinal stenosis is a medical condition in which the spinal canal narrows and compresses the spinal cord and nervesThis is usually due to the common occurrence of spinal degeneration that occurs with agingIt can also sometimes be caused by spinal disc herniation, osteoporosis or a tumorIn the cervical and lumbar region it can be a congenital condition to varying degrees
36 Spinal StenosisSpinal-nerve compression in these conditions can lead to sciatica pain that radiates down the lower extremitiesSpinal stenosis can cause lower-extremity pains that worsen with walking and are relieved by resting (mimicking poor circulation) (Neurogenic claudication)
37 Acute Back Pain in the Elderly Multiple compression fractures
38 Compression fractures More common among postmenopausal women with osteoporosis, or in men or women after long-term corticosteroid useOften occurs with forward flexion during normal activity or with trivial traumaSevere spinal painMarked muscle spasmSome relief with recumbency
39 Less common spinal conditions that can cause low back pain include Ankylosing spondylitisBacterial infectionSpinal tumorsPaget's diseaseScheuermann's disease
40 Spinal Infections Acute infection Bacterial Fungal Chronic infection TuberculosisBrucellosisSites of spinal infectionVertebral osteomyelitisDisk space infectionSeptic sacroiliitis
41 Spinal Infection Historical clues Fever, rigors Source of infection: IV drug abuse, trauma, surgery, dialysis, and skin infectionPhysical exam cluesFocal tenderness with muscle spasmOften cannot bear weightLab cluesMild anemia,Elevated ESR, and/or CRP
44 Spinal Malignancy Pain worse at night Multiple Myeloma Often associated local tendernessWBC, ESR, protein electrophoresis if ESR elevatedMultiple Myeloma
45 Other medical conditions that can cause pain that may be similar to low back pain include: Pelvic inflammatory diseaseAortic aneurysmPeptic ulcersGallbladder diseasePancreatitisUrinary disorders such as kidney stones or urinary tract infections.Prostate disease
46 What Are the Red Flags for Serious Low Back Pain? Fever, weight lossIntractable pain—no improvement in 4 to 6 weeksNocturnal pain or increasing pain severityMorning back stiffness with pain onset before age 40Neurologic deficits
47 Lower Extremity Pain Causes MUSCLE CRAMP Dehydration or low amounts of potassium, sodium, calcium, or magnesium in the blood.MedicationsDiuretics,Statins, which lower cholesterol and can cause muscle injuryMuscle fatigue or strain from overuse, too much exercise, or holding a muscle in the same position for a long time
48 Lower extremity pain A torn or overstretched muscle (strain) Hairline crack in the bone (stress fracture)Inflamed tendon (tendinitis)Shin splints - pain in the front of your leg related to overuse or repetitive pounding
49 Other common causes of leg pain AtherosclerosisDeep vein thrombosisOsteomyelitisArthritisNerve damageVaricose veins
50 Less common causesBenign tumors or cysts of the femur or tibia (osteoid osteoma)Legg-Calve-Perthes disease - poor blood flow to the hip that may stop or slow the normal growth of the legMalignant bone tumors (Osteosarcoma, Ewing sarcoma)Sciatic nerve pain (radiating pain down the leg) caused by a slipped disk in the back.Slipped capital femoral epiphysis - usually seen in boys and overweight children between 11 and 15 years old
51 Differential diagnosis Arteriogram to check blood flowBlood tests for specific diseasesBone biopsy if tumor is seen on MRI which may be malignantBone scanDuplex Doppler/ultrasound exam to look for a blood clotMRI if a malignant tumor is suspectedX-ray of your back or legs
53 Symptoms of nerve-root pressure LEG PAİN: If pain extends below the knee, it is more likely to be due to pressure on a nerve than to a muscle problem. The pain starts in the buttock and travels down the back of the leg as far as the ankle or foot. The pain usually affects only one leg.
54 Symptoms of nerve-root pressure Pain can be made worse by activities that cause you to forcefully contract the core muscles of your trunk, such as a cough, sneeze, or a difficult bowel movement, or if you hold your breath during an activity (Valsalva maneuver)Nerve-related problems, such as tingling, numbness, or weakness in one leg or in the foot, lower leg, or both legs
57 Most disc herniations occur at L4-L5 ve L5-S1 At least 30% of the healthy symptomless population have clinically significant disc protrusions.
58 Acute LBP: Red Flags for Emergent Surgical Consultation Cauda equina syndromeBilateral sciatica, saddle anesthesia, bowel/bladder incontinenceAbdominal aortic aneurysmPain pattern is variableBruits+/- pulsatile abdominal massSignificant neurologic deficitIf they can’t walk, they can’t be sent home
59 Other symptoms or conditions that may occur with low back pain and require additional evaluation and treatmentDepressionDrug or alcohol abuse. Use of intravenous illegal drugs is especially riskyUse of steroids over a long period of time.Unexplained weight lossFeverA history of cancerBladder or bowel problemsAn illness or condition that affects the immune system, such as diabetes, chemotherapy for cancer treatment, HIV (AIDS), or an organ transplant.
66 Treatment ApproachesAdequate treatment must address all the factors involved in producing pain.Adequate treatment starts with a good evaluation.A good evaluation must include an examination of muscle function.
72 Why Not Get an Operation for a Herniated Disk? Spontaneous recovery is the rule: 90% resolve over 6 weeksLong-term outcome of pain relief no different with or without surgery
73 How Can You Stay Pain-free ? Have good genes – studies of identical twins show a reasonably strong genetic component to disabling low back pain.Avoid sudden unintended movements. This is the presumed cause of most cases of somatic dysfunction.Maintain good posture. A spine that is too flat or too curved increases stress on all the joints and the discs.Exercise regularly and moderately.Have regular check-ups by your physician, to find and fix somatic dysfunctions before they cause bigger problems.
74 Nerve root compression can be caused by: A herniated diskOsteoarthritisSpondylolysisSpondylolisthesisSpinal stenosisFractures of the vertebraeSpinal deformities scoliosis or kyphosis