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Case of Back Pain 53 year old, right handed lady, hotelier 53 year old, right handed lady, hotelier 3 day history of severe lower back pain and weakness.

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Presentation on theme: "Case of Back Pain 53 year old, right handed lady, hotelier 53 year old, right handed lady, hotelier 3 day history of severe lower back pain and weakness."— Presentation transcript:

1 Case of Back Pain 53 year old, right handed lady, hotelier 53 year old, right handed lady, hotelier 3 day history of severe lower back pain and weakness in her legs 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 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 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 Sep 05Haematologists shoulder pains, lymphadenopathy and rash, fatigue, 7 kg weight loss in 6 months l-node < 1cm ALP 210 Rheum referral l-node < 1cm ALP 210 Rheum referral Subsequently admitted Subsequently admitted Ex In pain restricted spine ? leg weakness and altered sensation feet Ex In pain restricted spine ? leg weakness and altered sensation feet

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

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

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

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

7 BACK PAIN Jaya Ravindran Rheumatologist

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

9 Red flags – Age 50 with back pain for the 1 st 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) C5 Deltoid, biceps (biceps jerk) C6 Wrist extensors, biceps (biceps, brachioradialis jerk) C6 Wrist extensors, biceps (biceps, brachioradialis jerk) C7 Wrist flexors, finger extensors, triceps (triceps jerk) C7 Wrist flexors, finger extensors, triceps (triceps jerk) C8 Finger flexor, thumb extensors (triceps jerk) C8 Finger flexor, thumb extensors (triceps jerk) T1 finger abductors T1 finger abductors

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

15 DERMATOMESDERMATOMESDERMATOMESDERMATOMES

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

17 Examination MOVE – Lumbar flexion MOVE – Lumbar flexion Schober’s test – marks at “dimples of Venus” and 10 cm above. Measure at maximal flexion – usually 5 cm Schober’s test – marks at “dimples of Venus” and 10 cm above. Measure at maximal flexion – usually 5 cm MOVE – Lumbar lateral flexion MOVE – Lumbar lateral flexion MOVE – Cervical flexion/extension, lateral rotation and flexion, thoracic rotation 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 30-70 o – low lumbar (L5/S1) lesion or sciatic irritation Sciatic stretch (patient supine) - Straight leg raise and dorsiflexion of foot - pain in calf and posterior thigh between 30-70 o – 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 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 XR – tumour, fracture, infection, inflammation Bone scan – increased turnover eg infection, metastatic disease, fractures, Pagets Bone scan – increased turnover eg infection, metastatic disease, fractures, Pagets MRI – soft tissue, discs, facet joint, nerve roots, cord, inflammation MRI – soft tissue, discs, facet joint, nerve roots, cord, inflammation

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

21 Degenerative disease and sciatica

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

23 Malignancy

24 Malignancy

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

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

27 Infection Radiographic changes at 2 to 4 weeks Radiographic changes at 2 to 4 weeks bone scan can be positive as early as 2 days 75% specific. 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 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 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. 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 History of low trauma # - colles, NOF, vertebral, sacral or pelvic insufficiency Steroids Steroids Maternal history of NOF # Maternal history of NOF # Gonadal hormone deficiency Gonadal hormone deficiency Ca deficiency Ca deficiency Prolonged immobility Prolonged immobility Low BMI Low BMI Alcohol and smoking Alcohol and smoking

37 Causes of low bone density

38 Vertebral fractures

39 Osteoporosis

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

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

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

43 Spinal stenosis Symptoms 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 Examination –May be normal –Normal sensation and power –Reflexes normal or slightly reduced –Normal foot pulses

44 Spinal stenosis

45 Conservative – analgesics, NSAIDs, PT, epidural Conservative – analgesics, NSAIDs, PT, epidural Surgery – laminectomy (+arthrodesis) Surgery – laminectomy (+arthrodesis)

46 Cauda Equina Syndrome Back pain, lower limb weakness, saddle anaesthesia, sphincter disturbance, impotence Back pain, lower limb weakness, saddle anaesthesia, sphincter disturbance, impotence Causes – usually disc, rarely tumour, abscess, advanced AS 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 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 Urgent MRI and surgical decompression

47 Cauda Equina Syndrome

48 Pagets

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

50 AS

51 AS NSAIDs NSAIDs Sulphasalazine – peripheral joints Sulphasalazine – peripheral joints PT PT Anti-TNF Anti-TNF

52 AS

53 AS

54 AS

55 THE END THANK-YOU


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