1. Back pain Back pain is a common problem that affects most people at some point in their life. It usually feels like an ache, tension or stiffness in the back. The pain can be triggered by: bad posture while sitting or standing bending awkwardly lifting incorrectly

2. Back pain is not generally caused by a serious condition and, in most cases, it gets better within few days or weeks is most common in the lower back, although it can be felt anywhere along your spine, from your neck down to your hips It can usually be successfully treated by taking keeping mobile, painkillers, physioterapy

3. Back pain Dividing by its cause: nonspecific back pain back pain with radiculopathy or spinal stenosis (disk herniation, spondylartritis)radiculopathyspinal stenosis back pain associated with another specific cause (such as infection or cancer)cancer

4. Back pain Non specific pain indicates that the cause is not known precisely, but is believed to be due from the soft tissues such as muscles, fascia, and ligamentsmuscles fascialigaments

5. Back pain Other causes of back pain: Postural abnormalities (scoliosis, kyphosis) Congenital malformations (spondylolistesis) Trauma

6. Back pain The pain may radiate into the arms and hands as well as the legs or feetarms handslegsfeet may include symptoms other than pain tingling, weakness or numbness.

7. Back pain Back pain can be divided anatomically: neck pain, middle back pain, lower back pain neck painmiddle back painlower back pain By its duration: acute (up to 12 weeks), chronic (more than 12 weeks) and subacute (the second half of the acute period, 6 to12 weeks)

8. Spinal anatomy

10. Ligaments Spinal Anatomy

11. Spinal pathology

12. Disc Degeneration: chemical changes associated with aging causes discs to weaken, but without a herniation. Prolapse: the form or position of the disc changes with some slight impingement into the spinal canal. Also called a bulge or protrusion. Extrusion: the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc. Sequestration or Sequestered Disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP). The four stages to a herniated disc include:

14. Ligaments Facet joints

15. Osteophytes

17. Cervical osteophytes

18. Upper extremities dermatomes

21. Normally, the cervical spine has a slight anterior curvature (lordosis). The cervical spine is straightened, which may be due to paravertebral muscle spasm

22. Cervical myelopathy Spastic paraparesis Quadriparesis Difficulties with balance Spasticity – lower extremities Radicular symptoms – upper extremities Incontinence – uncommon, urinary frequency - common

24. Diagnostics Plane X-ray MRI CT

25. Fyziological diameters of spinal canal - L4 1. Interpedicular distance 20– 30 mm 2. výška pedikla 3–5 mm 3. výška facety 5–8 mm 4. AP sagital distance 15–25 mm 5. interfacetarna vzdialenosť 15–20 mm

26. Spinal canal stenosis Borderline anterio-posterior diameter for spinal canal Cervical – 11 mm Lumbar – 11-13 mm

27. Cervical myelopathy Cervical myelopathy refers to compression on the cervical spinal cord from either a disc herniation or cervical spinal stenosis.cervical spinal stenosis Generally, it is more common in the elderly population and is a slow process.

28. Cervical myelopathyk Symptoms include incoordination in the hands a heavy feeling in the legs or numbness and tingling in the legs It is generally a slowly progressive condition. It is usually not painful as compression of the spinal cord does not cause pain.

29. Cervical myelopathy

31. Lower extremities dermatomes

32. Lumbar nerve root compression

33. Lassegue root L5, S1 Opposite Lassegue root L4

34. Lassegue maneuver

35. Nerve root pain pattern Radiculopathy C6 Radiculopathy S1

36. Sign of toe

37. Thomayer

38. Location of Pain and Motor Deficits in Association with Nerve Root Involvement at Each Lumbar Disc Level Disc level Location of pain Motor deficit T12-L1 Pain in inguinal region and medial None thigh L1-2 Pain in anterior and medial aspect Slight weakness in quadriceps; of upper thigh slightly diminished suprapatellar reflex L2-3 Pain in anterolateral thigh Weakened quadriceps; diminished patellar or suprapatellar reflex L3-4 Pain in posterolateral thigh and Weakened quadriceps; anterior tibial area diminished patellar reflex L4-5 Pain in dorsum of foot Extensor weakness of big toe and foot L5-S1 Pain in lateral aspect of foot Diminished or absent Achilles reflex

39. Cauda equina syndrome L1-5 a S1-5. Areflexic and flaccid paraparesis Back pain that radiates down posterior aspect of both legs Sensory loss in distribution of involved roots (saddle distribution) Urinary and fecal incontinence (loss of bladder and bowel function)

40. Cauda equina syndrom

41. Fyziological diameters of spinal canal - L4 1. Interpedicular distance 20– 30 mm 2. výška pedikla 3–5 mm 3. výška facety 5–8 mm 4. AP sagital distance 15–25 mm 5. interfacetarna vzdialenosť 15–20 mm

42. Spinal canal stenosis Borderline anterio-posterior diameter for spinal canal Cervical – 11 mm Lumbar – 11-13 mm

43. Spinal canal

44. Lumbar stenosis medical condition in which the spinal canal narrows and compresses the spinal cord nerves at the level of the lumbar vertebra Leg pain (proximal to distal pain) Numbness Weakness exacerbated by standing or walking and relieved with lumbar flexion

45. Lumbar stenosis

46. Narrowing of the spinal canal or neural foramina that produces root compression Most common – L4-L5, L3-L4 Congenitally or degenerative disease Usually after 60 Single segment or multiple segments

49. Plain X-ray

50. L4/5 Spondylolisthesis

51. MRI

52. Prolapse of the disc - CT Diffuse prolapse of the disc and osteophyte Central prolapse of L4-L5 disc

53. Dif. dg. radiculopathy Vertebrate MTS Boreliosis Pelvic tumors (LS), lungs (Th, C) and others Intraspinal tumors Inflammatory diseases

54. Dif. dg. radiculopathy

55. Therapy – acute stage Rest Analgetics Non-steroid antiinflammatory drugs Myorelaxants Local anesthetics Epidural corticosteroides

56. Therapy - later Analgetics Non-steroid antiinflammatory drugs Myorelxants Local anesthetics Physiotherapy, exercising

57. Therapy Neuropathic pain – anticonvulsants (pregabalin) Surgery Cauda equina syndrome Pain Peripheral paresis

58. Therapy - surgery Cauda equina syndrome with urinary symptoms Marked muscular weakness pertaining to a nerve roots Progressive neurologic deficit Pain that exists more than 4 months