Another case of low back pain
This presentation is the property of its rightful owner.
Sponsored Links
1 / 38

Another Case of Low Back Pain PowerPoint PPT Presentation


  • 196 Views
  • Uploaded on
  • Presentation posted in: General

Another Case of Low Back Pain . Kristin Etzkorn, DO Georgia Regents University Augusta, GA. CC: Low back pain . HPI: 55 y/o white female Low back and cervical pain and stiffness Improved with activity and heat Morning pain lasting 2-3 hours

Download Presentation

Another Case of Low Back Pain

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Another case of low back pain

Another Case of Low Back Pain

Kristin Etzkorn, DO

Georgia Regents University

Augusta, GA


Cc low back pain

CC: Low back pain

  • HPI: 55 y/o white female

    • Low back and cervical pain and stiffness

      • Improved with activity and heat

      • Morning pain lasting 2-3 hours

      • Moderate relief w Percocet, Aleve, Nabumetone

    • Knee pain bilaterally presented first

      • X-ray consistent with OA

    • Seen by neurosurgery with CT, MRI and myelogram which showed stenosis of the cervical spine and a “bamboo spine”


Review of systems

Review of Systems

  • 20 lb. unintentional weight loss x 1 year,

    + fatigue, decreased appetite

  • No changes vision, no history uveitis

  • Dyspnea on exertion

  • No chest pain, edema

  • Color changes noted on hands and ears

  • Bruising tendency

  • Joint pain, no swelling

  • No changes in urination

  • Anxiety, depression


History

History

  • PMH:

    • Hemochromatosis- diagnosed by blood work, not phlebotomized

    • HTN

    • Emphysema

    • Sensory neuropathy

  • FH:

    • Mother: same arthritis and involvement of her joints, RA, possible AS, bone cancer, emphysema

    • Father: psoriasis, HTN, esophageal cancer

  • PSH: Appendectomy

  • Social: +tobacco abuse

  • Meds:

    • Naproxen 220mg

    • Caltrate 600 mg w/ D

    • Clonazepam 0.5mg

    • Melatonin

    • Neurontin 100mg

    • Percocet 5/325

    • Albuterol INH

    • HCTZ/Lisinopril 12.5/20mg

    • Nabumetone 750 mg


Physical exam

Physical Exam

  • 96.7 121/68 93 20 BMI 22

  • Thin, AAOx3, NAD

  • PERRLA, EOMI, normal conjunctiva

  • OP clear

  • Supple, NT

  • CTAB, respirations non-labored

  • RRR, no m/r


Physical exam1

Physical Exam

  • MSK:

    • Limited abduction of the right shoulder

    • Crepitus of the knees bilaterally, pain with full extension

    • Full ROM of all other joints, no swelling or deformity

    • C-spine- natural position slightly flexed, cannot extend beyond neutral,

    • L-spine- cannot extend beyond neutral

    • Schober- 1 cm increase on forward flexion opposed to neutral back

    • Levoscoliosis


Laboratory results

Laboratory Results

13.2

140

105

23

  • Calcium: 9.5

  • TP: 6.9

  • Albumin: 4.1

  • AST: 24

  • ALT: 12

  • Alk ф: 79

  • T. bili: 0.4

  • ESR: 13

  • Ferritin: 50

    (normal 11-307)

  • Transferrin: 220

    (normal 200-360)

121

244

5.9

4.5

0.48

32

38.7


X rays c spine

X-rays: C-spine


X ray c spine

X-ray: C-spine


X ray c spine1

X-ray: C-spine


X ray pelvis

X-ray: Pelvis


X ray pelvis1

X-ray: Pelvis


X ray l spine

X-ray: L-spine


X ray l spine flexion extension

X-ray: L-spine, flexion/extension


X ray l spine1

X-ray: L-spine


What would you do next

What would you do next ?

  • HLA-B27

  • Quantiferon gold and Hepatitis profile

  • Intact PTH

  • TSH

  • IGF-1

  • Ceruloplasmin

  • SPEP/UPEP


Physical exam2

Physical Exam


Workup

Workup

  • Urine screen for organic acids

    • Significantly elevated excretion of homogentisic acid

    • 2563 mmol/mol cr, reference value <11


X ray l spine2

X-ray: L-spine


Name this gentleman

Name This Gentleman


Alkaptonuria

Alkaptonuria

  • 1902- Sir Archibald Garrod

  • Rare inborn error of metabolism, autosomal recessive inheritance

    • Annually 1 case per 250,000 to 1 million live births


Another case of low back pain

Ranganath, LR, et al. J Clin Pathol 2013; 66: 367-373


Alkaptonuria1

Alkaptonuria

  • Large quantities of HGA excreted daily in urine

    • 5-8 gm/dy

  • Specimen dark iron oxide-like

    discoloration when exposed to

    sunlight or alkalized

Baeva et al. RadioGraphics 2011; 31:1163-1167


Ochronosis

Ochronosis

  • Accumulation in tissues of homogentisic acid (HGA) and its metabolites

  • Deposits in connective tissues and binds irreversibly to them and stimulates degeneration

    • High affinity for fibrillary collagens

  • Blue-black discoloration of connective tissues including sclera, cornea, auricular cartilage, heart valves, articular cartilage, tendons, ligaments

  • Pigmentation due to oxidation and polymerization of HGA


Ochronosis presentation

Ochronosis: Presentation

  • Dark pigmentation pinna, sclera, nasal ala

  • Darkening urine with exposure to air

  • Low back pain, stiffness, height loss

  • Hip and knee pain

  • Cardiac valve calcification and stenosis,

    coronary artery calcification

  • Renal and prostatic stones

Ryan, A. et al. NEJM 2012; 367:e26


Ochronotic arthropathy

Ochronotic arthropathy

  • Manifestation of long-standing alkaptonuria

  • Accumulation of pigment deposition in the joints of the axial and peripheral skeleton

  • Symptoms manifest in 3rd-4th decade

  • Most common presentation is low back pain

    • Long-standing pain and limited ROM in the spine and large joints

    • Severe degenerative arthritis and spondylosis

  • More rapid progression in men than women


Ochronosis pathology

Ochronosis: Pathology

  • H&E stain- extensive degenerative changes and brown pigmented deposits

  • Mechanism not fully understood of HGA accumulation leading to ochronosis and arthropathy

Baeva et al. RadioGraphics 2011; 31:1163-1167


Ochronosis diagnosis

Ochronosis: Diagnosis

  • Imaging with characteristic findings

  • Measure excretion homogentisic acid in urine

  • Characteristic findings on physical exam


Ochronosis imaging of the spine

Ochronosis: Imaging of the Spine

  • Lumbar spine affected initially

  • Widespread calcification of intervertebral disks

  • Narrowing intervertebral spaces

  • Osteopenia

  • Vacuum disk phenomenon

Baeva et al. RadioGraphics 2011; 31:1163-1167


Ochronosis imaging of the spine1

Ochronosis: Imaging of the Spine

  • Long standing disease:

    • Obliteration intervertebral spaces

    • Marginal intervertebral osteophytes

Baeva et al. RadioGraphics 2011; 31:1163-1167


Ochronosis imaging of the peripheral joints

Ochronosis: Imaging of the Peripheral Joints

  • Knee most commonly involved

    • Joint involvement more pronounced lateral compartment

  • Typically lack prominent osteophyte formation

  • Often see intra-articular osteochondral fragments in knees, hip, shoulder

  • Degenerative changes of the SI joints and pubic symphysis

Baeva et al. RadioGraphics 2011; 31:1163-1167


Differential diagnosis

Differential Diagnosis

  • Ankylosing spondylitis

    • Loss of lordosis, disk calcification, end-plate changes

    • Lack of erosions

  • OA

    • Unexpectedly advanced changes for the patient’s age

    • Less predominance of osteophyte formation than of joint space loss

    • Prominence of intra-articular osteochondral fragments

  • Disk calcification- most characteristic finding of ochronosis

    • Also seen in: Degenerative changes, trauma, CPPD, AS, hemochromatosis, hyperparathyroidism, acromegaly, amyloidosis


Ochronosis treatment

Ochronosis: Treatment

  • No medical treatment to prevent or slow progression

  • Education, PT

  • Analgesics

  • Dietary restriction

  • Antioxidants: Vitamin C , n-acetyl cysteine

  • Nitisinone

  • Joint replacement


Ochronosis treatment1

Ochronosis: Treatment

  • Dietary Restriction

    • Restrict tyrosine and phenylalanine

    • Significant reduction in HGA levels achieved in <12 y/o

    • Not demonstrated in older patients

    • Difficult to maintain


Ochronosis treatment2

Ochronosis: Treatment

  • Antioxidants

    • Vitamin C

      • Prevent oxidation HGA to benzoquinones that form deposits in cartilage and bone

      • Prevent rather than treat

      • Efficient if supplemented to infants before the onset ochronosis

      • Dose 1gram/day recommended for older children and adults

    • n-acetyl cysteine

      • In vitro shown to reduce HGA polymerization and accumulation

      • Combination with vitamin C may be effective in preventing or delaying ochronotic arthropathy

Ranganath, LR, et al. J Clin Pathol 2013; 66: 367-373


Ochronosis treatment3

Ochronosis: Treatment

  • Nitisinone (Orfadinᴿ)

    • Inhibitor 4-hydroxyphenylp-yruvate oxidase

    • Drug approval in 2002 for hereditary tyrosinemia

Ranganath, LR, et al. J Clin Pathol 2013; 66: 367-373


Ochronosis treatment4

Ochronosis: Treatment

  • Nitisinone

    • 95% reduction in urinary and serum HGA

    • Long-term randomized trial in 40 patients completed in 2009

      • Primary outcome- total hip ROM

        • Treatment group with gain 2◦per year over the 3 years vs placebo group average decline of 0.37◦/year

        • Not statistically significant

      • Secondary outcome- Schobersmeasurement of spinal flexion, 6-minute walk times, timed get up and go

        • No significant differences between the 2 groups

      • No patients in treatment group progressed to aortic stenosis or sclerosis

      • Well tolerated

    • No evidence prevents or reverses ochronosis

    • Longer clinical trial indicated to demonstrate clinical efficacy


References

References

  • Baeva et al. RadioGraphics 2011; 31: 1163-1167

  • Capkin E., et al. Rheumatol Int 2007; 28: 61-64

  • Introne, et al. Mol Gen Metab 2011; 103(4): 307-314

  • Ranganath, LR, et al. J Clin Pathol 2013; 66: 367-373

  • Ryan, A., et al. NEJM 2012; 367: e26

  • Tinti, et al. J. Cell. Physiolo. 225:84-91, 2010

  • Zhao et al. Knee Surg Sports Traumatol Arthrosc 2009; 17: 778-781


  • Login