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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. Case of Back Pain.

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case of back pain
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
case of back pain2
Case of Back Pain
  • Sep 05Haematologists shoulder pains, lymphadenopathy and rash, fatigue, 7 kg weight loss in 6 months
  • l-node < 1cm ALP 210 Rheum referral
  • Subsequently admitted
  • Ex In pain restricted spine ? leg weakness and altered sensation feet
case of back pain3
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
case of back pain4
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
gb syndrome
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
gb syndrome6
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
back pain jaya ravindran rheumatologist
BACK PAIN

Jaya Ravindran

Rheumatologist

causes
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
red flags
Red flags
  • Age <20 or >50 with back pain for the 1st time
  • Thoracic pain >50 yrs
  • Pain following a violent injury/trauma
  • Unremitting, progressive pain
red flags10
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
red flags11
Red flags
  • Bilateral leg radiation, sensory/motor/sphincter symptoms
  • Pain predominantly at night
inflammatory flags
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
myotomes
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
myotomes14
Myotomes
  • L2 Hip flexion
  • L3 Knee extension (knee jerk)
  • L4 Knee extension, ankle dorsiflexion (knee jerk)
  • L5 toe dorsiflexion
  • S1 foot plantar flexion, eversion
examination
Examination
  • LOOK – deformity, muscle wasting, kyphosis, scoliosis
  • LOOK – normal cervical lordosis, thoracic kyphosis, lumbar lordosis
  • FEEL – spinal processes and sacroiliac joints
examination17
Examination
  • MOVE – Lumbar flexion
  • Schober’s 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
examination18
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
imaging
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
degenerative disease and sciatica
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
malignancy
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
infection
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.
infection26
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
infection27
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
infection28
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.
osteoporosis risks
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
osteoporosis40
Osteoporosis
  • Bisphosphonates
  • SERMs
  • Strontium
  • Teriparatide
  • Calcitonin
  • Lifestyle factors
  • Ca and Vit D
slide41
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
spinal stenosis
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
spinal stenosis43
Spinal stenosis
  • 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
        • May be normal
        • Normal sensation and power
        • Reflexes normal or slightly reduced
        • Normal foot pulses
spinal stenosis45
Spinal stenosis
  • Conservative – analgesics, NSAIDs, PT, epidural
  • Surgery – laminectomy (+arthrodesis)
cauda equina syndrome
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
pagets49
Pagets
  • Pain, deformity
  • Skull, long bone, vertebra, pelvis, near hip
  • Neurologic compromise
  • Planned surgery
  • ?ALP 2X ULN
  • Rare: high output failure
slide51
AS
  • NSAIDs
  • Sulphasalazine – peripheral joints
  • PT
  • Anti-TNF
the end
THE END

THANK-YOU

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