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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 l.jpg
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


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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


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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


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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


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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


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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


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BACK PAIN

Jaya Ravindran

Rheumatologist


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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


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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


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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


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Red flags

  • Bilateral leg radiation, sensory/motor/sphincter symptoms

  • Pain predominantly at night


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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


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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


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Myotomes

  • L2 Hip flexion

  • L3 Knee extension (knee jerk)

  • L4 Knee extension, ankle dorsiflexion (knee jerk)

  • L5 toe dorsiflexion

  • S1 foot plantar flexion, eversion


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DERMATOMES


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Examination

  • LOOK – deformity, muscle wasting, kyphosis, scoliosis

  • LOOK – normal cervical lordosis, thoracic kyphosis, lumbar lordosis

  • FEEL – spinal processes and sacroiliac joints


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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


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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


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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


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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



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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




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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.


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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


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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


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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.









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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





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Osteoporosis

  • Bisphosphonates

  • SERMs

  • Strontium

  • Teriparatide

  • Calcitonin

  • Lifestyle factors

  • Ca and Vit D


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  • 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


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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


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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



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    Spinal stenosis

    • Conservative – analgesics, NSAIDs, PT, epidural

    • Surgery – laminectomy (+arthrodesis)


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    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




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    Pagets

    • Pain, deformity

    • Skull, long bone, vertebra, pelvis, near hip

    • Neurologic compromise

    • Planned surgery

    • ?ALP 2X ULN

    • Rare: high output failure



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    AS

    • NSAIDs

    • Sulphasalazine – peripheral joints

    • PT

    • Anti-TNF





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    THE END

    THANK-YOU


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