Low back pain Ys.pptx

Low back pain Ys.pptx

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  Presenter Yidersal S. (R3) Moderator Dr.Samson Y. (MD, neurologist ) Aug , 2021 Back pain
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  Outline • Case • Introduction •Epidemiology • Approach to back pain patient • Etiology • Management • Prognosis
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  Case • 35year oldfemale • Sustained falling down accident from 3m high ladder 2years back • Landed on her back and lost her consciousness for unknown period of time • Since time trauma she had difficulty of walking with limping of left leg • She has piercing type of pain over the lower back exacerbated during movement and decrease but not completely improved during rest which radiate to the posterior part of left leg • Other no history of bowel or bladder dysfunction • No history fever, weight loss
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  • No historyof headache, abnormal body mov’t • No history of previous back pain before trauma • she is a other of 4 and give birth all before accident • No history of abdominal pain, abdominal swelling or vaginal discharge • For the above compliant she took amitriptyline 25mg for 2yrs • Since 5 months back the pain become worse despite amitriptyline • No history of diabetes mellitus
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  Physical examination • GA=ASLin pain • v/s=BP 110/70 PR=84 RR =20 T=36.9 • MSK: – There is Gibbs deformity over the lumbar spine, no tenderness – Healed scar over left gluteal area • NS: – conscious and oriented – No cranial nerve palsy – power 5/5 on other extrimity – Normal tone – Reflex is ++ in ankle, knee and elbow bilaterally – Pain, touch, vibration sensation is intact – Coordination is ok – SLR is positive over the left leg – Crossed SLR is negative • What is the cause of her pain? • How do you manage her ?
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  Introduction • Why backpain is a concern in medical community ? – High cost – Most common cause of disability in individuals <45 years of age – Second most common reason for visiting a physician – More than four out of five people will experience significant back pain at some point in their lives • 84 % of adults have low back pain at some time in their lives • Most of them are self-limited
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  Anatomy of spine
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  Terminology • Spondylosis – Arthritisof the spine • Spondylolysis – A fracture in the pars interarticularis where the vertebral body and the posterior elements protecting the nerves are joined • Spondylolisthesis – The injured vertebra to shift or slip forward on the vertebra directly below it • Spinal stenosis: – Narrowing of the vertebral canal by bone or soft tissue elements. • Radiculopathy – Impairment of a nerve root, usually causing radiating pain, numbness, tingling, or muscle weakness .
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  Terminology -----
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  • Cauda equinasyndrome – Loss of bowel and bladder control – Numbness in the groin and saddle area of the perineum – Weakness of the lower extremities – Spine stenosis or a large herniated disc
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  Risk factors • Increasingage • Smoking • Muscle weakness in back and/or abdomen • Psychosocial factors • Occupational factors • Manual material handling, bending/twisting • Job dissatisfaction • Overweight • Repetitive lifting • Chronic Steroid use • Sedentary lifestyle • Female gender
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  Potential sources ofpain • Nerve roots • Intervertebral disc • Facet joint • Vertebral bodies • Ligaments or soft tissues
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  Approach to backpain patient History • Focus first on features of pain  Mode of onset  Character  Distribution  Associated motor and sensory symptoms  Bladder and bowel control  Exacerbating and remitting factors  History of predisposing factors (e.g., trauma, cancer, osteoporosis)
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  Type of pain •Back pain by duration – Acute LBP → < 6 weeks* – Sub acute LBP→ between 6 weeks and 12 weeks – Chronic LBP → > 12 weeks
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  Type of backpain • Local pain – injury to pain-sensitive structures that compress or irritate sensory nerve endings – The site of the pain is near the affected part of the back • Pain referred to the back – From abdominal or pelvic viscera – Unaffected by posture – The patient may occasionally complain of back pain only
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  Cont. • Pain ofspine origin – From upper lumbar spine tend to refer pain to the Lumbar Region, Groin, or Anterior Thighs – Pain from lower lumbar spine tend to refer to the buttocks, posterior thighs, or rarely the calves or feet • Sclerotomal pain VS. radiculopathy?
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  Sciatica • Pain radiatingdown posterior or lateral leg below the knee • The most common cause for sciatica is lumbar disk herniation • Symptoms that increase the specificity of sciatica – Pain that is worse in the leg than in the back – Typical dermatomal distribution of neurologic symptoms – Pain that is worse with the Valsalva maneuver
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  Cont. • Pain associatedwith muscle spasm Commonly associated with many spine disorders The spasms are accompanied by Abnormal posture Tense paraspinal muscles Dull or achy pain in the paraspinal region
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  “Red flags” inback pain • Age>55 • History of cancer • Unexplained weight loss • Failure to improve with conservative management after 4 weeks of treatment • Fever • Immunosuppression • Focal midline tenderness • Bacteremia • Indwelling catheter • Iv drug use • Bowel and bladder dysfunction
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  Physical examination • Thebasic physical examination should include the following components: – Inspection of back and posture – Range of motion – Palpation of the spine – Special tests – Neurologic assessment – Abdominal and rectal examination – Evaluation for malignancy (breast, prostate, lymph node exam) when persistent pain or history strongly suggests systemic disease
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  • Limited forwardbending – Paraspinal muscle spasm • Lateral bending to the side opposite the injured spine produce pain • Limited hyperextension of the spine – Nerve root compression, facet joint pathology, or other bony spine disease is present
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  • Pain fromhip disease may mimic the pain of lumbar spine disease • Hip pain can be reproduced – By internal and external rotation at the hip with the knee and hip in flexion (Patrick's Sign) – By tapping the heel with the examiner's palm while the leg is extended (Heel Percussion Sign)
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  Maneuver…. • Straight Leg–raisingManeuver  Passive dorsiflexion of the foot during the maneuver adds to the stretch • The crossed SLR sign is less sensitive but more specific for disk herniation than the SLR sign
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  • The ReverseSLR Sign – Stretches the L2-L4 nerve roots, lumbosacral plexus, and femoral nerve • Naffziger’s test – Pressure on jugular vein on patient lying on back for 10 second – Back pain reproduce in the case of herniated disc
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  • Kerning sign –Meningeal or spinal nerve root irritation • Hoover test – Real or malingering
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  Neurologic examination • Includes Focalweakness or muscle atrophy Focal reflex changes Diminished sensation in the legs, or Signs of spinal cord injury • Alert to the possibility of Breakaway Weakness, defined as fluctuating strength during muscle testing
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  • Breakaway weakness –may be due to pain or a combination of pain and underlying true weakness – Breakaway weakness without pain is almost always due to a lack of effort – Electromyography during ambiguous condition
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  Cervical radiculopathy
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  Non organic sign(Waddell's signs) • The most reproducible of these signs are – Superficial tenderness – Distracted straight leg raising (ie, discrepancy between seated and supine straight leg raising tests) – The observation of patient overreaction during the physical examination – Non dermatomal distribution of sensory loss, – Sudden giving way or jerky movements with motor examination – The presence of multiple Waddell's signs may suggest a behavioral component to a patient's pain
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  Laboratory and imaging •Laboratory studies are rarely needed for the initial evaluation of nonspecific back pain • CBC, ESR, urinalysis culture • No need to investigating, if no serious risk factor
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  Imaging
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  • No needof earlier use of imaging for low back – meta-analysis of six trials that compared immediate imaging with usual care for patients – Without signs or symptoms of infection or malignancy, found no significant differences in out come • Imaging scans often have abnormal findings in adults without low back pain – Disc herniation on MRI seen in 22 to 67% of asymptomatic adults and spinal stenosis in 21% of asymptomatic adults over age 60 – Radiologic facet joint osteoarthritis increased with age and there was no correlation with low back pain
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  Indication for imaging •Infection • Patients with cancer or at high risk of cancer • Neurologic complication • Radiculopathy with in need of intervention • Compression fracture • Patient with trauma
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  • Advanced imaging –MRI without contrast is initial test for most patients with low back pain who require advanced imaging – Which can demonstrate normal and pathologic discs, ligaments, nerve roots, epidural fat, as well as the shape and size of the spinal canal – MRI is more sensitive and specific than plain radiographs for the detection of spinal infection and malignancy – MRI enhancement with gadolinium allows the distinction of scar from disc in patients with prior back surgery – In patients who require advanced imaging but cannot have an MRI, we generally proceed with CT
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  Schmorl's nodes
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  Etiology • 85% ofpatients have nonspecific low back pain • Etiology of back pain can be categorized as – Mechanical vs. non mechanical – Back pain with led pain – Back pain with out leg pain – Back pain from visceral causes – Leg pain with out back pain
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  Etiology
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  Etiology • Causes oflower back pain without leg pain include: – Ligamentous strain – Muscle strain – Facet pain – Bony destruction – Inflammation
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  • Causes oflower back with lower limb pain – Radiculopathy – Plexopathy – Spinal stenosis • causes of leg pain without low back pain – Sciatic neuropathy – Femoral neuropathy – Peroneal neuropathy – Meralgia paresthetica – Peripheral polyneuropathies
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  • Back painfrom visceral – Pancreatitis – Nephrolithiasis – Pyelonephritis – Abdominal aortic aneurysm – Herpes zoster
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  Sprains and Strains •Minor, self-limited injuries • Lifting a heavy object, a fall, or a sudden deceleration • Pain is usually confined to the lower back • No radiation to the buttocks or legs • Assume unusual postures
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  Traumatic vertebral fractures •Results from injuries producing anterior wedging or compression • Fracture-dislocation or "burst" fracture involving the vertebral body and posterior elements • A pars interarticularis fracture of the L5 vertebra is common in case of falls from a height • Sudden deceleration in an automobile accident • Direct injury • Neurologic impairment is common, and early surgical treatment is indicated
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  • Metastatic cancer –The bone is one of the most common sites of metastasis – A history of cancer – Metastatic disease from breast, prostate, lung, thyroid, and kidney cancers account for 80 percent of skeletal metastases – ~ 60 % of patients with multiple myeloma have skeletal lytic lesions present at diagnosis – In patients with a history of cancer, sudden, severe pain raises concern for pathologic fracture – Patients may also have neurologic symptoms from either spinal cord compression or spinal instability
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  • Spinal epiduralabscess – Spinal epidural abscess is a rare but serious cause of back pain – Initial symptoms are often nonspecific – Over time, localized back pain may be followed by radicular pain and, left untreated, neurologic deficits – Risk factors include recent spinal injection or epidural catheter placement, injection drug use, contagious infections – Immunocompromised patients may also be at higher risk – Urgent antibiotic treatment and surgical therapy for those with neurologic symptoms is required for patients with spinal epidural abscess
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  • Vertebral osteomyelitis –Increases with age – Men >women – Post procedural from hematogenous spread of bacteremia – Immunocompromised state and injection drug use – Acute osteomyelitis typically presents with gradual onset of symptoms over several days – Present with back pain but may not have fevers or other systemic symptoms – Prompt antibiotic treatment improves outcomes
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  • Vertebral compressionfracture – 4 % of low back pain – From no symptom to acute localize back pain – There may be no history of preceding trauma – Advanced age, chronic glucocorticoid use and previous osteoporotic fracture – 3 to 4 % of patients with compression fracture will have a symptomatic disc herniation or spinal stenosis
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  • Radiculopathy – Resultsfrom degenerative changes in the vertebrae, disc protrusion, and other causes – Presentations vary according the level of nerve root or roots involved – >90 % is L5 and S1 radiculopathies – Patients present with pain, sensory loss, weakness, and/or reflex changes consistent with the nerve root involved – Many patients with symptoms of acute lumbosacral radiculopathy improve gradually with supportive care – Sciatica – SLR positive
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  • Spinal stenosis –Lumbar spinal stenosis is most often multifactorial – Spondylosis , spondylolistheses, Space-occupying lesions, traumatic and postoperative fibrosis – Neurogenic claudication – Back pain, sensory loss and weakness in the legs – Rare patients develop a cauda equina syndrome – Patients often have symptoms only when active – A trial of conservative, nonsurgical treatment is the initial therapy for most patients
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  • Ankylosing spondylitis –Few (0.5%-1%). – men under the age of 40 year – back pain with inflammatory etiology (morning stiffness, improvement with exercise, pain at night) – Extra skeletal disease manifestations (eg, uveitis) • Osteoarthritis – Facet joint or hip joint – Commonly presents in patients over the age of 40 – Pain is typically exacerbated by activity and relieved by rest – Osteoarthritis can lead to spinal stenosis
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  • Psychological distress –Who seek financial compensation (malingerers) – Substance abuse – Many patients with CLBP have a history of psychiatric illness – Childhood trauma (physical or sexual abuse) that antedates the onset of back pain
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  Management • Depends on –Symptom duration – Potential cause – Presence or absence of radicular symptoms – Corresponding anatomical or radiographic abnormalities
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  Acute back pain •Self limited • Pharmacologic – Acetaminophen – NSAIDs – SMRs • Non pharmacologic – Heat wrap: improved pain and function – Massage: improved pain and function – Acupuncture: improved pain – Spinal manipulation: improved function Grade 2C recommendation
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  Chronic back pain •Psychological evaluation and behaviorally based treatment paradigms are frequently helpful • Multidisciplinary approach – Neurology, anesthesiology, physical therapy, psychiatry, psychology, and primary care physicians • Goals of therapy – Improve pain – Getting a good night’s sleep – returning to work
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  • Pharmacologic – NSAIDs:improved pain – Opioids: improved pain and function – Tramadol: improved pain and function – Buprenorphine (patch or sublingual): improved pain – Duloxetine: improved pain and function
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  • Non pharmacologic –Exercise: improved pain and function – Motor control exercise: improved pain and function – Mindfulness-based stress reduction: improved pain and function – Yoga: improved pain and function – Progressive relaxation: improved pain and function
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  Surgical management • Indicatedfor – Neurologic deficits – Cauda equina syndrome or conus medullaris syndrome – No response with conservative management
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  Reference
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  Thank you