Transcript Neck and Back Pain - Family Practice Residency Program

Neck and Back Pain
By Kubra Al Sayed
&
Enas Al Ekri
Monday, April 4, 2005
Back Pain
• Differential Diagnosis
_Musculoligamentous strain
_Sciatica
_Spinal stenosis
_spondylolisthesis
_vertebral compression fracture
_Neoplasms
_Infections
_ankylosing spondylitis
_Psychogenic disease
_cauda equina syndrome
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Spinal Stenosis
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Predominant in elderly
Narrowing of lumbar spinal canal
Pain worsened by standing,walking
Relieved by rest,sitting and lying
down
• Numbness or weakness in
legs(psudoclaudication)
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Neoplasms
• Most common is metastatic Ca
• Waist –level or midback pain not relieved
by lying down
• Increasing in severity & aggravated by
activity
• Past hx of Ca :
breast,lung,prostate,GIT,GUT
• Myeloma is the commonest primary
tumor
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Infections
• Vertebral osteomyelitis
• Secondary to spinal procedures
:LP,disk surgery
• Tenderness to percussion of
affected vertebrae
• Fever absent in up to half of pts.
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Ankylosing Spondylitis
• Seronegative spondyloarthropathy
• Morning spinal stiffness
• Symptomatic improvement with
exercise
• HLA-B27 positive (immune disease)
• Films of sacroiliac joint may show
narrowing of the joint space and
active sclerosis (sacroiliitis)
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Psychogenic Disease
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Depression
Somatization
Malingering
Normal Physical Examination
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Cauda Equina Syndrome
• Injury by any process that
compromises the spinal canal
below the L-1 level.
• Massive midline disk herniation is
the most common cause.
• In 90% urinary retention.
• Saddle anesthesia: reduction in
sensation over the buttocks, upper
posterior thighs and perineum.
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Workup
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History
Physical Examination
Neurologic Examination
Radioimmaging
Management
Back exercises
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History
• Pain characteristics: quality,
location, onset, radiation.
• Fever, Neurological deficits: Bladder
dysfunction, saddle anesthesia.
• Hx of recent injury.
• Prior hx of cancer.
• Hx of recent lumbar puncture.
• Hx of prolonged use of
corticosteriod.
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• Aggravating and relieving factors.
• Impact of back pain on daily
activities.
• Emotional and social stressors.
• Check for depression.
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Physical Examination
• Examine the back with patient
standing and back uncovered.
• Inspect for asymmetry, muscle
bulk, posture, spinal curvature.
• Assess flexibility.
• Palpate for focal tenderness,
masses.
• SLR Test.
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Neurologic Examination
• Test for S1 root function (L5-S1
disk): Plantar flexion against
resistance, ankle deep tendon
reflexes and lateral foot sensation.
• Test for L5 root function (L4-L5
disk): dorsiflexion of the ankle and
big toe against resistance and
sensation on the anterior, medial
dorsal foot.
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Radioimmaging
• Lumbo-sacral spine films.
• CT
• MRI
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L-S Spine Films
• Neither cost-effective nor useful in
decision making
• When suspected :
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Malignancy
compression fracture
ankylosing spondylitis
chronic osteomyelitis
major trauma
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Management
• Bed rest xxx continuing activity
• Local application of heat or warm
compresses
• NSAIDs
• Physiotherapy
• Pt. Education
• Back care & hyeigiene
• Refer
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Evaluation of neck
pain
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Pathophysiology and Clinical
Presentation
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Neck strain
Degenerative disease
Inflammatory disease
Malignancy
Referred pain
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Neck Strain
• Most common form of neck pain
• Caused by paraspinal muscle spasm
• Self limited if aggravating activities is
avoided
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Severe neck strain
• Seen in cervical hyperextension
(whiplash) injury
• Results in
musculoligamentous strain
muscle fibers tear
• Symptoms become most severe the
day after the acute event
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Cont…
• Neurologic deficits rare (unless #
of spine is present)
• Refractory pain > 6months
represent zygapophyseal joint
injury
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Degenerative disease
• Recurring neck stiffness
• Mild aching discomfort
• Progressive limitation of neck
motion
• Lateral rotation & lateral flexion
are restricted
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Cont…
• Usually localized to lower cervical
levels
• Narrowing of neural foramina
causes root impingement & pain
• Radiating pain of affected root,
paresthesia, numbness & weakness
may be associated
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Cont…
C-5 root compression:
• Involves anterosuperior shoulder &
anterolateral aspect of upper arm
& forearm
• Decreased biceps jerk & weakness
of elbow flexion found in
examination
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Cont…
C-6 root compression:
Affects the dorsoradial aspect of
forearm & thumb
C-7 root compression
Alters sensation in the middle of
hand
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Inflammatory disease
(Rheumatoid)
• Pain worsening in the morning
• Symmetric polyarthropathy &
subluxation at C1-2 are
charactiristic
• In spondyloarthropaties , neck pain
occurs as diffuse back & sacroiliac
discomfort
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Cont…
• In polymyalgia rheumatica neck
pain accompanies aching
discomfort & stiffness of shoulder
& hip girdle
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Malignancy
• Metastasis to spinal cord or
vertebral bodies may produce pain
that is worse at night or while
bending down
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Referred pain
• Coronary ischemia, pain worsen by
physical activity
• Concurrent arm pain, simulate
cervical radiculopathy
• Esophageal disease, referred pain
to neck
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Differential Diagnosis
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Lymphadenopathy
Thyroditis
Angina pectoris
Meningitis
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Work up
History:
Precipitating events
Aggravating & alleviating factors
Area of maximal tenderness
Radiation
Numbness or weakness in the
extremities
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Cont…
Coarse of the disease
Past history of similar problem
Previous medication
Symptoms of coronary artery
disease or meningeal irritation
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Examination
Visualization of neck, thorax, &
upper extremities
Assessment of neck motion (
flexion, extension, left & right
lateral flexion & left & right
rotation)
Palpation of the neck ( point of
local tenderness)
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Cont…
Examination of upper extremities
(tendon reflexes, strength,
sensation, range of motion, &
pulses)
Meningeal signs (patient with fever
& neck pain)
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Laboratory studies
• Traumatic neck strain: cervical spine
films (rule out structural damage)
• Clinical evidence of root compression:
MRI is indicated; CT with myelography
if MRI not available
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Cont..
• Degenerative disease & ankylosing
spondylitis: neck plain film
• Tumors: bone scan or CT if bony
involvement; MRI if marrow or
cord compression of concern
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Symptomatic management
• Strain:
Heat, ice & gentle massage
Muscle relaxants: useful in shortterm basis
NSAIDS:( e.g., aspirin, ibuprofen)
with small nighttime dose of
diazepam(5mg)
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Cont…
Strengthening & range of motion
exercise
Soft cervical collar to rest sore neck
muscle, avoid prolonged use (disuse
atrophy)
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Cont…
• Degenerative disease:
NSAIDS( ibuprofen or naproxen)
Cervical collar (minimize
compression)
Home cervical traction( severe,
chronic, or recurrent neck
pain)applied 20-30 min 2-4
times/day
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Cont…
Surgical management in refractory
disease, when neurologic
compromise is present
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Indication for referral and
admission
• Meningeal signs
• Chronic pain unresponsive to
conservative measures
• Significant weakness of upper
extremity
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Cont…
• Signs of cord injury
hyperreflexia
incontinence
retention
bilateral neurologic deficits
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Thank You
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