Transcript differential diagnosis and treatment of low back

DIFFERENTIAL DIAGNOSIS AND
TREATMENT OF LOW BACK AND
LOWER EXTREMITY PAIN
Prof. Dr. Ece Aydoğ
PMR
Learning objectives
• 1. be able to differentiate mechanical and non-
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mechanical pain
2. be able to enumerate the risk factors for low back
pain
3. be able to define spondylosis, spondylolysis,
spondylolisthesis and spondylitis
4. be able to describe clinical presentation and
treatment for acute muscular strain, lumbar
discopathy, spinal stenosis and spondylolisthesis
and spondylolysis.
5. be able to enumerate non-mechanic causes of low
back pain and describe differential diagnosis.
Learning objectives
• 6. be able to enumerate the red flags of serious low
back pain
• 7. be able to enumerate the reasons which cause
pain in the lower extremity and make the differential
diagnosis.
• 8. be able to enumerate situations that require
emergency surgery for lumbar back pain and
surgical indications in lumbar discopathy.
• 9. be able to enumerate diagnostic methods,
treatment approaches, pharmacological and non
pharmacological methods for low back pain.
Who gets back pain ?
• Almost Everybody
– Estimates run as high
as 80% of the
population.
– Only 1-2 % need
surgery.
– 5-10 % develop
chronic pain.
– 75 % of patients have
relapses.
– Peak occurrence is
between age 30 and
45.
The spine has two basic jobs:
1) to protect the spinal cord
2) to allow us to move
Back pain usually involves some
loss of ability to move easily.
SPİNAL SEGMENT
Every level of the spine is
composed of a disc in the front
and paired facet joints in the
back. The disc acts as a shock
absorber in between the
vertebrae, whereas the paired
facet joints restrain motion.
They allow the spine to bend
forwards (flexion) and
backwards (extension) but do
not allow for a lot of rotation.
Classifications
• Transient—duration is hours to days, only brought
to medical attention when episodic
• Acute—duration is days to weeks; most recover
spontaneously
• Persistent—lasts more than 3-6 months; does not
improve with time; no psychological co-morbidities
(often associated with spondylotic disease)
• Chronic—lasts more than 6 months; worsens with
time, associated with major psychological comorbidities
• 90% of low back pain is “mechanical”
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Injury to muscles, ligaments, bones, disks
Spontaneous resolution is the rule
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Nonmechanical causes uncommon but don’t
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miss them!
Spondyloarthropathy
Spinal infection
Osteoporosis
Cancer
Referred visceral pain
Risk Factors
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Age
Sendentary lifestyle
Pregnancy
Obesity
Smoking
Injury
Preexisting back injury due
to:
– Lifting a heavy object
– Improper lifting
– Sudden movement,
bending, or twisting
– Prolonged sitting or
standing
– Bad posture
– Vibration from vehicles
or heavy equipment
• Prior back surgery
• Other factors which
may negatively
influence back pain
include:
– Psychological factors,
such as low job
satisfaction
– Fatigue or sleep deficit
– Drug or alcohol abuse
– Stress
Congenital bone conditions
Congenital causes (existing from birth) of low back pain include
scoliosis and spina bifida
Scoliosis is a sideways (lateral) curvature of the spine that can
be caused when one lower extremity is shorter than the other
(functional scoliosis) or because of an abnormal design of the
spine (structural scoliosis)
Children who are significantly affected by structural scoliosis
may require treatment with bracing and/or surgery to the spine
Adults infrequently are treated surgically but often benefit by
support bracing
Classification of Scoliosis
• Congenital
– Failure of formation
– Failure of segmentation
– Mixed
• Neuromuscular
- Myopathic
- Arthrogryhosis
- Muscular dystrophy
-Neuropathic
– Upper motor neuron
– Lower motor neuron
– Dysautonomia (Riley-Day
syndrome)
• İdiopathic
– Infantil (0-3 years)
– Juvenil (3-10 years)
– Adolescent (10y + years)
• Others
– Neurofibromatosis
– Mesenchymal (Ehler Danlos s,
Marfan’s s)
– Traumatic
– Tumors
– Osteochondrodystrophies
Spina bifida and scoliosis
Common Sources of LBP
Somatic dysfunction
Muscle in “spasm”
Nerve root
In somatic dysfunction, some muscles become overactive (“spasm”)
and other muscles become inactive.
There are many more
joints in the back than
discs.
There are many more
muscles than joints.
The most common cause
of low back pain is when
one or more muscles
“forget” to relax. We call
this a somatic
dysfunction.
Common Sources of LBP
Any dysfunction
involving the
thoracic or lumbar
spine, the sacroiliac
joint or the hip can
create low back
pain.
Common Sources of LBP
Long dorsal si ligament
piriformis
sacrospinous ligament
sciatic nerve
sacrotuberous ligament
Role of the sacroiliac joint
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The sacroiliac joint
requires muscle activity
to keep it stable.
If muscles can’t work
correctly, perhaps
because of a somatic
dysfunction, the joint
becomes unstable and
painful.
The most common causes of low back pain;
• Injury or overuse of
muscles, ligaments,
facet joints, and the
sacroiliac joints.
Lumbar Strain
• stretching injury to the ligaments, tendons, and/or muscles of
the low back
• microscopic tears of varying degrees in these tissues
• one of the most common causes of low back pain
• occur because of overuse, improper use, or trauma
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• "acute" if it has been present for days to weeks
• "chronic" lasts longer than three months
Symptoms
• Pain, mostly in the back and buttocks
• Muscle spasms, cramping, and stiffness
• It is aggravated by weight-bearing or specific movements and
is relieved by rest
• The most severe pain usually lasts 48 to 72 hours and may be
followed by days or weeks of less severe pain
• The back is easily reinjured during this time
Spondylosis
Disc Herniations
Spondylolysis
• Spondylolysis (spondylo = spine; lysis=dissolved)
refers to the defect (black arrows) present when the
pars interarticularis is fractured. This results is the
lamina and inferior facet joints being disconnected
from the vertebral body.
Spondylolysis
• Spondylolysis isn't something that people are born
with, but develop in childhood /adolescence
• It is thought to be a stress fracture that doesn't heal
• It is seen most often in football linemen and in
gymnasts
Spondylolisthesis
• Spondylolisthesis (spondylo=spine;
listhesis=to slip) occurs in the presence of a
spondylolysis when the intervertebral disc
stretches and allows the vertebral body to
slide forward on the vertebra below. This
results in widening of the pars defect. This is
known as an isthmic spondylolisthesis.
Spondylolisthesis
• Displastic (congenital dysplasia between the L5-S1)
• Degenerative (elderly people)
• Traumatic (fracture in the posterior stractures except
isthmus)
• Patologic (metabolic bone disease, metastatic Ca..)
Spondylolisthesis
Spinal Stenosis
• Spinal stenosis is a medical condition in which the spinal canal
narrows and compresses the spinal cord and nerves
• This is usually due to the common occurrence of spinal
degeneration that occurs with aging
• It can also sometimes be caused by spinal disc herniation,
osteoporosis or a tumor
• In the cervical and lumbar region it can be a congenital
condition to varying degrees
Spinal Stenosis
• Spinal-nerve compression in these
conditions can lead to sciatica pain that
radiates down the lower extremities
• Spinal stenosis can cause lower-extremity
pains that worsen with walking and are
relieved by resting (mimicking poor
circulation) (Neurogenic claudication)
Acute Back Pain
in the Elderly
Multiple compression fractures
Compression fractures
• More common among postmenopausal women with
osteoporosis, or in men or women after long-term
corticosteroid use
• Often occurs with forward flexion during normal
activity or with trivial trauma
• Severe spinal pain
• Marked muscle spasm
• Some relief with recumbency
Less common spinal conditions that can
cause low back pain include
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Ankylosing spondylitis
Bacterial infection
Spinal tumors
Paget's disease
Scheuermann's disease
Spinal Infections
• Acute infection
• Bacterial
• Fungal
• Chronic infection
• Bacterial
• Fungal
• Tuberculosis
• Brucellosis
• Sites of spinal
infection
• Vertebral
osteomyelitis
• Disk space
infection
• Septic sacroiliitis
Spinal Infection
• Historical clues
• Fever, rigors
• Source of infection: IV
drug abuse, trauma,
surgery, dialysis, and
skin infection
• Physical exam clues
• Focal tenderness with
muscle spasm
• Often cannot bear weight
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Lab clues
• Mild anemia,
• Elevated ESR, and/or
CRP
Spondylodiscitis
Spinal Malignancy
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Pain worse at night
Often associated
local tenderness
WBC, ESR, protein
electrophoresis if
ESR elevated
• Multiple Myeloma
Other medical conditions that can cause pain
that may be similar to low back pain include:
• Pelvic inflammatory disease
• Aortic aneurysm
• Peptic ulcers
• Gallbladder disease
• Pancreatitis
• Urinary disorders such as kidney stones or urinary tract
infections.
• Prostate disease
What Are the Red Flags for Serious
Low Back Pain?
• Fever, weight loss
• Intractable pain—no improvement in 4 to 6 weeks
• Nocturnal pain or increasing pain severity
• Morning back stiffness with pain onset before age 40
• Neurologic deficits
Lower Extremity Pain
Causes
• MUSCLE CRAMP
1. Dehydration or low amounts of potassium, sodium,
calcium, or magnesium in the blood.
2. Medications
1. Diuretics,
2. Statins, which lower cholesterol and can cause
muscle injury
3. Muscle fatigue or strain from overuse, too much
exercise, or holding a muscle in the same position
for a long time
Lower extremity pain
• A torn or overstretched muscle (strain)
• Hairline crack in the bone (stress fracture)
• Inflamed tendon (tendinitis)
• Shin splints - pain in the front of your leg
related to overuse or repetitive pounding
Other common causes of leg pain
• Atherosclerosis
• Deep vein thrombosis
• Osteomyelitis
• Arthritis
• Nerve damage
• Varicose veins
Less common causes
• Benign tumors or cysts of the femur or tibia (osteoid
osteoma)
• Legg-Calve-Perthes disease - poor blood flow to the
hip that may stop or slow the normal growth of the
leg
• Malignant bone tumors (Osteosarcoma, Ewing
sarcoma)
• Sciatic nerve pain (radiating pain down the leg)
caused by a slipped disk in the back.
• Slipped capital femoral epiphysis - usually seen in
boys and overweight children between 11 and 15
years old
Differential diagnosis
• Arteriogram to check blood flow
• Blood tests for specific diseases
• Bone biopsy if tumor is seen on MRI which
may be malignant
• Bone scan
• Duplex Doppler/ultrasound exam to look for
a blood clot
• MRI if a malignant tumor is suspected
• X-ray of your back or legs
Sciatic nerve pain
Symptoms of nerve-root
pressure
•LEG PAİN: If pain extends below the
knee, it is more likely to be due to
pressure on a nerve than to a muscle
problem. The pain starts in the buttock
and travels down the back of the leg as
far as the ankle or foot. The pain usually
affects only one leg.
Symptoms of nerve-root
pressure
– Pain can be made worse by activities that cause you
to forcefully contract the core muscles of your trunk,
such as a cough, sneeze, or a difficult bowel
movement, or if you hold your breath during an
activity (Valsalva maneuver)
– Nerve-related problems, such as tingling, numbness,
or weakness in one leg or in the foot, lower leg, or
both legs
Lomber disc herniation
•Most disc herniations occur at
L4-L5 ve L5-S1
•At least 30% of the healthy
symptomless population have
clinically significant disc
protrusions.
Acute LBP: Red Flags for
Emergent Surgical Consultation
• Cauda equina syndrome
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Bilateral sciatica, saddle anesthesia,
bowel/bladder incontinence
• Abdominal aortic aneurysm
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Pain pattern is variable
Bruits
+/- pulsatile abdominal mass
• Significant neurologic deficit
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If they can’t walk, they can’t be sent home
Other symptoms or conditions that may occur
with low back pain and require additional
evaluation and treatment
• Depression
• Drug or alcohol abuse. Use of intravenous illegal
drugs is especially risky
• Use of steroids over a long period of time.
• Unexplained weight loss
• Fever
• A history of cancer
• Bladder or bowel problems
• An illness or condition that affects the immune
system, such as diabetes, chemotherapy for
cancer treatment, HIV (AIDS), or an organ
transplant.
Diagnosis
Treatment Approaches
•Adequate treatment must
address all the factors
involved in producing pain.
•Adequate treatment starts
with a good evaluation.
•A good evaluation must
include an examination of
muscle function.
Bel Egzersizleri
•
Bel Egzersizleri
Why Not Get an Operation for
a Herniated Disk?
• Spontaneous recovery is the rule: 90%
resolve over 6 weeks
• Long-term outcome of pain relief no
different with or without surgery
How Can You Stay Pain-free ?
Have good genes – studies of identical twins show a
reasonably strong genetic component to disabling low back
pain.
Avoid sudden unintended movements. This is the presumed
cause of most cases of somatic dysfunction.
Maintain good posture. A spine that is too flat or too curved
increases stress on all the joints and the discs.
Exercise regularly and moderately.
Have regular check-ups by your physician, to find and fix
somatic dysfunctions before they cause bigger problems.
• Nerve root compression
can be caused by:
– A herniated disk
– Osteoarthritis
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– Spondylolysis
– Spondylolisthesis
– Spinal stenosis
– Fractures of the vertebrae
– Spinal deformities scoliosis or
kyphosis