Transcript differential diagnosis and treatment of low back and

LOW BACK PAİN AND HİP PAİN
Prof. Dr. Ece Aydoğ
PMR
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.
• 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.
Spina bifida and scoliosis
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
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one of the most common causes of low back pain
occur because of overuse, improper use, or trauma
"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.
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.
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• 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.
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• 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.
• No early warning, 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
• Ankylosing spondylitis
• Bacterial infection
• Spinal tumors
• Paget's disease
• Scheuermann's disease
Other medical conditions that can cause
pain that may be similar to low back pain
include:
• Pelvic inflammatory
disease
• Aortic aneurysm
• Pancreatitis
• Urinary disorders
(kidney stones or urinary
tract infections)
• Peptic ulcers
• Prostate disease
• Gallbladder 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
• Pressure on nerve roots in the
spinal canal. Nerve root
compression can be caused by:
– A herniated disk
– Osteoarthritis
– Spondylolysis
– Spondylolisthesis
– Spinal stenosis
– Fractures of the vertebrae
– Spinal deformities scoliosis
or kyphosis
Symptoms of nerve-root
pressure
•The leg pain starts in the buttock and travels
down the back of the leg as far as the ankle or
foot.
•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
A “herniated” disc ?
•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
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.
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
HIP PAIN
Pathology
• According the four general anatomic area:
– Intraarticular
– Extra-articular bony structures
– Extra-articular soft tissues
– Outside of the hip area
Pathology
• Intraarticular hip joint pathology
– articular cartilage (e.g., osteoarthritis)
– synovium (e.g., rheumatoid arthritis, pigmented
villonoduler synovitis)
– intraarticular soft tissue structures (e.g., tearing
or infolding of the labrum)
– bones forming the joints (e.g., avascular necrosis
affecting the femoral head and trauma)
• Pathology of the extra-articular bony
structures around the hip joint:
– including any process of the femoral shaft
(e.g., fracture or tumor)
– including any process of the pelvic bones
(e.g., pelvic fracture, stress fracture, and,
osteitis pubis)
• Pathology of the extra-articular soft
tissues:
– muscular pathology
– soft tissue overuse syndromes (e.g.,
tendinitis, bursitis)
– local nerve process (e.g., meralgia
paresthetica)
• Pathology outside the hip area:
– lumbosacral radiculopathy
– femoral and inguinal hernias
– intrapelvic pathology (e.g., endometriosis,
lymphoma)
Etiology
• Infections: septic arthritis and osteomiyelitis
• Degenerative conditions: osteoarthritis
• Metabolic conditions: paget disese
• Inflammotory conditions: RA, synovial
chondromatosis, pigmented villonodular synovitis
• Neurogenic conditions: radiculopathy and local
nerve entrapment
• Traumas: femoral neck fractures and stress or
insufficiency fractures
• Overuse syndromes: tendinitis and osteitis pubis
• Tumors: metastatic disease to the femoral neck or
pelvis
• Vascular conditions: avascular necrosis of the
femoral head and claudications with pain referred to
the hip and leg
History
• Pain: time of onset, location, whether
or not trauma
• Time: Pain came on
– Gradually (osteoarhtritis)
– Acutely (fracture)
Location
• Radiculopathy: Begining in the low back and
radiating down the buttock and back of the
leg to the side of the calf and lateral side of
the foot
• Arthritic hip pain: Pain deep in the groin or
the front of the hip that radiates down the
thigh to the knee, accompanied by hip
stiffness and pain with weigth bearing
• General medical history:
– Prolonged oral steroid treatment;
avascular necrosis
– Thin runner with menstruel irregularities or
amenorrhea; insufficiency or stress
fractures
Physical examination
• Gait: Antalgic limp, trendelenburg’s
weakness, steppage gait, footdrop
• Range of motion examination: Lack of
internal rotation motion and pain
Hip joint pathology;
OA, avascular necrosis, inflammatory
synovitis
Physical examination
• Tenderness on trochanter: trocantheric
bursitis
• Hip irritabilite signs
– Can not straigth leg off the table against
gravity or hold the leg straigth against
resistance or experiencing pain
Physical examination
• Palpation of the inguinal region:
osteitis pubis, pubic ramus fractures,
ischial tendinitis or fractures
• Palpation of the groin; femoral or
inguinal hernia, lymphadenopathy
• Neurological examination
Diagnostic Testing
• Plain radiography;
– AP pelvic radiograph
– Frog- legg lateral hip radiograph
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fractures
joint space narrowing (OA)
spurs or osteophytes (OA)
segmental radiolucency or sclerotic changes of
the femoral head (avascular necrosis)
• calcification (synovial chondromatosis)
• soft tissue calcification (calcific tendinitis)
Diagnostic Testing
• Computed Tomography:
- most useful in the assessment of fractures
• Magnetic Resonance Imaging:
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Standard technic
Avascular necrosis
Occult hip fracture in the elderly
Transient osteoporosis of the hip
Bony or soft tissue tumors
Synovitis
Stress fractures
Labral pathology
Diagnostic Testing
• Electromyography and nerve
conduction velocity studies
(lumbosacral plexopathies)
• Injections
Disorders Causing Hip Pain
• Intra-articular Disorders:
– pain in the groin or thigh
– involve anterior hip more than posterior
– hip pain often worse with weigth bearing and
associated with true passive loss of motion
(internal rotation and extension)
– pain on forced internal rotation and with straigth
leg raising against resistance
Intra-articular Disorders
• Osteoarthritis
• Avascular necrosis of the femoral head
• Inflammatory arthritis
• Septic hip joint
Labral Pathology
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Tear of the acetebular labrum
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Young, active adult
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History of trauma
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Hip pain accompanied by a painful mechanical snap
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Pivoting and twisting exacerbates these symptoms
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Devolepment of early OA
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MR arthrography
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Nonsurgical treatment: activities restricted and NSAİDs
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Surgery
Stress Fractures
• Insufficiency fractures:
– routine activity
– older persons with osteopenic bone
• Fatique fractures:
– healthy bones
– repeatedly subjected to high level stress
– young healthy persons involved in new
activities
Stress Fractures
• Femoral neck
• Pelvic rami
• Diagnosis; MRI
– Inferior side
– Superior side; higher propencity for
displacement and often requires
prophylactic screw fixation
Transient Osteoporosis
• Young and middle aged men
• Pregnant women in the third trimester
• Dull, aching pain
• Sometimes accompanied by minor trauma
• Weigth bearing exacerbates the condition
• Radiographs show deminerilization of the femoral head and
neck
• Laboratory normal
Transient Osteoporosis
• Diagnosis; MRI, Bone Scan
• Self limiting: pain resolves and function returns within 2-6
months
• In early stages osteonecrosis can produce similar MRI findings
• Treatment;
– activity modification: protective weigth bearing during the
active phase
– maintenance of range of motion
– gradual ambulation
– pain relief; NSAİDs, analgesic
Snapping Hip
– Young
– Athletes or dancers
– History of trauma or repetitive overuse activity such as
running
– External causes most common
• Thickening of the posterior part of the iliotibial band or of the anterior
border or the gluteus maximus, with snapping over the great
trochanter
• Percieve the problem to be in the area of the greater trochanter
Snapping Hip
• Treatment
– streching of the iliotibial band
– reduction of inflammation (e.g., ice, NSAİDs)
– injection of glucocorticoids
– short term acvtivity modification
– if the pain remains significant; surgical treatment
Snapping Hip
• Internal causes:
• 1.Iliopsoas tendon snapping back and forth over the femoral
head
• Painful snapping sensation in the anterior hip and groin
• İliopsoas bursography or iliopsoas tenography
• Treatment
– streching of the iliopsoas in extension
– reduction of inflammation (e.g., ice, NSAİDs)
– short term acvtivity modification
– İf the pain remains significant; surgical treatment
2.Tearing of the acetebular labrum
Snapping Hip
• Other causes;
– traumatic loose body
– synovial chondromatosis
– post traumatic femoral head defects
Bursitis
• Pain on the side of the hip over or posterior to the
greater trochanteric area:
– Referred pain from the low back with sciatica
– Referred pain from intra-articular hip pathology
(most often OA)
– Local soft tissue inflammation (trochanteric
bursitis)
Bursitis
• Middle-aged female
• Overweigth
• Pain is aggravated by activity such as walking or stair climbing,
is typically worse at nigth, and lying on the affected side
• Localized tenderness over the greater trochanter
• Plain radiographs: peritrochtanteric calcification
• MRI may not be warrented except to exclude other pathologic
conditions
• Aspiration of the bursa with corticosteroid injection is
sometimes effective
• Resection of bursa
Regional Disorders;
Lumbosacral radiculopathy
Miscellaneous Disorders;
– Meralgia paresthetica:
– Lateral femoral cutaneous nerve
– Femoral and inguinal hernias
– Lymphomas
– Metastatic bone disease
– Low intrapelvic pathology (e.g., ovarian pathology, endometriosis)