Transcript lower back pain

LOWER BACK PAIN
Erestain-Garan
CASE
Age: 45 years old
 CC: Lower back pain
 Occupation: office secretary
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CHRONOLOGY OF EVENTS
• Patient lifted a box of papers. She suddenly felt a snap
and pain in the LEFT LUMBAR AREA
•Pain was then felt in the POSTEROLATERAL aspect of
the RIGHT THIGH, LEG down to the RIGHT HEEL.
•Patient was admitted and placed on BED REST and
PELVIC TRACTION for 3 weeks with no improvement
NEUROLOGIC EXAMINATION
FINDINGS
BP: 130/80
PR: 88
(NORMAL or HIGH
NORMAL)
(within normal PR levels of
60-100 beats per minute)
Vital
Statistics
RR: 18
(within normal adult range
of 12–20 breathes per
minutes)
T: 37°C
(normal)
NEUROLOGIC EXAMINATION
FINDINGS
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Patient in left lateral decubitus with knee flexed
Numbness: back of the right calf muscle, lateral
heel, foot and toe
Weakness: right plantar flexion of foot and toes
Difficulty of walking on toes on the right
Atrophy: Right gastrocnemius and soleus muscles
Knee jerk: (++) both right and left
Ankle jerk: (++) left; (absent) right
Babinski: (-) both right and left
The rest of the neurological exam is within
normal limit
SALIENT FEATURES
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Age: 45 years old
sudden snap and pain in the LEFT LUMBAR AREA
Patient in left lateral decubitus with knee flexed
Numbness: back of the right calf muscle, lateral
heel, foot and toe
Weakness: right plantar flexion of foot and toes
Difficulty of walking on toes on the right
Atrophy: Right gastrocnemius and soleus muscles
Knee jerk: (++) both right and left
Ankle jerk: (++) left; (absent) right
Babinski: (-) both right and left
Nature of the Problem
Diagnosis of Spinal Injury
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Spinal Injury is present if:
◦ The person complains of severe pain in his or
her neck or back.
◦ An injury has exerted substantial force on the
back or head.
◦ The person complains of weakness, numbness
or paralysis or lacks control of his or her limbs,
bladder or bowel.
◦ The neck or back is twisted or positioned
oddly.
Spinal Cord Injury
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Possibility of a SCI
◦ Pain
◦ Numbness
◦ Difficulty with limb
movements
Nature of the Problem
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Non-traumatic Spinal Cord Injury
◦ Age
◦ Pain – left lumbar area
◦ Resulted from normal physical
strain (lifting a box of papers)
Lumbar Spine
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Various forces that could be applied on
the spine
•nerve pathways narrowing and
causing nerve impingement,
inflammation, and pain
Key muscles = level of injury
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C5 - Elbow flexors (biceps, brachialis)
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C6 - Wrist extensors (extensor carpi radialis longus and
brevis)
C7 - Elbow extensors (triceps)
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C8 - Finger flexors (flexor digitorum profundus) to the middle
finger
T1 - Small finger abductors (abductor digiti minimi)
L2 - Hip flexors (iliopsoas)
L3 - Knee extensors (quadriceps)
L4 - Ankle dorsiflexors (tibialis anterior)
L5 - Long toe extensors (extensors hallucis longus)
S1 - Ankle plantar flexors (gastrocnemius, soleus)
•Numbness in the back of the R calf
muscle (S1-S2)
•Atrophy of R gastrocnemius and
soleus
Numbness in the lateral heel (S1)
Numbness in the foot and toe
(L4-L5, S1-S2)
Numbness in the foot and toe
(L4-L5, S1-S2)
Weakness of the R plantar
flexion of foot and toes
Difficulty walking on toes on
the R
What is the difference between a radicular
and myelopathic manifestations and what
is the significance of each in relation to the
signs and symptoms and clinical
management?
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Radiculopathy
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Pain and numbness involving the degeneration or
inflammation of the spinal nerve roots
◦ usually without objective signs of neurologic
dysfunction
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Myelopathy
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involves degeneration or any disease of the spinal
cord
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In Radiculopathy, compression of single
root may not cause significant sensory loss
(due to overlap of dermatomes in the body)
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The main symptom: sharp, burning pain or
“shooting pains”.
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Follow a dermatomal distribution,
accompanied by paresthesias, and loss of
muscle power innervated by the root.
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Symptoms of myelopathy would usually
depend on the cause and severity of the
condition
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Trauma, herniated disc, OA of the spine, and
tumors cause myelopathy
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Symptoms: pain, loss of sensation or
movement, decreased spinal range of motion,
weakness, and deformity
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Upon PE, clonus would usually indicate an
UMN disorder
Significance
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From the signs and symptoms along with
the PE results, we can achieve the correct
diagnosis of our patient.
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The persisting signs and symptoms would
help us determine the appropriate
mangement.
How does one localize the lesion
based on anatomical diagnosis
and other ancillary procedures?
Lower Motor Neuron Lesion
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In the Case:
◦ Patient has the following LMN symptoms:
 (+) Atrophy of right gastrocnemius muscle and
soleus muscles
 (+) Areflexia in Right ankle jerk
 (-) Babinski bilaterally
Peripheral Nerve Lesion
WEAKNESS
Distal, symmetrical
OBJECTIVE/SENSORY DEFICITS
Distal, symmetical
AUTONOMIC DISTURBANCES
May be present
REFLEXES
Areflexia
Lumbar Radiculopathy L5-S1
◦ In the patient:
Numbness in the back of the right calf
muscle, lateral heel, foot and toe
 Weakness of the right plantar flexion of
foot and toes
 Difficulty walking on toes on the right
 Right ankle jerk absent
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Weakness of the right plantar flexion of foot and toes
Numbness in back of the right calf
muscle, lateral heel, foot and toe
Numbness in lateral heel, foot and toe
Both knee jerks are (++)
Right ankle jerk absent, left ankle jerk (++)
Diagnosis
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If no improvement in symptoms have occurred in six weeks
or red flags are present, imaging is appropriate.
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CT scan  used to evaluate the bony anatomy in the
lumbar spine, which can show how much space is
available for the nerve roots.
◦ NEUROFORAMEN- vulnerable point of compression
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MRI scan useful for determining where the nerve
roots are being compressed ; shows the details of
soft-tissue structures, like nerves and discs.
Diagnosis
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MR neurography
◦ modified MRI technique providing better
pictures of the spinal nerves and the effect of
compression on these nerves.
◦ may help in diagnosis and treatment of
sciatica/lumbar radiculopathy.
Treatment
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goals of treatment :
◦ relieve pain
◦ prevent or reduce stress on the disc
◦ maintain normal function
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ranges from conservative therapies to
surgical interventions
Conservative Treatment
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Most treatment plans involve a combination of
self-administered treatments, medications,
and therapeutic measures. Self-administered
treatments include the following:
– Learn/practice proper posture and body mechanics
– Rest and restrict activities
– Limited bed rest to take pressure off the spine
– Mild activity (exercise) such as walking, biking, and
swimming
– Apply cold and/or hot packs
– Wear a brace for support (may not be helpful in all
cases)
Conservative Treatment
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Therapeutic treatments for DDD include
the following:
◦ Chiropractic treatment to manipulate the
spine
◦ Acupuncture to relieve pain
◦ Massage therapy to relieve muscle spasms and
tension
◦ Physical therapy to improve function and
increase flexibility and strength
Medications
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Are used to supplement conservative therapy.
– Non-steroidal anti-inflammatory drugs (NSAIDs; e.g., aspirin,
ibuprofen, naproxen)
– Pain relievers (e.g., acetaminophen)
– Muscle relaxants
– Spinal injections (anesthetics or corticosteroids)
– Antidepressants
– Sleep aids
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Other non-surgical treatments
– ultrasound therapy : uses sound waves to warm the area,
increase blood flow, and relieve discomfort
– transcutaneous electrical nerve stimulation (TENS): uses
electrical stimulation of the nerve to interrupt pain signals
Surgical
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Primary reasons for surgery are to:
◦ relieve pressure on a nerve root or the spinal
cord
◦ stabilize an unstable or painful vertebral
segment
◦ prevent or limit radiculopathy (nerve damage)
◦ reduce deformity or curvature of the spine
(e.g., scoliosis)
Surgical
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Discectomy and fusion
– involves removing the damaged intervertebral disc and replacing it with
a piece of bone or another material
– this replacement fuses with the adjacent vertebrae
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Corpectomy
– a section of the vertebrae and discs is removed to create more space
for the remainder of the spine
– A bone graft and/or metal plate with screws – attached to stabilize the
spine
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Facetectomy, laminotomy, and spinal laminectomy
– procedures that involve removing a portion of the bony structure of the
spine to relieve pressure on the nerve roots
– Foraminotomy and laminoplasty can be used to enlarge areas of the
spinal column to make more room for the nerves and spinal cord
Surgical
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Micro-discectomy
– removes a disc through a very small incision using a microscope.
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Percutaneous disc decompression
– reduces or eliminates a small portion of the bulging disc through
a needle inserted into the disc, minimally invasive
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Spinal decompression
– A non-invasive procedure that enlarges the Intra Vertebral
Foramen (IVF) by aiding in the rehydration of the spinal discs.
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Spinal laminectomy
– relieves pressure of spinal stenosis
– part of the lamina is removed or trimmed to widen the spinal
canal and create more space for the spinal nerves.
Indications for Surgery
Indications for Surgery
Surgery may be recommended:
1. If the conservative treatment options do not
provide relief within two to three months.
2. If leg or back pain limits normal activity
3. If there is weakness or numbness in the legs
4. If it is difficult to walk or stand, or if
medication or physical therapy are ineffective,
surgery may be necessary, most often spinal
fusion.
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Lumbar surgery
◦ indicated in patients with severe spinal stenosis, in those with intractable pain,
and in patients in whom an appropriate 6- to 12-month nonoperative course of
treatment fails.
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In elective cases, other conservative modalities should
have been tried and observed to fail.
In cases of cervical disk disease with radiculopathy
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indications for surgical treatment are intractable pain, progressive motor or
sensory deficit, or symptoms refractory in a reasonable period of nonoperative
therapy
In cases of cervical disk disease with myelopathy
◦ early surgery to decompress the spinal cord is recommended to arrest
progression if the clinical and radiographic changes are well correlated
Thank You!
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References:
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http://www.cedars-sinai.edu/515.html
http://www.cedars-sinai.edu/889.html
http://www.cedars-sinai.edu/5757.html
http://www.neurologychannel.com/degenerative-discdisease/treatment.shtml
◦ http://www.dcmsonline.org/jaxmedicine/1999journals/april99/degenerative.htm
◦ http://emedicine.medscape.com/article/1265453treatment