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Slide 1 - Case of Back Pain 53 year old, right handed lady, hotelier 3 day history of severe lower back pain and weakness in her legs bending over at work and had noticed a mild back pain, which progressed Night and rest pain, leg radiation, worse with movement. Unable to walk
Slide 2 - Case of Back Pain Sep 05Haematologists shoulder pains, lymphadenopathy and rash, fatigue, 7 kg weight loss in 6 months l-node < 1cm ALP 210 Rheum referral Subsequently admitted Ex In pain restricted spine ? leg weakness and altered sensation feet
Slide 3 - Case of Back Pain ALP 320, ALT 89 CRP 96 XR normal MRI spine normal Symptoms progressed Tingling in upper limbs, noted to have reduced reflexes
Slide 4 - Case of Back Pain CSF protein 2.55 g ?Guillan-Barre Transferred to neurology IV Ig, Rehab, FVC, vitals monitoring Campylobacter IgG and IgA 160 EBV +ve
Slide 5 - GB syndrome Post-infective acute inflammatory demyelinating polyneuropathy 1-3 weeks post viral Distal numbness and weakness – evolves over days to weeks ascending Back and leg pain can be a feature 20% severe with autonomic and respiratory complications Weakness, areflexia, sensory loss
Slide 6 - GB syndrome Rare – ocular and ataxia – Miller-Fisher syndrome NCS: slowing of conduction or block CSF: 1-3g/l IV Ig, supportive, ventilation, plasmapharesis, rehab
Slide 7 - BACK PAIN Jaya Ravindran Rheumatologist
Slide 8 - Causes Simple mechanical eg ligamentous strain Degenerative disease with/without neural, cord or canal compromise Metabolic – osteoporosis, Pagets Inflammatory – Ankylosing spondylitis Infective – bacterial and TB Neoplastic Others, (trauma,congenital) Visceral
Slide 9 - Red flags Age <20 or >50 with back pain for the 1st time Thoracic pain >50 yrs Pain following a violent injury/trauma Unremitting, progressive pain
Slide 10 - Red flags Past or current history of cancer On Steroids or immunosuppressants Drug abuser or +ve HIV Systemic symptoms - fever, appetitie and weight loss, malaise
Slide 11 - Red flags Bilateral leg radiation, sensory/motor/sphincter symptoms Pain predominantly at night
Slide 12 - Inflammatory flags Morning stiffness and pain >30 mins -1 hr Better with activity Peripheral joint involvement Anterior uveitis Psoriasis Inflammatory bowel disease Recent GI or GU infection Family history
Slide 13 - Myotomes C5 Deltoid, biceps (biceps jerk) C6 Wrist extensors, biceps (biceps, brachioradialis jerk) C7 Wrist flexors, finger extensors, triceps (triceps jerk) C8 Finger flexor, thumb extensors (triceps jerk) T1 finger abductors
Slide 14 - Myotomes L2 Hip flexion L3 Knee extension (knee jerk) L4 Knee extension, ankle dorsiflexion (knee jerk) L5 toe dorsiflexion S1 foot plantar flexion, eversion
Slide 16 - Examination LOOK – deformity, muscle wasting, kyphosis, scoliosis LOOK – normal cervical lordosis, thoracic kyphosis, lumbar lordosis FEEL – spinal processes and sacroiliac joints
Slide 17 - Examination MOVE – Lumbar flexion Schober’s test – marks at “dimples of Venus” and 10 cm above. Measure at maximal flexion – usually 5 cm MOVE – Lumbar lateral flexion MOVE – Cervical flexion/extension, lateral rotation and flexion, thoracic rotation
Slide 18 - Examination Sciatic stretch (patient supine) - Straight leg raise and dorsiflexion of foot - pain in calf and posterior thigh between 30-70o – low lumbar (L5/S1) lesion or sciatic irritation Femoral stretch (patient prone) – knee is flexed and then hip extended – pain in anterior thigh – high lumbar (L2-L4) lesion
Slide 19 - Imaging XR – tumour, fracture, infection, inflammation Bone scan – increased turnover eg infection, metastatic disease, fractures, Pagets MRI – soft tissue, discs, facet joint, nerve roots, cord, inflammation
Slide 20 - Degenerative disease and sciatica Very common Facet joint OA, disc disease, osteophyte Mechanical back pain Sciatica – most resolve NB persistent, neurology, bilateral, red flags Analgesia, PT, pain clinics
Slide 21 - Degenerative disease and sciatica
Slide 22 - Malignancy Unremittting, progressive and night pain Systemic symtoms Past hx Ca Breast, bronchus, thyroid, kidney, prostate and myeloma/plasmacytoma Osteolytic (prostate osteoblastic) XR can be normal in early stages – further imaging if suspicion high Predilection for vertebral body and pedicles
Slide 23 - Malignancy
Slide 24 - Malignancy
Slide 25 - Infection discitis, osteomyelitis, and epidural abscess. hematogenously spread most often Staphylococcus aureus. Gram-negative rods in postoperative or immunocompromised patients normal skin flora is less commonly isolated in postoperative patients. Postoperative patients develop symptoms 2 to 4 weeks after surgery after an initial improvement in pain.
Slide 26 - Infection Pseudomonas organisms in intravenous drug users. Mycobacterium tuberculosis in developing nations and immigrant population. Fungal infections are rare. Only one third have fever and 3% to 15% present with neurologic deficit. Infections typically involve the intervertebral disc and vertebral body endplate
Slide 27 - Infection Radiographic changes at 2 to 4 weeks bone scan can be positive as early as 2 days 75% specific. MRI appearance is decreased T1- and increased T2-weighted signal in the infected disk. Enhancement after gadolinium
Slide 28 - Infection Conservative treatment of antibiotics, rigid bracing to prevent deformity and control pain Surgery : neurologic deficit, presence of abscess, extensive bone loss with kyphosis and instability, failure of blood work and biopsy to isolate any organism, excision of a sinus tract, or no response to conservative treatment.
Slide 29 - Infection
Slide 30 - Infection
Slide 31 - Osteoporosis
Slide 32 - DEXA
Slide 33 - T scores
Slide 34 - Osteoporosis
Slide 35 - Low bone density
Slide 36 - Osteoporosis - risks History of low trauma # - colles, NOF, vertebral, sacral or pelvic insufficiency Steroids Maternal history of NOF # Gonadal hormone deficiency Ca deficiency Prolonged immobility Low BMI Alcohol and smoking
Slide 37 - Causes of low bone density
Slide 38 - Vertebral fractures
Slide 39 - Osteoporosis
Slide 40 - Osteoporosis Bisphosphonates SERMs Strontium Teriparatide Calcitonin Lifestyle factors Ca and Vit D
Slide 41 - 7-dehydrocholesterol sunlight cholecalciferol (diet) liver 25-hydroxycholecalciferol kidney 1-hydroxylase 1,25-dihydroxycholecalciferol (-) increased GI Ca2+ absorption Ca2+ Bone resorption Thyroid (-) Parathyroid Gland PTH  Renal Ca2+ (-) Calcitonin reabsorption
Slide 42 - Spinal stenosis Canal or foraminal narrowing with possible subsequent neural compression Cause Ligamanetum flavum hypertrophy, facet joint hypertrophy, vertebral body osteophytes, herniated disc Rare: Pagets, AS, acromegaly
Slide 43 - Spinal stenosis Symptoms Age - >50 Dull aching pain in the lower back and legs Exertional leg pain/weakness/numbness Symptoms relieved leaning forward, sitting or lying Examination May be normal Normal sensation and power Reflexes normal or slightly reduced Normal foot pulses
Slide 44 - Spinal stenosis
Slide 45 - Spinal stenosis Conservative – analgesics, NSAIDs, PT, epidural Surgery – laminectomy (+arthrodesis)
Slide 46 - Cauda Equina Syndrome Back pain, lower limb weakness, saddle anaesthesia, sphincter disturbance, impotence Causes – usually disc, rarely tumour, abscess, advanced AS Diminished sensation L4 to S2 (sacral numbness), weakness ankle and plantar dorsiflexion, loss ankle jerks, urinary retention, loss anal tone Urgent MRI and surgical decompression
Slide 47 - Cauda Equina Syndrome
Slide 48 - Pagets
Slide 49 - Pagets Pain, deformity Skull, long bone, vertebra, pelvis, near hip Neurologic compromise Planned surgery ?ALP 2X ULN Rare: high output failure
Slide 50 - AS
Slide 51 - AS NSAIDs Sulphasalazine – peripheral joints PT Anti-TNF
Slide 52 - AS
Slide 53 - AS
Slide 54 - AS