Back Pain

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Back Pain

• Tanya Potter
• Consultant Rheumatologist

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Case of Back Pain

• 34 year old lady on post-natal ward
• Admitted with left sided lumbosacral pain
• Relevant questions/thoughts?

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Case of Back Pain

• 4th pregnancy, uncomplicated delivery, no
  epidural
• Night and rest pain, left thigh radiation, worse
  with movement, unable to walk or weight bear
• Episode of feeling cold and shivery 4 days
  previously

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Case of Back Pain

• OE in pain, not unwell, afebrile,
  haemodynamically stable
• Tender left lumbosacral region, unable to do SLR
• Hip ok
• No neurology, bladder and normal PR

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Case of Back Pain
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Case of Back Pain

• ESR 101, CRP 201
• ALP 489, ALB 19
• Hb 9.8 MCV 76
• Differential diagnosis and further
  investigations?

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MRI
septic  arthritis  of  left  SIJ  with  an 
abscess  in  thegreater  sciatic  notch
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• Blood cultures Beta-haemolytic Strep.
• IV Antibiotics
• Orthopaedic review
• CT guided aspiration
• Few weeks later CRP 28
• Repeat MRI

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MRI

• Some resolution of abscess, marrow oedema, some
  destruction of SIJ

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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

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Triggers to investigate/ refer

• Red Flags ?

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Red flags

• Age lt20 or gt50 with back pain for the 1st time
• Thoracic pain gt50 yrs
• Pain following a violent injury/trauma
• Unremitting, progressive pain

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Red flags

• Past or current history of cancer
• On Steroids or immunosuppressants
• Drug abuser or ve HIV
• Systemic symptoms - fever, appetite and weight
  loss, malaise

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Red flags

• Bilateral leg radiation, sensory/motor/sphincter
  symptoms
• Pain predominantly at night

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• Inflammatory flags ?

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Inflammatory flags

• Morning stiffness and pain gt30 mins -1 hr
• Better with activity
• Peripheral joint involvement
• Anterior uveitis
• Psoriasis
• Inflammatory bowel disease
• Recent GI or GU infection
• Family history

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• Myotomes and dermatomes ?

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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

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Myotomes

• L2 Hip flexion
• L3 Knee extension (knee jerk)
• L4 Knee extension, ankle dorsiflexion (knee jerk)
• L5 toe dorsiflexion
• S1 foot plantar flexion, eversion

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DERMATOMES
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• Principles of examination

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Examination

• LOOK deformity, muscle wasting, kyphosis,
  scoliosis
• LOOK normal cervical lordosis, thoracic
  kyphosis, lumbar lordosis
• FEEL spinal processes and sacroiliac joints

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Examination

• MOVE Lumbar flexion
• Schobers 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

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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

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Imaging

• XR
• Isotope Bone scan
• MRI
• CT

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Imaging

• XR tumour, fracture, infection, inflammation
• Isotope Bone scan
• MRI
• CT

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Imaging

• XR tumour, fracture, infection, inflammation
• Bone scan increased turnover eg infection,
  metastatic disease, fractures, Pagets
• MRI
• CT

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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
• CT

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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

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Degenerative disease and sciatica
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Malignancy

• Which cancers associated with bone mets?

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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

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Malignancy
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Malignancy
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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.

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Infection

• Pseudomonas organisms
• 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

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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

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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.

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Infection
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Infection
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Osteoporosis
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• Risk factors for osteoporosis?

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• Treatment for OP ?

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• Lifestyle
• Medication
• vertebroplasty

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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

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• Symptoms of spinal stenosis ?

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Spinal stenosis

• Symptoms
• Age - gt50
• 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

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Spinal stenosis
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Spinal stenosis

• Conservative analgesics, NSAIDs, PT, epidural
• Surgery laminectomy (arthrodesis)

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cauda equina

• Features?

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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

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Cauda Equina Syndrome
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Another cause of back pain (older)
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Another cause of back pain (younger)
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Later on
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AS
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New hope for AS

• TNF alpha blockade significant and sustained
  improvement in disease activity, function and
  quality of life
• Role in extra-articular disease, enthesitis,
  dactylitis, peripheral joint disease

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Summary

• Multiple causes for back pain
• Think of red flags
• Image only when it might change management