Instance of Back Pain 53 year old, right gave woman, hotelier 3 day history of serious lower back agony and shortcoming in her legs twisting around at work and had seen a mellow back torment, which advanced Night and rest torment, leg radiation, more regrettable with development. Not able to walkSlide 2
Case of Back Pain Sep 05Haematologists shoulder agonies, lymphadenopathy and rash, weariness, 7 kg weight reduction in 6 months l-hub < 1cm ALP 210 Rheum referral Subsequently conceded Ex In agony confined spine ? leg shortcoming and changed sensation feetSlide 3
Case of Back Pain ALP 320, ALT 89 CRP 96 XR typical MRI spine ordinary Symptoms advanced Tingling in upper appendages, noted to have lessened reflexesSlide 4
Case of Back Pain CSF protein 2.55 g ?Guillan-Barre Transferred to neurology IV Ig, Rehab, FVC, vitals checking Campylobacter IgG and IgA 160 EBV +veSlide 5
GB disorder Post-infective intense incendiary demyelinating polyneuropathy 1-3 weeks post viral Distal deadness and shortcoming – develops over days to weeks rising Back and leg agony can be a component 20% serious with autonomic and respiratory inconveniences Weakness, areflexia, tactile misfortuneSlide 6
GB disorder Rare – visual and ataxia – Miller-Fisher disorder NCS: moderating of conduction or piece CSF: 1-3g/l IV Ig, steady, ventilation, plasmapharesis, recoverySlide 7
BACK PAIN Jaya Ravindran RheumatologistSlide 8
Causes Simple mechanical eg ligamentous strain Degenerative sickness with/without neural, line or channel bargain Metabolic – osteoporosis, Pagets Inflammatory – Ankylosing spondylitis Infective – bacterial and TB Neoplastic Others, (trauma,congenital) VisceralSlide 9
Red banners Age <20 or >50 with back torment for the 1 st time Thoracic torment >50 yrs Pain taking after a fierce harm/injury Unremitting, dynamic tormentSlide 10
Red banners Past or ebb and flow history of tumor On Steroids or immunosuppressants Drug abuser or +ve HIV Systemic manifestations - fever, appetitie and weight reduction, discomfortSlide 11
Red banners Bilateral leg radiation, tangible/engine/sphincter side effects Pain overwhelmingly around evening timeSlide 12
Inflammatory banners Morning solidness and torment >30 mins - 1 hr Better with action Peripheral joint association Anterior uveitis Psoriasis Inflammatory gut illness Recent GI or GU disease Family historySlide 13
Myotomes C5 Deltoid, (biceps jerk) C6 Wrist extensors, (biceps, brachioradialis jerk) C7 Wrist flexors, finger extensors, (triceps jerk) C8 Finger flexor, thumb extensors (triceps jerk) T1 finger abductorsSlide 14
Myotomes L2 Hip flexion L3 Knee expansion (knee jerk) L4 Knee augmentation, lower leg dorsiflexion (knee jerk) L5 toe dorsiflexion S1 foot plantar flexion, eversionSlide 15
D E R M A T O M E SSlide 16
Examination LOOK – deformation, muscle squandering, kyphosis, scoliosis LOOK – ordinary cervical lordosis, thoracic kyphosis, lumbar lordosis FEEL – spinal procedures and sacroiliac jointsSlide 17
Examination MOVE – Lumbar flexion Schober\'s test – marks at "dimples of Venus" and 10 cm above. Measure at maximal flexion – typically 5 cm MOVE – Lumbar parallel flexion MOVE – Cervical flexion/augmentation, sidelong pivot and flexion, thoracic revolutionSlide 18
Examination Sciatic stretch (patient prostrate) - Straight leg raise and dorsiflexion of foot - torment in calf and back thigh between 30-70 o – low lumbar (L5/S1) sore or sciatic disturbance Femoral stretch (patient inclined) – knee is flexed and after that hip developed – torment in foremost thigh – high lumbar (L2-L4) soreSlide 19
Imaging XR – tumor, break, contamination, irritation Bone sweep – expanded turnover eg contamination, metastatic illness, cracks, Pagets MRI – delicate tissue, plates, aspect joint, nerve roots, rope, aggravationSlide 20
Degenerative ailment and sciatica Very regular Facet joint OA, circle ailment, osteophyte Mechanical back agony Sciatica – most resolve NB relentless, neurology, reciprocal, warnings Analgesia, PT, torment facilitiesSlide 21
Degenerative malady and sciaticaSlide 22
Malignancy Unremittting, dynamic and night torment Systemic symtoms Past hx Ca Breast, bronchus, thyroid, kidney, prostate and myeloma/plasmacytoma Osteolytic (prostate osteoblastic) XR can be ordinary in early stages – further imaging if suspicion high Predilection for vertebral body and pediclesSlide 23
Infection discitis, osteomyelitis, and epidural ulcer. hematogenously spread frequently Staphylococcus aureus. Gram-negative poles in postoperative or immunocompromised patients typical skin greenery is less normally segregated in postoperative patients. Postoperative patients create side effects 2 to 4 weeks after surgery after an underlying change in agony.Slide 26
Infection Pseudomonas living beings in intravenous medication clients. Mycobacterium tuberculosis in creating countries and outsider populace. Contagious diseases are uncommon. Stand out third have fever and 3% to 15% present with neurologic deficiency. Contaminations normally include the intervertebral plate and vertebral body endplateSlide 27
Infection Radiographic changes at 2 to 4 weeks bone sweep can be certain as right on time as 2 days 75% particular. X-ray appearance is diminished T1-and expanded T2-weighted sign in the contaminated plate. Upgrade after gadoliniumSlide 28
Infection Conservative treatment of anti-infection agents, unbending propping to anticipate distortion and control torment Surgery : neurologic shortfall, nearness of boil, broad bone misfortune with kyphosis and precariousness, disappointment of blood work and biopsy to segregate any creature, extraction of a sinus tract, or no reaction to traditionalist treatment.Slide 29
T scoresSlide 34
Low bone thicknessSlide 36
Osteoporosis - dangers History of low injury # - colles, NOF, vertebral, sacral or pelvic inadequacy Steroids Maternal history of NOF # Gonadal hormone lack Ca insufficiency Prolonged stability Low BMI Alcohol and smokingSlide 37
Causes of low bone thicknessSlide 38
Vertebral cracksSlide 39
Osteoporosis Bisphosphonates SERMs Strontium Teriparatide Calcitonin Lifestyle components Ca and Vit DSlide 41
7-dehydrocholesterol daylight cholecalciferol (diet) liver 25-hydroxycholecalciferol kidney 1 - hydroxylase 1,25-dihydroxycholecalciferol (- ) expanded GI Ca2+ ingestion Ca2+ Bone resorption Thyroid (- ) Parathyroid Gland PTH Renal Ca2+ (- ) Calcitonin reabsorptionSlide 42
Spinal stenosis Canal or foraminal narrowing with conceivable consequent neural pressure Cause Ligamanetum flavum hypertrophy , aspect joint hypertrophy, vertebral body osteophytes, herniated circle Rare: Pagets, AS, acromegalySlide 43
Spinal stenosis Symptoms Age - >50 Dull throbbing agony in the lower back and legs Exertional leg torment/shortcoming/deadness Symptoms calmed inclining forward, sitting or lying Examination May be typical Normal sensation and force Reflexes ordinary or marginally decreased Normal foot beatsSlide 44
Spinal stenosisSlide 45
Spinal stenosis Conservative – analgesics, NSAIDs, PT, epidural Surgery – laminectomy (+arthrodesis)Slide 46
Cauda Equina Syndrome Back torment, lower appendage shortcoming, saddle anesthesia, sphincter unsettling influence, feebleness Causes – generally plate, once in a while tumor, ulcer, progressed AS Diminished sensation L4 to S2 (sacral deadness), shortcoming lower leg and plantar dorsiflexion, misfortune lower leg jerks, urinary maintenance, misfortune butt-centric tone Urgent MRI and surgical decompressionSlide 47
Cauda Equina SyndromeSlide 48
Pagets Pain, disfigurement Skull, long bone, vertebra, pelvis, close hip Neurologic bargain Planned surgery ?ALP 2X ULN Rare: high yield disappointmentSlide 50
AS NSAIDs Sulphasalazine – fringe joints PT Anti-TNFSlide 52
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