Case 1: Low Back Pain Diagnosis

Back Pain

• 55-year-old man presents with right-sided low back pain for 2 weeks, radiating to the buttock area and down the legs posteriorly, worsening with prolonged sitting.
• Physical examination reveals tenderness in the right-sided low back area with a positive straight-leg test.
• The most likely diagnosis is Sciatica, which refers to pain that radiates along the path of the sciatic nerve, which branches from the lower back through the hips and buttocks and down each leg.

Sciatica

• Common causes of Sciatica include:
  • Bulging or herniated disc
  • Degenerative disk disease/spinal stenosis
  • Spondylolisthesis
• Diagnosis involves:
  • History
  • Physical examination
  • Imaging (MRI, CT scan)
• Treatment options include:
  • Analgesia
  • Physiotherapy
  • Surgery

Degenerative Disk Disease

• Not a disease, but an age-related condition
• As we age, the spinal disc begins to degenerate, which can cause herniated disc, bulging disc, spinal stenosis, and osteoarthritis

Pathological Fractures

• A break in a bone caused by an underlying disease
• Causes include:
  • Osteoporosis
  • Multiple myeloma
  • Primary Bone tumors and bone metastasis
  • Benign bone tumors and cysts in children
  • Osteomalacia
  • Paget's disease
  • Osteitis
  • Osteogenesis imperfecta

Osteoporosis

• Diagnosis involves:
  • DEXA scan: a bone density scan uses low-dose X-rays to see how dense (or strong) the bones are
  • DEXA scores are reported as T-scores and Z-scores
• Management of Osteoporosis involves:
  • Non-pharmacological intervention
  • Modification of general lifestyle
  • Pharmacological intervention (e.g. Bisphosphonate, Denosumab, Teriparatide)

Multiple Myeloma

• A malignant proliferation of plasma cells in the bone marrow
• Diagnosis involves:
  • More than 10% plasma cell in bone marrow
  • High abnormal paraproteins (M proteins) in serum and/or urine
  • End-organ damage (anemia, hypercalcemia, osteolytic lesion, kidney injury)
• The most common immunoglobulin produced in multiple myeloma is IgG

Acute Cord Compression Syndrome

• Causes:
  • Trauma (e.g. vertebral crush fracture with displacement of fracture fragments)
  • Acute disk herniation
  • Metastatic tumor
  • Severe bone or ligamentous injury causing hematoma
  • Vertebral subluxation or dislocation
• Clinical presentation:
  • Back pain
  • Paraparesis or quadriparesis
  • Hyporeflexia (when acute)
  • Hyperreflexia
  • Extensor plantar responses
  • Loss of sphincter tone (with bowel and bladder dysfunction)
  • Sensory deficit
• Management:
  • IV corticosteroids
  • Surgical decompression
  • Radiotherapy

Cauda Equina Syndrome

• Collection of nerve roots distal to the conus medullaris (end of the spinal cord)
• Causes:
  • Disc herniation
  • Tumor
  • Fractures
  • Epidural hemorrhage or abscess
• Clinical presentation:
  • Back pain
  • Buttock pain
  • Saddle anesthesia
  • Bilateral leg pains
  • Bilateral leg weakness
  • Bladder and bowel dysfunction

Spondyloarthropathies

• Ankylosing spondylitis:
  • Association with the HLA-B27 gene
  • Enthesitis
  • Sacroiliitis
  • Bamboo spine
  • Extra-articular manifestations such as uveitis and skin rash
• Other types of spondyloarthropathies include:
  • Reactive arthritis (including Reiter's syndrome)
  • Psoriatic arthritis
  • Inflammatory bowel disease–associated spondyloarthropathy
  • Undifferentiated spondyloarthropathy