Back Pain Presentation (PDF)

BACK PAIN Dr. Khalfan Al Zeedy Case 1 55 years old man presents with rt sided low back pain for 2 weeks duration. The pain radiated to the buttock area and down the legs posteriorly. The pain is worsening with prolong sitting Physical examination : Tenderness right sided low back area with positive...

BACK PAIN Dr. Khalfan Al Zeedy Case 1 55 years old man presents with rt sided low back pain for 2 weeks duration. The pain radiated to the buttock area and down the legs posteriorly. The pain is worsening with prolong sitting Physical examination : Tenderness right sided low back area with positive straight-leg test? What is the most likely Diagnosis ? O 1- Sciatica 2- Muscular strain 3- Osteoporosis 4- bone metastasis Sciatica Sciatica refers to pain that radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down each leg Common causes › Bulging or herniated disc › Degenerative disk disease / spinal stenosis › Spondylolisthesis Straight- leg test more Pain Diagnosis › History › Physical examination › Imaging (MRI , CT scan) Treatment › Analgesia › Physiotherapy › Surgery Degenerative Disk Disease › Not a disease but age- related condition. › As we age , the spinal disc begin to degenerate. This can cause herniated disc , bulging disc , spinal stenosis and osteoarthritis. Case 2 › 61 years old man presents with 5 days h/o back pain after slipping in his house. He fell on carpets on his back. He has no symptoms apart from the back pain › Physical examination showed tenderness at lumbar Area › X ray lumbosacral area showed what is the most likely diagnosis? › Degenerative disc disease › Osteoporosis › Multiple myeloma › Tumor Pathological factures › A pathologic fracture is a break in a bone that is caused by an underlying disease › Causes – Osteoporosis – Multiple myeloma – Primary Bone tumors and bone metastasis – Benign bone tumors and cysts children – osteomalacia – Paget's disease – Osteitis – osteogenesis imperfect Osteoporosis Cortisol cashing viiiit Diagnosis › 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. – The T-score is a comparison of a person's bone density with that of a healthy 30-year-old of the same sex. – The Z-score is a comparison of a person's bone density with that of an average person of the same age and sex. Diagnosis IMPORTANT Management of Osteoporosis › Non-pharmacological intervention › Modification of general lifestyle › – Balanced diet containing calcium and vitamin D, › – Smoking cessation › – Avoid heavy alcohol use MY › Regular exercise (weight-bearing and muscle-strengthening) last › Pharmacological intervention oste Bisphosphonate (ibandronate, alendronate, risedronate, zoledronate) Monoclonal Antibody to RANK-L Denosumab É Selective Estrogen Receptor Modulator (SERM) (Raloxifene) Estrogen not Monoclonal Antibody to RANK-L Denosumab Teriparatide. This powerful drug is similar to parathyroid hormone and stimulates new bone growth. Multiple Myeloma Multiple Myeloma immunity › A malignant proliferation of plasma cells in the bone marrow › Diagnosis: – 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) important Very n think ngin Multible Myloma Serum protein electrophoresis (SPEP) d 0 What is the most common immunoglobulin produced in multiple myeloma? o › IgG › IgA › IgM highglobal Skeletal Survey Back to the case Laboratories › Hb 9.8 gm/dl low anemia › Wbc 6.2 normal › Platelets 200 normal › Ca 3.2 mmol/l high › ESR 80 high › Liver profile :albumin 40 gm/l ,normal, protein 100 gm/l high › Renal profile : creatinine 250 µmol/L ( high) Tidney injury The likely diagnosis ? › Osteoporosis › Multiple myeloma › Degenerative disc disease › Sciatica What is your next step in management ? › Serum and urine protein electrophoresis (SPEP , UPEP) › Skeletal survey › Bone marrow aspirate and biopsy Case 3 › 26 years old Omani male presents with 2 weeks history of low back pain. › Denied history of trauma , bowel or urinary incontinence › h/o fever on/off and weight loss ,around 8 kg last one month › Physical examination: Very serious – Tenderness at around L1 to L3 – Normal neurological examination of lower limbs – Needle marks in his arms IV drugabuse – Systemic examination including cardiovascular examinations are normal Lookingfor mifestforditis What is the likely diagnosis ? › Muscular strain › Spinal stenosis › Spine metastasis › Vestibular osteomyelitis important to ruggt Which findings in history and his clinical examination corelate with red flag signs? › Duration of symptoms › Weight loss › Normal neurological examination › Tenderness over spine › fever › Young Age What is the importance of needle marks? and what important questions you need to ask the patient at this time ? › Wbc 20 high › HB 11 mg/dl › Renal profile : normal › CRP 200 high › Blood culture : Gram positive cocci What is the likely organisms?? › Staphylococcus aureus › Streptococcus pyrogens › Hemophilus influenzae › Listeria Moncytogenes Gram Positive Bacteria GRAM-POSITIVE COCCI GRAM-POSITIVE BACILLI › Staphylococcus species › Bacillus anthracis › Streptococcus species › Enterococcus species › Corynebacterium diphtheria › Listeria Moncytogenes. gramel › Why it is important to exam the CVS and particularly look carefully for murmurs??? What is your next step in management ? ▪ Reassume patients and give him coarse of analgesia and antibiotics. ▪ Refer him to spine surgeon. ▪ Order X ray spine ▪ Obtain blood tests and request MRI spine urgent MRI spine Diagnosis › Acute pyogenic vertebral osteomyelitis › Why it is important to do neurological examination of lower limbs ??? because How long does it take to treat acute pyogenic osteomyelitis? › 1 weeks › 2 weeks › 3 weeks › 4 to 6 weeks Prolongal course of antibiotics upto 6 weeks Case 3 › 43 years old woman known for Breast cancer. She underwent mastectomy 2 years ago. She completed 6 cycle of chemotherapy. The last cycle was 2 months ago. She presents to Emergency with one day h/o of back pain and weakness at lower limbs. Physical Examination : › Tenderness at lower thoracic area › Power both lower limbs around 1/5 › Bilateral upgoing planter response › absence sensation for pain and touch from umbilical area downwards › Labs calcium 3.3 mmol/l (very high) IT What are the red flags features in this case?? › h/o breast cancer › Weakness of lower limbs › Decrease in sensation › Hypercalcemia What is the likely diagnosis? 0 1-Acute cord compression syndrome? 2- Cauda Equina syndrome? What is the likely causes of cord compression ? › Multiple myeloma › Tumor › Herniated disk › Osteoporosis and fracture What is the next management step? 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 Sensory level › Sensory Level: The sensory level is the most caudal, intact dermatome for both pin prick and light touch sensation Management IV corticosteroids Surgical decompression Radiotherapy Which of the following suggestive of cauda equina syndrome: › Low back pain without a clear precipitating event › Presence of other systemic symptoms (eg, fever, weight loss, dysuria) › New-onset bowel or bladder dysfunction 0 › Straight-leg test results indicating pain radiating to below the knee, not merely in the back or hamstrings What is Cauda Equina? › Collection of nerve roots distal to the conus medullaris ( end of the spinal cord) , which are horsetail-like in appearance and hence called the cauda equina (Latin for horse's tail) 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 Case 5 › 30 years old man presents with 2 year h/o back pain with morning stiffness lasted for about one hour. Physical examination is significant limitation in bending his back. He has restricted movement of both of his hip joints. He has tenderness at the insertion of Achilles tendon at right foot › Hb 11 › Esr 70 › Renal function normal What is most likely diagnosis? › Degenerative disk disease › Osteoporosis › Ankylosing spondylitis 0 › Multiple myeloma Spondyloarthropathies › Ankylosing spondylitis › Association with the HLA-B27 gene › Reactive arthritis (including Reiter’s syndrome) › Enthesitis › Psoriatic arthritis › Sacroiliitis › Inflammatory bowel disease– › Bamboo spine associated spondyloarthropathy › Extra-articular manifestations such as uveitis and skin rash. › Undifferentiated spondyloarthropathy Bamboo spine Bamboo spine develops when the outer fibers of the fibrous ring the intervertebral discs ossify, which results in the formation of marginal syndesmophytes between adjoining vertebrae Thanks