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APPROACH TO LOW BACK PAIN
LOW BACK PAINIS A SYMPTOM- NOT A DISEASE McNab
Cause of the pain may be -Within the spineLesion outside the spine
Within the spine-SpondylogenicNeurogenicOutside the spineViscerogenicVascularpsychogenic
SpondylogenicBony componentsSoft tissues of motion segment-disc,lig,musclesSI joints
Congenital- spina bifida, listhesis,hemivertebra,sacralisationTraumatic - fractures, lig injuries, LS strain, ruptured d...
NeurogenicTensionIrritationcompression
Discogenic painDisc herniationAnnular tearSinuvertebral nerveDecrease pH within a deg disc –irritate the nerve root
Arise frfom ventral rootand gray ramicommunicants near DRGInnervates PLL,antdura,post annulus,bloodvesselsALL,lat & ant...
FACET JOINT PAINInnervated by medial branches of dorsal primary ramiFacet capsule-contains encapsulated,non encapsulated...
mechanismInjury to articular cartilage as in OADEGEN changes of facet jt-static n dynamic compression ofnerve root-later...
radiculopathyMechanical deformation-intraneural tissue rreactionsNerve roots –no effective blood nerve barrier --lack ep...
Outside the spineAbdominal – pancreatitis, cholecystitis , peptic ulcerPelvic – ovaries,tubes,intrapelvic tumoursVascul...
AIMTO LOCALISE THE PAIN GENERATOR IN THE SPINE-facet,disc…THE NEUROLOGICAL LOCALISATION-Myelopathy/Radiculopathy(root le...
APPROACHHISTORYPHYSICAL EXAMINATIONNEUROLOGICAL EXAMINATIONINVESTIGATION
HISTORYPAIN- Commonest symptomSite of painAxialRadicular involving limbscombination of both
Onset,Duration,ProgressionAcute onset – fall,lifting weights, sports injuryInsidious onset with rapid progression-infect...
duration of painAcute- strains, sprainsChronic- degenerative conditionsa/c on chronicRadiation of painNature of pain...
Nature and intensity of painDiscogenic- focal,aching in nature,increased with activity causingaxial loading,decreased wit...
Neurogenic pain-radicular,claudicatonRadicularthoracic spine-band like along the ribLumbar spine-radiates below kneeL3...
Neurogenic claudicationDiffuse pain n numbnessProgressive loss of walking ability/forward stooping walkingSymptoms prod...
Neuorgenic vs vascular
Occupational history-return to heavy physical work may notbe possibleFamily n social history- assess pts resources and s...
Nonorganic physical signs-The WaddellsignsTenderness-superficial,nonanatomicalSimulation- axial loading, rotationDistra...
INSPECTIONGaitAntalgic one leg-nerve root irritation,muscle weaknessSciatica :walk with hip more extended & knee more f...
Trendelenburgs : L5 - abductor lurchS1- extensor lurch toe walking not possibleL4-heel walking not possible
Look from front/back &sidesLevel of shouldersiliac crest-pelvic obliquity-LLD,SpineCoronal plane-scoliosisSagittal pla...
The plumb line
Sciatic listShoulder disc Axillary disc
Any swellings-cold abscess.Spina bifida-occulta/manifestaStep signAny scars/sinuses
PalaptionTempTendernessdirect pressureTwistdeep thrust
Step + in > 50% slipParaspinal localised tenderness-facet arthritis, TP #Cold abscess
movementsFlexionExtensionRotatonSide bendingSchober testExtension catch-instability,disc pathologyExt&lat bending-p...
MeasurementsChest expansion-at nipple levelShould be 5 cm,< 2.5cm suggests ASR/o LLD
Neurological examinationMSECNGait-type -PostureSciatica-walk with hip extended n knee flexed - to reduce tension on ...
motorBulkTonePowerCoordinationAbnormal movementsreflexes
L2
L3
L4
L5
coordinationHeel shin testRombergs signInvoluntary movements
sensory
Touch-supDeepPain& tempPosterior column-joint sense,vibration
Reflexes- superficial
Plantar reflex
Bulbocavernous reflex
Deep reflexes
Bladder- voluntary controlRetentionDribblingfrequencyBowelControl of sphinctersconstipation
Nerve root tension signsSLR LASEGUE/BRAGGARD
BOWSTRING TESTSUDDEN SCIATICSTRETCH TEST
FNSTWell leg raising test-axillary disc
Piriformis syndromeEntrapment of sciatic nerve by the piriformis as it passes thru thesciatic notchCauses:hypertrophyTr...
Clinical featuresHistory of trauma to SI or gluteal regionExacerbation of symptoms by lifting leg orstooping/difficulty ...
Positive SLR,Lasegue signFreiberg sign-pain with forced int rotation of extended thighPositive sign of Pace and Nagle-p...
TreatmentPhysiotherapyNSAIDStretchingUltrasoundLocal steroid/anaestheticIf no relief-surgical release of piriformis ...
TEST FOR SI JTCOMPRESSION TEST DISTRACTION TEST
Axial rotation stress testPump handle test Gaenslen’s test
FABER test
Hip joints/other jointsOther systems
investigationsBloodPlain x rayCtMriBonescanInjection studiesBiopsy
Plain Xray APAlignment of vertebral columnLesion of pedicles/ TPSide to side collapseParavertebral soft tissue shadow...
Lateral viewShape n size of vertebralbodyAnterior n posterior walls integritySuperior n inferior surfaces of bodyWedgi...
oblique views-for pars defectsScannograms-to view the entire spinal columnCt-demonstrates bony lesions betterMri- demo...
Back ache
Back ache
Back ache
Back ache
Back ache
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Back ache

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Transcript of "Back ache"

  1. 1. APPROACH TO LOW BACK PAIN
  2. 2. LOW BACK PAINIS A SYMPTOM- NOT A DISEASE McNab
  3. 3. Cause of the pain may be -Within the spineLesion outside the spine
  4. 4. Within the spine-SpondylogenicNeurogenicOutside the spineViscerogenicVascularpsychogenic
  5. 5. SpondylogenicBony componentsSoft tissues of motion segment-disc,lig,musclesSI joints
  6. 6. Congenital- spina bifida, listhesis,hemivertebra,sacralisationTraumatic - fractures, lig injuries, LS strain, ruptured discInflammatory-TB, pyogenic, brucellosis, RA, Anks spondDegenerative- DDD, spondylosis, senile osteoporosisNeoplastic-primary secondary
  7. 7. NeurogenicTensionIrritationcompression
  8. 8. Discogenic painDisc herniationAnnular tearSinuvertebral nerveDecrease pH within a deg disc –irritate the nerve root
  9. 9. Arise frfom ventral rootand gray ramicommunicants near DRGInnervates PLL,antdura,post annulus,bloodvesselsALL,lat & ant annulus –sympatheticsSP.VIP,CGRP
  10. 10. FACET JOINT PAINInnervated by medial branches of dorsal primary ramiFacet capsule-contains encapsulated,non encapsulated & freenerve endingsMechanoreceptors-inflamation sensitizes these to movements offacet jtNociceptors-unmyelinated & plexiform fibres sensitizes tochemical or mechanical stimulus
  11. 11. mechanismInjury to articular cartilage as in OADEGEN changes of facet jt-static n dynamic compression ofnerve root-lateral recess stenosisBlockage of facet by synovial fold
  12. 12. radiculopathyMechanical deformation-intraneural tissue rreactionsNerve roots –no effective blood nerve barrier --lack epineuriumInflammation with mechanical compresion
  13. 13. Outside the spineAbdominal – pancreatitis, cholecystitis , peptic ulcerPelvic – ovaries,tubes,intrapelvic tumoursVascular- aortic aneurysms,PVDPsychogenic- Wadells signs
  14. 14. AIMTO LOCALISE THE PAIN GENERATOR IN THE SPINE-facet,disc…THE NEUROLOGICAL LOCALISATION-Myelopathy/Radiculopathy(root lesion)The Aetiological/Pathological localisation –cong/trauamatic/infective/inflammatory/degenerative/neoplastic
  15. 15. APPROACHHISTORYPHYSICAL EXAMINATIONNEUROLOGICAL EXAMINATIONINVESTIGATION
  16. 16. HISTORYPAIN- Commonest symptomSite of painAxialRadicular involving limbscombination of both
  17. 17. Onset,Duration,ProgressionAcute onset – fall,lifting weights, sports injuryInsidious onset with rapid progression-infection, path #,tumours 1* 2*Referred pain-pancreatitis,aortic aneurysm,pelvic and rectalconditions
  18. 18. duration of painAcute- strains, sprainsChronic- degenerative conditionsa/c on chronicRadiation of painNature of painAggravating/relieving factors
  19. 19. Nature and intensity of painDiscogenic- focal,aching in nature,increased with activity causingaxial loading,decreased with restFacetal pain-pain on extension of spine (Can be of muscle strain)Degenerative-Pain and stiffness in morningInflammatory-prolonged pain with stifness > 1hrTumour/infection- Night Pain unrelieved by rest
  20. 20. Neurogenic pain-radicular,claudicatonRadicularthoracic spine-band like along the ribLumbar spine-radiates below kneeL3-4-Anterior thighL5- Dorsum of foot, 1 web spaceS1-Buttock/posterior thigh
  21. 21. Neurogenic claudicationDiffuse pain n numbnessProgressive loss of walking ability/forward stooping walkingSymptoms produced by activities causing extension of spine,relieved by flexionTo r/o vascular claudication
  22. 22. Neuorgenic vs vascular
  23. 23. Occupational history-return to heavy physical work may notbe possibleFamily n social history- assess pts resources and support fortreatment planOther systems assessment-CVS,PULMO,GI ,GU,ENDO
  24. 24. Nonorganic physical signs-The WaddellsignsTenderness-superficial,nonanatomicalSimulation- axial loading, rotationDistraction-SLRRegional-weakness,sensoryOverreaction-disproportionate verbalization,inappropriatefacial expression,tremor,collapsing,sweating
  25. 25. INSPECTIONGaitAntalgic one leg-nerve root irritation,muscle weaknessSciatica :walk with hip more extended & knee more flexedHigh stepping : foot drop -to clear the groundSpastic:drags the foot
  26. 26. Trendelenburgs : L5 - abductor lurchS1- extensor lurch toe walking not possibleL4-heel walking not possible
  27. 27. Look from front/back &sidesLevel of shouldersiliac crest-pelvic obliquity-LLD,SpineCoronal plane-scoliosisSagittal plane-Kyphosis/lordosisAngular kyphusKnuckle-1 vertebraGibbus-2 vertebraRound kyphus- > 2 vertebraOverall spinal balance
  28. 28. The plumb line
  29. 29. Sciatic listShoulder disc Axillary disc
  30. 30. Any swellings-cold abscess.Spina bifida-occulta/manifestaStep signAny scars/sinuses
  31. 31. PalaptionTempTendernessdirect pressureTwistdeep thrust
  32. 32. Step + in > 50% slipParaspinal localised tenderness-facet arthritis, TP #Cold abscess
  33. 33. movementsFlexionExtensionRotatonSide bendingSchober testExtension catch-instability,disc pathologyExt&lat bending-pain nfacet pathology
  34. 34. MeasurementsChest expansion-at nipple levelShould be 5 cm,< 2.5cm suggests ASR/o LLD
  35. 35. Neurological examinationMSECNGait-type -PostureSciatica-walk with hip extended n knee flexed - to reduce tension on Sciatic NHeel walking-L4Toe walking - S1
  36. 36. motorBulkTonePowerCoordinationAbnormal movementsreflexes
  37. 37. L2
  38. 38. L3
  39. 39. L4
  40. 40. L5
  41. 41. coordinationHeel shin testRombergs signInvoluntary movements
  42. 42. sensory
  43. 43. Touch-supDeepPain& tempPosterior column-joint sense,vibration
  44. 44. Reflexes- superficial
  45. 45. Plantar reflex
  46. 46. Bulbocavernous reflex
  47. 47. Deep reflexes
  48. 48. Bladder- voluntary controlRetentionDribblingfrequencyBowelControl of sphinctersconstipation
  49. 49. Nerve root tension signsSLR LASEGUE/BRAGGARD
  50. 50. BOWSTRING TESTSUDDEN SCIATICSTRETCH TEST
  51. 51. FNSTWell leg raising test-axillary disc
  52. 52. Piriformis syndromeEntrapment of sciatic nerve by the piriformis as it passes thru thesciatic notchCauses:hypertrophyTraumaExcessive exercisesSpasm n inflammationAnomalies of piriformisPseudo aneurysm of inf gluteal arteryTraumatic myositis ossifcans
  53. 53. Clinical featuresHistory of trauma to SI or gluteal regionExacerbation of symptoms by lifting leg orstooping/difficulty in walkingTenderness over sciatic notchSausage shaped mass over piriformisFelt by rectal exmn-pathognomonic
  54. 54. Positive SLR,Lasegue signFreiberg sign-pain with forced int rotation of extended thighPositive sign of Pace and Nagle-pain with resistance toabduction n ER the thighTibial nerve is less affected than peroneal
  55. 55. TreatmentPhysiotherapyNSAIDStretchingUltrasoundLocal steroid/anaestheticIf no relief-surgical release of piriformis muscle
  56. 56. TEST FOR SI JTCOMPRESSION TEST DISTRACTION TEST
  57. 57. Axial rotation stress testPump handle test Gaenslen’s test
  58. 58. FABER test
  59. 59. Hip joints/other jointsOther systems
  60. 60. investigationsBloodPlain x rayCtMriBonescanInjection studiesBiopsy
  61. 61. Plain Xray APAlignment of vertebral columnLesion of pedicles/ TPSide to side collapseParavertebral soft tissue shadowsscoliosis
  62. 62. Lateral viewShape n size of vertebralbodyAnterior n posterior walls integritySuperior n inferior surfaces of bodyWedgingDisc spaceSpinal canal-between post end of body n lamina-spaceoccupied by cord
  63. 63. oblique views-for pars defectsScannograms-to view the entire spinal columnCt-demonstrates bony lesions betterMri- demonstrates soft tissues betterScrrening of whole spine
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