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Back ache
 

Back ache

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    Back ache Back ache Presentation Transcript

    • 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 discInflammatory-TB, pyogenic, brucellosis, RA, Anks spondDegenerative- DDD, spondylosis, senile osteoporosisNeoplastic-primary secondary
    • 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 annulus –sympatheticsSP.VIP,CGRP
    • 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
    • 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
    • radiculopathyMechanical deformation-intraneural tissue rreactionsNerve roots –no effective blood nerve barrier --lack epineuriumInflammation with mechanical compresion
    • Outside the spineAbdominal – pancreatitis, cholecystitis , peptic ulcerPelvic – ovaries,tubes,intrapelvic tumoursVascular- aortic aneurysms,PVDPsychogenic- Wadells signs
    • 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
    • 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-infection, path #,tumours 1* 2*Referred pain-pancreatitis,aortic aneurysm,pelvic and rectalconditions
    • duration of painAcute- strains, sprainsChronic- degenerative conditionsa/c on chronicRadiation of painNature of painAggravating/relieving factors
    • 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
    • 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
    • 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
    • Neuorgenic vs vascular
    • 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
    • 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
    • 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
    • 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 plane-Kyphosis/lordosisAngular kyphusKnuckle-1 vertebraGibbus-2 vertebraRound kyphus- > 2 vertebraOverall spinal balance
    • 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-pain nfacet pathology
    • 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 Sciatic NHeel walking-L4Toe walking - S1
    • 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TraumaExcessive exercisesSpasm n inflammationAnomalies of piriformisPseudo aneurysm of inf gluteal arteryTraumatic myositis ossifcans
    • 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
    • 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
    • TreatmentPhysiotherapyNSAIDStretchingUltrasoundLocal steroid/anaestheticIf no relief-surgical release of piriformis muscle
    • 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 shadowsscoliosis
    • 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
    • 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