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  • 1. BACK PAIN Classification and Pathology By Wafer Aldulaimi/ Denmark
  • 2. Introduction 80% of all individuals have experienced back pain in thier life time by the age of 60 years.
  • 3. Classification of back pain Pain is differentiated into nociceptive, inflammatory, neuropathic and functional pain.
  • 4. Functional pain
  • 5. Functional pain • No morphological correlate can be found in functional pain. • Peripheral tissue damage and neural injuries changes in the pain pathways abnormal responsiveness or function of the dorsal root ganglion of the nervous system , as follows:
  • 6. • Reduction in pain threshold (allodynia) • increased response to noxious stimuli (hyperalgesia) • increase in the duration of response to brief stimulation (persistent pain) and a spread of pain .
  • 7. This phenomenon is called neuroplasticity
  • 8. Syndromes which belong to this class of pain are • • • • • Fibromyalgia Irritable bowel syndrome Non-cardiac chest pain Tension headache Whiplash syndrom
  • 9. NB • Genetic predisposition and biopsychosocial factors have a significant influence on pain perception . • Adjuvant drugs (e.g. antidepressants, anticonvulsants, anxiolytics) enhance the centraleffect of analgesics and should be included for an adequate treatment of moderate to severe pain .
  • 10. Anatomy
  • 11. Causes ofpain 1. 2. 3. 4. 5. 6. 7. Spinal degeneration Trauma Chronic pathological changes Spinal deformity Inflammatory diseases Space occupying and destructive lesions Referred pain
  • 12. Spinal Degeneration The Intervertebral Disc start as small tears in the annulus fibrosus increase in size to form radial fissures  extend into the nucleus pulposus  loss of proteoglycans and water content from the nucleus  loss of the height of the disc  disc collapses  shortening the distance between the two vertebral bodies  vertebral sclerosis + Osteophytes.
  • 13. The cardinal symptoms of discogenic back pain are : 1) predominant low-back pain . 2) pain aggravation in disc compression and flexion by forward bending, sitting, coughing, sneezing , walking. 3) non-radicular pain radiation in the anterior thigh ( referred pain)
  • 14. The facet joint Begin with an inflammatory synovitis  gradual thinning of the cartilage  subperiosteal osteophytes  enlarge both the inferior and superior facets.
  • 15. The cardinal symptoms of facet joint pain are : 1) predominant low-back pain 2) osteoarthritis pain type (morning stiffness , improvement during motion- early stage) 3) pain aggravation in extension and rotation (backward bending ,standing, walking downhill) 4) non-radicular pain radiation in the posterior thigh (referred pain )
  • 16. Treatment of the degenerative disc and facet joint Non-operative Treatment The mainstay of non-operative management rests on three pillars: 1) pain management (medication) 2) functional restoration (physical exercises) 3) cognitive-behavioral therapy (psychological intervention)
  • 17. Operative Treatment • Non-instrumented Spinal Fusion
  • 18. • Instrumented Spinal Fusion 1. Pedicle Screw Fixation 2. Translaminar Screw Fixation 3. Cage Augmented Interbody Fusion 4. Total Disc Arthroplasty
  • 19. TRAUMA Disc Herniation Compressive or rotational forces on the spine  tear of the annulus fibrosis  the nucleus pulposus may migrate through the tear, causing a protrusion of the disc . Degenerated discs that already have some degree of annular tearing, have less elasticity and are less able to withstand these forces.
  • 20. • If the disc herniation protrudes posteriorly in the midline compression of the cauda equina or spinal cord . • If the disc protrudes laterally  compression on the nerve root .
  • 21. symptoms • Radiculopathic symptoms. • These symptoms must correspond to the respective dermatome and myotome of the compromised nerve root to allow for a conclusive diagnosis.
  • 22. Treatment Conservative Measures for mild radiculopathy 1) Bed rest (< 3 days) 2) Analgesics 3) Anti-inflammatory medication 4) Physiotherapy
  • 23. Operative Treatment for severe radiculopathy ( Cauda equina syndrom, severe paresis ,etc.) Standard operations  Laminotomy and discectomy
  • 24. Fractures With or without neurological symptoms. Operative and non-operaive treatment.
  • 25. Chronic Pathological changes The effects of acute and cumulative trauma  progressive degenerative changes that affect both the intervertebral disc and the posterior facets.
  • 26. Spinal Stenosis Degenerative changes  significant stenosis of the central canal and lateral foramina  disrupt function within the spinal cord and nerve roots.
  • 27. A pathomorphological changes as: 1) hypertrophy of the ligamentum flavum 2) hypertrophy of the facet joints 3) osteophyte formations 4) disc herniation 5) vertebral displacements (anterior/lateral)
  • 28. Symptoms are : pain or numbness in the legs on activity and which is relieved with rest, known as  neurogenic claudication.
  • 29. Treatment Conservative treatment  mild symptoms 1) medication (analgetics, NSAIDs, muscle relaxants) . 2) postural education and therapeutic exercise with avoidance of extension . 3) epidural infiltration of corticosteroids .
  • 30. Operative treatment  Decompression with or without instrumentation.
  • 31. MUSCLE TRAUMA, IMMOBILIZATION AND ATROPHY Pain due to degenerative changes  reduces the patients activity  atrophy of the paraspinal muscles.
  • 32. • Muscle atrophy is visible within 3-4 weeks and after 3 months completemuscle atrophy. • The atrophied muscles is replaced by fibrous collagen. • Muscle atrophy can cause functional pain.
  • 33. Normal muscle tissue
  • 34. After 4 weeks of immobilisation
  • 35. After 7 weeks immobilisation
  • 36. After 3 months of immobilisation
  • 37. SPINAL DEFORMITY Traumatic, congenital and degenerative changes can all result in deformity of spinal structures.
  • 38. SPONDYLOLYSIS • The vertebral arch attaches to the vertebral body through the pedicles. The laminae originate from the pedicle at a comparatively weak area known as the pars interarticularis or isthmus. • In childhood and adolescence, this area is subject to fatigue fracture, which may not heal properly and can lead to a fibrous union rather than a stable bony union.
  • 39. • This can happen unilaterally or bilaterally. • If it occurs bilaterally , it creates an area of weakness between the anterior and posterior components of the vertebral arch. • If this is stable , it may not be clinically important and can be an incidental finding seen on X-rays and CT scan.
  • 40. ISTHMIC SPONDYLOLISTHESIS Bilateral spondylolysis , can  separation of the anterior and posterior elements of the vertebral arch  slippage of the superior vertebral body on the inferior vertebral body  degenerative changes.
  • 41. As the spondylolisthesis progresses  widening of the central spinal canal.
  • 42. DEGENERATIVE SPONDYLOLISTHESIS During the process of degeneration , there is a period in which the two adjacent segments are hypermobile  slippage  narrowing of the central spinal canal
  • 43. Treatment • Conservative for mild cases: pain relief , physiotherapy • Operative for severe cases: spinal fusion (instrumented and non instrumented)
  • 44. SCOLIOSIS • Deformity of the normal vertical and/or sagital alignment of spinal segments. • The causes : congenital , spontaneous and degenerative.
  • 45. INFLAMMATORY DISEASES There are a number of systemic diseases that impact on the spine and can result in changes in bony structure, resulting in deformity.
  • 46. Rheumatoid arthritis
  • 47. Paget’s disease
  • 48. Ankylosing spondylitis (Bekhterev's disease)
  • 49. Space-occupying and destructive lesions Spinal tumors Tumors that affect the spine can be primary benign or malignant .Primary or metastatic tumors spreading from other organs .
  • 50. SPINAL INFECTIONS The vertebral column , the intervertebral discs, the dural sac or the space around the spinal cord may become infected. The infection may be caused by bacteria or fungal organisms.
  • 51. REFERRED PAIN
  • 52. TAK