2. Disorders of the back
Clinical manifestations of a back problem
pain
Neurologic compromise
(paresthesia, power loss, pee and pooh-pooh
problems)
Deformity
2
3. Back Pain
• 2nd most common symptom prompting a
patient to visit a physician (next to upper
respiratory infections)
• Most prevalent among the 25-45 year age
group with no gender predilection
3
4. Back Pain
Main points to be considered by a physician in
determining etiology
AGE
Children- developmental disorders, infections, primary
tumors
Young adults- lumbar disc herniation, spondylolisthesis,
acute fractures, infections
Older adults- spinal stenosis, metastatic disease,
osteoporotic vertebral body fractures
4
5. Back Pain
ONSET
Acute- fractures, infection, disc herniation, inflammatory arthritis,
muscle strain
Gradual- inflammatory and non-inflammatory arthritis, Potts
disease, malignancy, spinal stenosis
AGGRAVATING AND RELIEVING FACTORS
Aggravated by motion and position(mechanical)- motion segment
pathology
Persistent- infection, malignancy, inflammatory arthritis
ASSOCIATED NEUROLOGIC COMPROMISE
Predominantly back pain vs. unilateral leg pain
Sensory, motor, autonomic deficits
Positive nerve root tension signs
5
6. Back Pain
SYSTEMIC SIGNS AND SYMPTOMS
Eye, heart, urinary tract involvement-
spondyloarthropathy
Appendicular joint – inflammatory and non-
inflammatory arthritis
Primary extraspinal malignancy- metastatic spinal
disease
Manifestations of an infection- vertebral
osteomyelitis, Potts disease, discitis
System-specific laboratory findings
6
7. Back Pain
REFERRED PAIN FROM ADJACENT ORGAN
Cardiovascular- heart disease, aortic aneurysm
Urinary tract- pyelonephritis, urolithiasis
Digestive tract- pancreatitis, cholecystitis, acute appendicitis,
colo-rectal malignancy
Reproductive tract- ovarian malignancy, pelvic inflammatory
disease
Sacroiliitis and hip arthritis
PSYCHOGENIC
Esp. in chronic, recurrent cases, litigation & compensation
issues
Special tests can evaluate
7
8. Imaging
Diagnostic in most cases.
Plain radiographs
CAT scan
MRI
Central Dexa Bone Densitometry
Directed by symptoms from history and findings on
PE
Collaborated by pertinent positive and negative lab
results
8
9. Laboratory tests
To rule in or rule out: malignancy, infection,
inflammatory arthritis
Cbc with differential count, ESR, CRP, ASO
Serum RF, anti-ccp, ANA, HLA-B27
Serum electrolytes
Serum alkaline phosphatase, acid phosphatase
Prostatic-specific antigen in males
Serum electrophoresis
9
15. Conservative management
Directed at specific etiology
Short-term pain relief
• Oral meds: Analgesics, NSAIDS, muscle relaxants, oral
steroids, bone density improvement
• Epidural steroids with fluoroscopic guidance
• 3-day bed rest
• Physical therapy
– heating modalities (hot moist pack, ultrasound, microwave,
lasers)
– TENS
– Flexibility, strengthening, balance training
15
16. Conservative management
Long-term
• Patient education and assurance
• Back school and hygiene
– Behavior modification
– Activity restriction
– Orthotic use
• Home exercise program
16
17. USING YOUR BACK
• Back wants to be
upright with
maintenance of the
normal curves.
19. USING YOUR BACK
• Lying on a flat firm surface. Pillows under thighs.
• Using a stepboard. Mirror at eye level.
• Adjusting distance from steering wheel.
20. USING YOUR BACK
• Do not use back as a lever. Use lower extremities.
• Use proper footwork in sports. Turn whole body.
• Use a stool or reacher instead of stretching the back eliminating the
normal curves.
21. USING YOUR BACK
• Sit less often.
• Lie down.
• Stand up and shift positions regularly.
• Walk in comfortable flat rubber-soled
footwear.
28. Stabilizing the spine
Arthrodesis
• Fusing the motion segment to facilitate bone or
fracture healing to eliminate movement
permanently
Instrumentation
• Holds the bone fragments in place until fusion
becomes complete
• Increases the fusion rate
28
29. Stabilizing the spine
Arthrodesis
Ways of bridging the bone gap
• Use of autologous bone grafts
• Use of allografts
• Use of bone graft substitutes
– Demineralized bone matrix
– Calcium sulfate tablets
– Hydroxyapatite
– Bone growth factors
– Biodegradable and non-biodegradable polymers
29
32. Arthrodesis
Use of bone substitutes
• Demineralized bone matrix, calcium sulfate
tablets, hydroxyapatite powder, bone
morphogenetic protein, polymers
34. Kinds of spine instrumentation
What segment is being stabilized
cervical, thoracic, lumbar
Where it is placed
Anterior vs posterior
Several different types
Rods and hooks
Plates and screws
Rods and screws
Interlaminar wiring
Interspinous wiring
Interbody fusion cages 34
43. 33 vertebrae of the bony spine
24 movable
• 7 cervical
• 12 thoracic
• 5 lumbar
14 fused
• 5 fused sacral
• 4 fused coccygeal
• 2 primary curves
• 2 secondary curves
• 72-75 cm in length
– ¼ are IV discs
44. Motion segment
• 3 JOINTS
– INTERVERTEBRAL DISC- (synarthroses=bone-con. tissue-bone); cartilage joint
– 2 FACET /APOPHYSEAL JOINTS (diarthroses=bone-joint capsule-bone); synovial
joint
• Pedicles
– Half the height of corresponding body forming a superior and inferior notch
– Adjacent inferior and superior notches form the intervertebral foramen thru
neural and vascular structures pass
46. Intervertebral disc
Central nucleus
– High water & proteoglycan (hydrophilic)=glycosaminoglycans(GAGs) +
water
– GAGs- chondroitin-4-sulfate, chondroitin-6-sulfate, hyaluronate, keratan
sulfate
– Lower collagen (type II-better for compression) content
– Exerts pressure radially against the annulus and endplate on weight-
bearing
47. Intervertebral disc
Peripheral annulus
– Higher collagen fibers
(type I-higher resistance to
tension) arranged
concentric lamellae
– Attached to the vertebral
cartilaginous endplates,
epiphyseal ring (Sharpey’s
fibers), vertebral body
periosteum, longitudinal
ligaments
– On weight-bearing, fibers
become horizontal
47
54. Muscle strain
Back extensors need to
exert a lot more force to
maintain the extensor
torque greater than the
flexion torque of your
slouched body.
Fatigue sets in leading to
microtears- strain
Most common cause of
low back pain.
54
Quadratus lumborum
55. Degenerative Changes
Disc- loss of disc height
• loss of water content
• loss of proteoglycans which maintain disc
hydration
Facet joints- degenerative arthritis
• Osteophyte formation
• Joint capsule thickening
Ligamentum flavum
• thickening
55
56. Degenerative changes
END RESULT:
BACK PAIN +/-
NUMBNESS/PARESTHESIAS OF
LEGS
– Narrowing of the neural foramen
and spinal canal
– Compression of neural elements
– Instability of the motion segment
– Diagnosis is RAYUMA.
• SPINAL STENOSIS
• DEGENERATIVE OSTEOARTHRITIS
• SPONDYLOSIS
56
58. Disc herniation
• Improper back use
exceeding tensile
strength of fibers
• Tears=back pain
• Healing of
tear=symptom relief
but weaker disc
59. Disc herniation
• Continued improper back
use
• Tears getting bigger
• Unable to hold “beach
ball in the middle”
• Strong PLL posteriorly
• Beach ball “slips”
posterolaterally
60. Disc herniation
• Nerve root
compression
(SCIATICA)
– Pain
– Paresthesias
– Power loss
• Exaggerated pain
when nerve put in
tension clinically
64. Spine fractures
2 major groups:
Acute, high-energy trauma, young age group
stabilize patient at scene, transport to hospital
Chronic osteoporotic fractures in the elderly
64
65. Relevant anatomy in acute spine trauma
3 column theory of stability (Denis) of the thoracolumbar spine
Anterior column: ALL, anterior half vertebral body, anterior annulus fibrosus
Middle column: Posterior half vertebral body, posterior annulus fibrosus, PLL
Posterior column: Facet joints and capsule, pedicle, lamina, ligamentum flavum,
interspinous ligament, supraspinous ligament
65
66. Vertebral column fractures
Classified according to the
mechanism of injury to
the middle column
1. Wedge compression
2. Burst
3. Chance fracture (GQ
Chance, 1948)
4. Flexion-distraction
5. Translational
66
67. Chance fracture
• Lapbelt flexion injury
with horizontal avulsion
of 2 or 3 columns with
axis of rotation in front
of vertebral column
• ½ with abdominal
injuries
• May have neurologic
compromise
• Should be checked in a
young px after a VA
67
68. Determinants of instability
McAfee et al. (1983)
• Progressive neurological deficit
• Greater than 20° of kyphosis
• Greater than 50% loss of vertebral body height
• Retropulsed bone fragments within the neural
canal
68
69. Management of Acute Spine Fractures
Stabilize the patient and the spine at the scene
of accident.
Determine stability of the fracture and
neurologic compromise.
70. Conservative management for stable fractures.
Brace wear for 3 months
Analgesics
Progressive strengthening after brace
Surgery for unstable fractures.
decompression and fusion
70
Management of Acute Spine Fractures
71. Osteoporotic compression fractures
Osteoporosis= low bone mass
At risk:
post-menopausal
elderly
women with small frame
white or asian
cigarette smoking
low calcium diet
eating disorders
sedentary lifestyle
high glucocorticosteroid state
hyperthyroidism
71
72. Osteoporotic compression fractures
Low energy or cumulative trauma
Clinically manifests as chronic pain, kyphotic
deformity, loss of height, and rarely neurologic
compromise.
Pain from spine deformity causing deformation
of pain-innervated structures like the
peripheral annulus, facet joint capsule, and
ligaments and muscle spasms.
72
73. Conservative management for
osteoporotic fractures
• Orthotic use
• Pharmacologic intervention
– Analgesia
– Calcitonin nasal spray
– Bone density improvement
• biphosphonates
• Strengthening of back muscles
• Improvement of flexibility
• Activity modification and functional lifestyle
73
77. Percutaneous balloon kyphoplasty
77
Recent randomized trials showed good improvement in pain
and function scores at 1 month follow-up. No difference with
placebo at 1 year.
83. Scoliosis
• Any lateral curvature of the spine with a
Cobb’s angle of less than 15 degrees have a
similar chance of progressing as a straight
spine.
• Less than 30 degrees rare chance of
progression after skeletal maturity. Keep a
curve below 30 degrees until maturity.
• 50 degree curves will progress.
83
84. Brace wear guidelines
Cobb’s angle Risser 0 Risser 1 to 2 Risser 3, 4 or 5
<25 Observe Observe Observe
25-45 Brace Brace Observe
>45 Surgery Surgery Surgery if >50
84
For idiopathic scoliosis, Tachdjian’s Pediatric Orthopedics, 2008
86. Scoliosis
Heart and lung compromise occur at curves of
90 and 100 degrees.
Brace wear is dose-dependent at least 23h/day
until skeletal maturity.
Juvenile scoliosis (< age 9) has the best bracing
results.
Congenital and neuromuscular scoliosis progress
very fast, are resistant to brace wear and have
poor prognosis.
86
87. Surgical intervention for scoliosis
Prevention of curve progression
• Fusion with or without instrumentation
• Instrumentation without fusion in young
growing patients
87
89. Spine tumor
Most common tumor of the spine is metastatic.
Most common primary malignant tumor of the
spine is multiple myeloma.
Problems of spinal tumor:
tumor removal
spinal stabilization
neurologic compromise
89
92. infoposter
• Compose and print an infoposter about selected
orthopedics topics and present it for 5 min
• Target audience: general public, medical students
(scope of ortho), pediatricians and parents (ddh
and clubfeet)
• 10 groups, 7 members, 1 topic
• To be printed on a 2’x 6’ tarpaulin sheet with
stand
• Choice of members and topic
92
93. infoposter
• Graded as a long exam
• Criteria: 50% content completeness and accuracy,
30% visual impact and creativity, 20% 5 min oral
presentation on March 4
• Need to have specific content approved first by
the 15th Feb
• Posters have to be displayed by 1pm on March 4
in the classroom
• Assign a spokesman for the group to speak about
the poster (max 5 min) and answer questions
93
94. topics
1. Orthopedics (definition, scope,
subspecialties, work being done, recruit med
students to take up orthopedic residency)
2. Fractures (early recognition, first aid,
treatment by doctors not hilots, cast care,
rehab)
3. Hand disorder (cumulative trauma disorders
like trigger finger, cts, de quervains, causes,
recognition, treatment and how to avoid)
94
95. topics
4. DM foot (causes, recognition, treatment,
prevention)
5. Osteosarcoma or enlarging mass in general
(recognition, treatment)
6. Osteoporosis (causes, recognition,
consequences, treatment, prevention)
7. Developmental hip dysplasia or clubfoot
(causes, recognition, newborn screening,
treatment)
95
96. topics
8. Sports injuries (injuries when taking up
running, recognition, proper shoes, warm-up,
training for marathon, diet)
9. Arthritis (differentiate bet osteoarthritis, RA
and gout, conservative treatment)
10. Low back pain (when to see a doctor, causes,
prevention)
96
