Failed conservative management – Spinal stenosis with neurogenic claudication – Herniated disc with radiculopathy – Spinal instability or deformity – Vertebral compression fracture with neurologic deficit – Spinal infection or tumor

1. Presenter
Yidersal S. (R3)
Moderator
Dr. Samson Y. (MD, neurologist )
Aug , 2021
Back pain

2. Outline
• Case
• Introduction
• Epidemiology
• Approach to back pain patient
• Etiology
• Management
• Prognosis

3. Case
• 35year old female
• Sustained falling down accident from 3m high ladder 2years back
• Landed on her back and lost her consciousness for unknown period of
time
• Since time trauma she had difficulty of walking with limping of left
leg
• She has piercing type of pain over the lower back exacerbated during
movement and decrease but not completely improved during rest
which radiate to the posterior part of left leg
• Other no history of bowel or bladder dysfunction
• No history fever, weight loss

4. • No history of headache, abnormal body mov’t
• No history of previous back pain before trauma
• she is a other of 4 and give birth all before accident
• No history of abdominal pain, abdominal swelling or vaginal discharge
• For the above compliant she took amitriptyline 25mg for 2yrs
• Since 5 months back the pain become worse despite amitriptyline
• No history of diabetes mellitus

5. Physical examination
• GA=ASL in pain
• v/s=BP 110/70 PR=84 RR =20 T=36.9
• MSK:
– There is Gibbs deformity over the lumbar spine, no tenderness
– Healed scar over left gluteal area
• NS:
– conscious and oriented
– No cranial nerve palsy
– power 5/5 on other extrimity
– Normal tone
– Reflex is ++ in ankle, knee and elbow bilaterally
– Pain, touch, vibration sensation is intact
– Coordination is ok
– SLR is positive over the left leg
– Crossed SLR is negative
• What is the cause of her pain?
• How do you manage her ?

6. Introduction
• Why back pain is a concern in medical community ?
– High cost
– Most common cause of disability in individuals <45 years of age
– Second most common reason for visiting a physician
– More than four out of five people will experience significant back
pain at some point in their lives
• 84 % of adults have low back pain at some time in their lives
• Most of them are self-limited

7. Anatomy of spine

10. Terminology
• Spondylosis
– Arthritis of the spine
• Spondylolysis
– A fracture in the pars interarticularis where the vertebral body and the posterior
elements protecting the nerves are joined
• Spondylolisthesis
– The injured vertebra to shift or slip forward on the vertebra directly below it
• Spinal stenosis:
– Narrowing of the vertebral canal by bone or soft tissue elements.
• Radiculopathy
– Impairment of a nerve root, usually causing radiating pain, numbness, tingling,
or muscle weakness .

12. Terminology -----

13. • Cauda equina syndrome
– Loss of bowel and bladder control
– Numbness in the groin and saddle area of the perineum
– Weakness of the lower extremities
– Spine stenosis or a large herniated disc

15. Risk factors
• Increasing age
• Smoking
• Muscle weakness in back and/or abdomen
• Psychosocial factors
• Occupational factors
• Manual material handling, bending/twisting
• Job dissatisfaction
• Overweight
• Repetitive lifting
• Chronic Steroid use
• Sedentary lifestyle
• Female gender

16. Potential sources of pain
• Nerve roots
• Intervertebral disc
• Facet joint
• Vertebral bodies
• Ligaments or soft tissues

17. Approach to back pain patient
History
• Focus first on features of pain
 Mode of onset
 Character
 Distribution
 Associated motor and sensory symptoms
 Bladder and bowel control
 Exacerbating and remitting factors
 History of predisposing factors (e.g., trauma, cancer, osteoporosis)

18. Type of pain
• Back pain by duration
– Acute LBP → < 6 weeks*
– Sub acute LBP→ between 6 weeks and 12 weeks
– Chronic LBP → > 12 weeks

19. Type of back pain
• Local pain
– injury to pain-sensitive structures that compress or irritate
sensory nerve endings
– The site of the pain is near the affected part of the back
• Pain referred to the back
– From abdominal or pelvic viscera
– Unaffected by posture
– The patient may occasionally complain of back pain only

20. Cont.
• Pain of spine origin
– From upper lumbar spine tend to refer pain to the
Lumbar Region, Groin, or Anterior Thighs
– Pain from lower lumbar spine tend to refer to the
buttocks, posterior thighs, or rarely the calves or feet
• Sclerotomal pain VS. radiculopathy?

21. Sciatica
• Pain radiating down posterior or lateral leg below the
knee
• The most common cause for sciatica is lumbar disk
herniation
• Symptoms that increase the specificity of sciatica
– Pain that is worse in the leg than in the back
– Typical dermatomal distribution of neurologic symptoms
– Pain that is worse with the Valsalva maneuver

23. Cont.
• Pain associated with muscle spasm
Commonly associated with many spine disorders
The spasms are accompanied by
Abnormal posture
Tense paraspinal muscles
Dull or achy pain in the paraspinal region

24. “Red flags” in back pain
• Age>55
• History of cancer
• Unexplained weight loss
• Failure to improve with conservative management after 4 weeks of
treatment
• Fever
• Immunosuppression
• Focal midline tenderness
• Bacteremia
• Indwelling catheter
• Iv drug use
• Bowel and bladder dysfunction

25. Physical examination
• The basic physical examination should include the following
components:
– Inspection of back and posture
– Range of motion
– Palpation of the spine
– Special tests
– Neurologic assessment
– Abdominal and rectal examination
– Evaluation for malignancy (breast, prostate, lymph node exam)
when persistent pain or history strongly suggests systemic disease

26. • Limited forward bending
– Paraspinal muscle spasm
• Lateral bending to the side opposite the injured spine
produce pain
• Limited hyperextension of the spine
– Nerve root compression, facet joint pathology, or other bony
spine disease is present

27. • Pain from hip disease may mimic the pain of lumbar spine
disease
• Hip pain can be reproduced
– By internal and external rotation at the hip with the knee and hip in
flexion (Patrick's Sign)
– By tapping the heel with the examiner's palm while the leg is
extended (Heel Percussion Sign)

28. Maneuver….
• Straight Leg–raising Maneuver
 Passive dorsiflexion of the foot during the maneuver adds
to the stretch
• The crossed SLR sign is less sensitive but more specific for
disk herniation than the SLR sign

29. • The Reverse SLR Sign
– Stretches the L2-L4 nerve roots, lumbosacral plexus, and
femoral nerve
• Naffziger’s test
– Pressure on jugular vein on patient lying on back for 10
second
– Back pain reproduce in the case of herniated disc

30. • Kerning sign
– Meningeal or spinal nerve root irritation
• Hoover test
– Real or malingering

31. Neurologic examination
• Includes
Focal weakness or muscle atrophy
Focal reflex changes
Diminished sensation in the legs, or
Signs of spinal cord injury
• Alert to the possibility of Breakaway Weakness,
defined as fluctuating strength during muscle testing

32. • Breakaway weakness
– may be due to pain or a combination of pain and
underlying true weakness
– Breakaway weakness without pain is almost always due
to a lack of effort
– Electromyography during ambiguous condition

35. Cervical radiculopathy

37. Non organic sign (Waddell's signs)
• The most reproducible of these signs are
– Superficial tenderness
– Distracted straight leg raising (ie, discrepancy between seated and supine
straight leg raising tests)
– The observation of patient overreaction during the physical examination
– Non dermatomal distribution of sensory loss,
– Sudden giving way or jerky movements with motor examination
– The presence of multiple Waddell's signs may suggest a behavioral
component to a patient's pain

38. Laboratory and imaging
• Laboratory studies are rarely needed for the initial evaluation of
nonspecific back pain
• CBC, ESR, urinalysis culture
• No need to investigating, if no serious risk factor

39. Imaging

40. • No need of earlier use of imaging for low back
– meta-analysis of six trials that compared immediate imaging with usual
care for patients
– Without signs or symptoms of infection or malignancy, found no
significant differences in out come
• Imaging scans often have abnormal findings in adults without
low back pain
– Disc herniation on MRI seen in 22 to 67% of asymptomatic adults and
spinal stenosis in 21% of asymptomatic adults over age 60
– Radiologic facet joint osteoarthritis increased with age and there was no
correlation with low back pain

42. Indication for imaging
• Infection
• Patients with cancer or at high risk of cancer
• Neurologic complication
• Radiculopathy with in need of intervention
• Compression fracture
• Patient with trauma

43. • Advanced imaging
– MRI without contrast is initial test for most patients with low back pain who require
advanced imaging
– Which can demonstrate normal and pathologic discs, ligaments, nerve roots, epidural
fat, as well as the shape and size of the spinal canal
– MRI is more sensitive and specific than plain radiographs for the detection of spinal
infection and malignancy
– MRI enhancement with gadolinium allows the distinction of scar from disc in patients
with prior back surgery
– In patients who require advanced imaging but cannot have an MRI, we generally
proceed with CT

45. Schmorl's nodes

46. Etiology
• 85% of patients have nonspecific low back pain
• Etiology of back pain can be categorized as
– Mechanical vs. non mechanical
– Back pain with led pain
– Back pain with out leg pain
– Back pain from visceral causes
– Leg pain with out back pain

47. Etiology

48. Etiology
• Causes of lower back pain without leg pain include:
– Ligamentous strain
– Muscle strain
– Facet pain
– Bony destruction
– Inflammation

49. • Causes of lower back with lower limb pain
– Radiculopathy
– Plexopathy
– Spinal stenosis
• causes of leg pain without low back pain
– Sciatic neuropathy
– Femoral neuropathy
– Peroneal neuropathy
– Meralgia paresthetica
– Peripheral polyneuropathies

50. • Back pain from visceral
– Pancreatitis
– Nephrolithiasis
– Pyelonephritis
– Abdominal aortic aneurysm
– Herpes zoster

52. Sprains and Strains
• Minor, self-limited injuries
• Lifting a heavy object, a fall, or a sudden deceleration
• Pain is usually confined to the lower back
• No radiation to the buttocks or legs
• Assume unusual postures

53. Traumatic vertebral fractures
• Results from injuries producing anterior wedging or compression
• Fracture-dislocation or "burst" fracture involving the vertebral body and
posterior elements
• A pars interarticularis fracture of the L5 vertebra is common in case of falls from
a height
• Sudden deceleration in an automobile accident
• Direct injury
• Neurologic impairment is common, and early surgical treatment is indicated

54. • Metastatic cancer
– The bone is one of the most common sites of metastasis
– A history of cancer
– Metastatic disease from breast, prostate, lung, thyroid, and kidney cancers
account for 80 percent of skeletal metastases
– ~ 60 % of patients with multiple myeloma have skeletal lytic lesions present at
diagnosis
– In patients with a history of cancer, sudden, severe pain raises concern for
pathologic fracture
– Patients may also have neurologic symptoms from either spinal cord
compression or spinal instability

55. • Spinal epidural abscess
– Spinal epidural abscess is a rare but serious cause of back pain
– Initial symptoms are often nonspecific
– Over time, localized back pain may be followed by radicular pain and, left
untreated, neurologic deficits
– Risk factors include recent spinal injection or epidural catheter placement,
injection drug use, contagious infections
– Immunocompromised patients may also be at higher risk
– Urgent antibiotic treatment and surgical therapy for those with neurologic
symptoms is required for patients with spinal epidural abscess

56. • Vertebral osteomyelitis
– Increases with age
– Men >women
– Post procedural from hematogenous spread of bacteremia
– Immunocompromised state and injection drug use
– Acute osteomyelitis typically presents with gradual onset of
symptoms over several days
– Present with back pain but may not have fevers or other
systemic symptoms
– Prompt antibiotic treatment improves outcomes

57. • Vertebral compression fracture
– 4 % of low back pain
– From no symptom to acute localize back pain
– There may be no history of preceding trauma
– Advanced age, chronic glucocorticoid use and previous
osteoporotic fracture
– 3 to 4 % of patients with compression fracture will have a
symptomatic disc herniation or spinal stenosis

58. • Radiculopathy
– Results from degenerative changes in the vertebrae, disc protrusion, and other
causes
– Presentations vary according the level of nerve root or roots involved
– >90 % is L5 and S1 radiculopathies
– Patients present with pain, sensory loss, weakness, and/or reflex changes
consistent with the nerve root involved
– Many patients with symptoms of acute lumbosacral radiculopathy improve
gradually with supportive care
– Sciatica
– SLR positive

59. • Spinal stenosis
– Lumbar spinal stenosis is most often multifactorial
– Spondylosis , spondylolistheses, Space-occupying lesions,
traumatic and postoperative fibrosis
– Neurogenic claudication
– Back pain, sensory loss and weakness in the legs
– Rare patients develop a cauda equina syndrome
– Patients often have symptoms only when active
– A trial of conservative, nonsurgical treatment is the initial
therapy for most patients

61. • Ankylosing spondylitis
– Few (0.5%-1%).
– men under the age of 40 year
– back pain with inflammatory etiology (morning stiffness, improvement with exercise,
pain at night)
– Extra skeletal disease manifestations (eg, uveitis)
• Osteoarthritis
– Facet joint or hip joint
– Commonly presents in patients over the age of 40
– Pain is typically exacerbated by activity and relieved by rest
– Osteoarthritis can lead to spinal stenosis

62. • Psychological distress
– Who seek financial compensation (malingerers)
– Substance abuse
– Many patients with CLBP have a history of psychiatric illness
– Childhood trauma (physical or sexual abuse) that antedates the
onset of back pain

64. Management
• Depends on
– Symptom duration
– Potential cause
– Presence or absence of radicular symptoms
– Corresponding anatomical or radiographic abnormalities

65. Acute back pain
• Self limited
• Pharmacologic
– Acetaminophen
– NSAIDs
– SMRs
• Non pharmacologic
– Heat wrap: improved pain and function
– Massage: improved pain and function
– Acupuncture: improved pain
– Spinal manipulation: improved function
Grade 2C recommendation

66. Chronic back pain
• Psychological evaluation and behaviorally based treatment paradigms are
frequently helpful
• Multidisciplinary approach
– Neurology, anesthesiology, physical therapy, psychiatry, psychology, and
primary care physicians
• Goals of therapy
– Improve pain
– Getting a good night’s sleep
– returning to work

67. • Pharmacologic
– NSAIDs: improved pain
– Opioids: improved pain and function
– Tramadol: improved pain and function
– Buprenorphine (patch or sublingual): improved pain
– Duloxetine: improved pain and function

68. • Non pharmacologic
– Exercise: improved pain and function
– Motor control exercise: improved pain and function
– Mindfulness-based stress reduction: improved pain and function
– Yoga: improved pain and function
– Progressive relaxation: improved pain and function

70. Surgical management
• Indicated for
– Neurologic deficits
– Cauda equina syndrome or conus medullaris syndrome
– No response with conservative management

71. Reference

72. Thank you