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Low Back Pain (Newer) - Low Back Pain Low H Shraideh MD...

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Unformatted text preview: Low Back Pain Low H Shraideh, MD, FAANS Department of Neurosciences, JUST Anatomy/ Spine •Trijoint complex •Anterior elements; 80% of Anterior the load the Posterior elements; 20% Posterior •static stability: Bony static elements and intervertebral disk. •Dynamic stability: muscular Dynamic and ligamentous supports and Brad Bunney, MD Anatomy • Vertebra – body, neural arch, bony Vertebra process process • Ligaments & muscles = stability • Cervical nerve roots pass above body (All others pass below) Brad Bunney, MD Epidemiology 50-60% Life time incidence of LBP 15-30% prevalence among adults 1% of population are disabled because of LBP 15% of the sick leave 85% no specific diagnosis can be made Highest prevalence 40-60 year of age Overall incidence of LBP 45/1000 person per year M=F Brad Bunney, MD Clinical presentation LBP +/- radiculopathy Pain exacerbated with physical stress and Pain relieved with bed rest relieved P/E differentiate mechanical (non-specific) P/E LBP from serious spinal conditions (radiculopathy or cauda equina syndrome caused by PID, tumors, infections…..) caused Brad Bunney, MD History / red flags Hx Hx of cancer (prostate, breast, kidney, thyroid, lung) lung) Unexplained wt loss Immunosuppression Pain that worse at rest psuedoclaudication Pain not responding to conservative Rx Skin or other systemic infection Urine and fecal incontinence Brad Bunney, MD Examination / red flags Fever Spinal deformity Tenderness & L.O.M +ve SLR test Motor and /or sensory deficits Motor Brad Bunney, MD Recommendations absent red flags Bed rest Activity modification Analgesia Reassurance > 85 % show improvement within 4 weeks 85 without the need for diagnostic studies without Brad Bunney, MD Diagnostic work / pts with red flags Plain L.S Xray L.S CT scan L.S. MRI L.S. Myelography Brad Bunney, MD Lower back pain + red flags PID; PID; Traumatic (Acute) vs degenerative (gradual) (gradual) Spinal tumors (intradural vs extradural) Spinal infections (osteomyelitis, epidural Spinal abcess) abcess) Brad Bunney, MD PID Displacement Displacement of disc material beyond confines of the disc space the Pain start with back pain, which after days or Pain weeks produce radicular pain with reduction of the back pain back Precipitating factors are identified < 20% of cases Radicular pain is relieved by flexing the knee and Radicular hip hip Pain exacerbated by coughing and sneezing or Pain straining (cough effect) straining Bladder symptoms (usually retention) < 5% Brad Bunney, MD PID Physical signs (NL-sensory & motor loss) Lesègue sign (slow leg raising test) Brad Bunney, MD PID L3-L4 Compressed Compressed root root L4-L5 L5-S1 L4 L5 S1 % 5-10% 40-45% 40-45% Reflex affected Knee - Ankle jerk Motor Q. Femoris Q. (knee ex) (knee EHL & tibialis EHL (foot drop) (foot Gastrocnemius Gastrocnemius (plantarflexion) (plantarflexion) Sensory M. maleolus Dorsum of Dorsum foot foot Brad Bunney, MD L. maleolus PID Brad Bunney, MD Disc Herniation • L4-5, L5-S1 most common • Cervical and thoracic do occur • Thoracic: abrupt neuro deficits - • Narrow canal Postero-lateral aspect of the Postero-lateral disc disc Brad Bunney, MD Disc Herniation • Not necessary to have history of Not strain or injury strain • Unilateral radicular back pain with Unilateral nerve root impingement nerve Brad Bunney, MD Disc Herniation • X-ray only good if inter-vertebral X-ray disc is narrow disc • MRI is gold standard • Electromyelography localizes the Electromyelography specific nerve root specific Brad Bunney, MD Disc Herniation Brad Bunney, MD PID Most common at L4-L5 & L5-S1 L4-L5 Bulge, protrusion, Bulge, extrusion, sequestered, migrated migrated Midline or lateral Brad Bunney, MD PID Brad Bunney, MD Brad Bunney, MD PID -Traumatic -Degenerative Brad Bunney, MD DDD - - - Aging process Progressive dehydration of Progressive the nucleus pulposus and loss of disk volume loss Degenerative tear in the Degenerative annulus with herniation of the nucleus pulposus through this tear. through Present with L.B.P and Present L.O.M L.O.M Brad Bunney, MD DDD Three Phases: - phase I, circumferential tears or fissures in phase the outer annulus. +/- endplate separation or failure, interrupting blood supply to the disk and impairing nutritional supply and waste removal. Such changes may be the result of repetitive microtrauma. Circumferential tears may coalesce to form radial tears. radial Brad Bunney, MD Brad Bunney, MD DDD Phase II; The unstable phase, loss of mechanical integrity of the trijoint complex. Internal disk disruption (IDD), loss of disk-space height. Concurrent changes in the facet joints include cartilage. leading to segmental instability (Spondylolisthesis). Brad Bunney, MD DDD Phase III; Stabilization phase, characterized by further disk resorption, disk-space narrowing, endplate destruction, disk fibrosis, and osteophyte formation Brad Bunney, MD DDD Brad Bunney, MD Disc Herniation • Initial therapy is to decrease Initial pressure on the root pressure • Bed rest up to 4 weeks • Non-steroid anti-inflammatory • Muscle relaxants Brad Bunney, MD Disc Herniation • Absolute indication for surgery - Significant muscle weakness - Progressive neurological deficit with Progressive bed rest bed - Bowel or bladder dysfunction Brad Bunney, MD Disc Herniation • Relative indication for surgery - Pain despite bed rest - Recurrent episodes of severe pain Brad Bunney, MD PID / Discectomy • Emergency surgery for: - Progressive motor deficit - Cauda equina syndrome Brad Bunney, MD PID / Discectomy Brad Bunney, MD PID / Discectomy Brad Bunney, MD Brad Bunney, MD Discectomy / Complications Infection (superficial vs deep) Increased deficit (injury to neural structure) Dural tear (CSF leak) Complications of positioning Failed surgery (incorrect dx, incomplete Failed surgery) surgery) Vascular injury Brad Bunney, MD Thecal sac compression • Malignant epidural spinal cord Malignant compression (MESCC) • Spinal epidural abscess (SEA) • Spinal epidural hematoma Spinal (SEH) (SEH) Brad Bunney, MD Thecal sac compression Thecal Factors Factors • Force of compression • Direction of compression • Rate of compression Brad Bunney, MD MESCC • Hematogenous spread • Bone marrow • Compress cord and vascular supply • Edema, infarction Brad Bunney, MD MESCC • Prostate • Lung • Breast • Non-Hodgkin’s lymphoma • Multiple myeloma • Renal cell cancer Brad Bunney, MD MESCC • Initial presentation in 20% of Initial malignancies malignancies • Cervical, thoracic & lumbar by Cervical, proportion of vertebral body volume proportion • Thoracic is most common Brad Bunney, MD MESCC • 95% have back pain • Precedes other symptoms by 1-2 Precedes months months • Percussion tendencies, thoracic Percussion location, worse lying down location, Brad Bunney, MD MESCC • 75% have weakness by time of 75% diagnosis diagnosis • Weakness symmetric • Ascending numbness • Autonomic dysfunction, urinary Autonomic retention retention Brad Bunney, MD MESCC • Plain X-ray 10-17% false negative • 30-50% of bone must be destroyed 30-50% for X-ray to be positive for • MRI, CT myelography are MRI, standards standards Brad Bunney, MD MESCC • Plain X-ray 10-17% false negative • 30-50% of bone must be destroyed 30-50% for X-ray to be positive for • MRI, CT myelography are MRI, standards standards Brad Bunney, MD MESCC Brad Bunney, MD MESCC • Corticosteroids first line for edema • Dexamethosone, 20-100 mg load, Dexamethosone, 4-24 mg 4 times/day 4-24 • Radiation therapy within 24 hours Brad Bunney, MD MESCC • Surgery for: - • unresponsive to radiation therapy Acute neurological deteriorations Chemotherapy – Non-Hodgkin’s Chemotherapy lymphoma lymphoma Brad Bunney, MD The Case 55 yo male with low back pain. The pain is sharp, right-sided, 55 worse with movement and non-radiating. He has no weakness, numbness or incontinence. No hx of trauma. Pmhx: HTN, irritable bowel syndrome, cervical disc herniation Pmhx: Meds: none Sochx: alcohol use PE: afebrile, VSS Back: mild tenderness right paraspinal area, L2-3 Neuro: normal What do you want to do? Brad Bunney, MD The Case He is given NSAI which makes him better and is sent He home. 5 days later he is at a new hospital with the complaint of back pain, says it is the same as before, “I ran out of my medicine”. ran PE: Afebrile, VSS Back: right paraspinal tenderness, worse with movement Neuro: numbness anterior and med thigh What do you want to do? Brad Bunney, MD The Case He has an abdominal CT scan to R/O renal stone which was He normal. He is given a shot of paracetamol which makes him feel better and is discharged with paracetamol and Valium. He returns 2 days later with worsening pain that radiates to the right foot and left knee. He has numbness to the thighs and groin, and has been incontinent of stool. incontinent PE: Afebrile, VSS Back: diffuse tenderness to lumbar spine palpation Neuro: RLE- 3/5 strength, numbness anterior and med thigh, Neuro: decreased reflex. LLE- 4/5 strength. decreased What do you want to do? Brad Bunney, MD The Case Brad Bunney, MD The Case MRI is done which confirms a compressive lesion from MRI L2 to L4. WBC = 18,000. The patient is given antibiotics and is admitted to neurosurgery. An L3-L4 laminectomy is done and pus is drained. Organism= Streptococcus and Stomatococcus mucilaginosis Patient was discharged to a rehab facility on hospital day 13 for 6 weeks of Vancomycin therapy. At the time of discharge he was continent, but could only ambulate Brad Bunney, MD with assisted use of a walker. Conclusion • Back pain is common in the ED • Radicular pain requires diligence to find Radicular the cause the • The severity of spinal cord compression The is related to force, duration and rate is • Emergent therapy is necessary • “Spinal Cord Attack” Brad Bunney, MD SEA Risk Factor • IVDA • Diabetes • Trauma • Prior spinal surgery or nerve blocks • Immune compromised host Brad Bunney, MD SEA Presenting Complaints • Back pain • Paresthesias • Motor deficits • Fever Brad Bunney, MD SEA Diagnosis • WBC • Sedimentation Rate • MRI = gold standard Brad Bunney, MD SEA Organisms • Staphylococcus aureus - Methicillin resistant – 15% • Streptococcus • Escherichia coli • Pseudomonas • Klebsiella • Brad Bunney, MD Mycobacterium Tuberculosis SEA Treatment • Surgery – depending on - Extent of spine involved - • severity of neuro deficits Infecting organism Antibiotics Brad Bunney, MD SEA Non-Operative Indications • Panspinal involvement • Lumbosacral SEA and normal neuro Lumbosacral exam exam • Fixed neuro deficit for > 48 hours Brad Bunney, MD SEA Antibiotics • Start immediately • Vancomycin • Aminoglycoside or 3rd generation cephalosporin cephalosporin • 4 to 6 weeks Brad Bunney, MD Vertebral Osteomyelitis -IVDA -D.M -Hemodialysis -Elderly -Immune compromised patients -Postoperative -Lumbar spine, Thoracic, Cervical, Sacrum -Neurological findings develop late -Neurological (delayed Dx) (delayed -Vertebral body collapse, Kyphotic Vertebral deformity deformity -Staph. Aureus -Medical vs. Surgical Brad Bunney, MD Medical VO / Epidural abcess Brad Bunney, MD Spinal Epidural Hematoma (SEH) Risk Factors • Coagulapathy • Trauma • Vascular lesion • Surgery • Epidural catheterization Brad Bunney, MD SEH Diagnosis • Back pain, neuro deficit • Symptom onset to max. neuro deficit = 13 Symptom hours hours • All segments of spinal cord • MRI = gold standard • Plain X-ray or CT scan for fractures or Plain dislocation dislocation Brad Bunney, MD SEH Treatment • Surgical evacuation • Immediate surgery within 12 hours of Immediate presentation had better outcome than later surgery than Brad Bunney, MD LBP Spinal Spinal stenosis Ankylosing spondylitis Spinal tumors Brad Bunney, MD First line of therapy for epidural spinal First cord compression from metastatic cancer is: is: A. Radiation therapy B. Surgery Surgery C. Corticosteroids C. Corticosteroids D. Chemotherapy D. Brad Bunney, MD The most common site of epidural spinal The cord compression from metastatic cancer is: is: A. Cervical spine B. Thoracic spine C. Lumbar spine D. Sacral spine Brad Bunney, MD All of the following are indications for nonoperative treatment of spinal epidural operative abscesses except: abscesses A. Pan-spinal involvement B. Lumbosacral SEA and normal neurological Lumbosacral exam exam C. Fixed neurological deficits for greater than 48 Fixed hrs hrs D. Urinary incontinence and sensory deficit Brad Bunney, MD All of the following contribute to the All severity of spinal cord compression except: except: A. Force of compression B. Length of spinal cord compressed C. Duration of compression D. Rate of compression Brad Bunney, MD The most common organism cultured in The spinal epidural abscesses is: spinal A. Streptococcus B. Pseudomonas C. Staphylococcus aureus D. Klebsiella E. Mycobacterium Mycobacterium tuberculosis tuberculosis Brad Bunney, MD Objectives • • • • Discuss the different types of LBP Review anatomical principles Review nontraumatic etiologies for LBP Treatment options for patients with LBP Brad Bunney, MD Nerve Root Diagnosis L4 • Pain = lateral back, antero-lateral Pain thigh, anterior calf thigh, • Numbness = anterior thigh • Weakness = quadriceps • Diminished knee jerk • Squat and rise Brad Bunney, MD Nerve Root Diagnosis L5 • Pain = hip, groin, postero-lateral Pain thigh, lateral calf and dorsum of foot thigh, • Numbness = lateral calf • Weakness = dorsiflex great toe • Heel walking Brad Bunney, MD Nerve Root Diagnosis S1 • Pain = mid-gluteal region, posterior Pain thigh, posterior calf to heel & sole thigh, • Numbness = posterior calf • Weakness = plantar flex great toe • Diminished ankle jerk • Walk on toes Brad Bunney, MD PID / Discectomy Brad Bunney, MD ...
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