Back PainBack Pain

Tanya PotterTanya Potter

Consultant RheumatologistConsultant Rheumatologist

Case of Back PainCase of Back Pain

34 year old lady on post-natal ward34 year old lady on post-natal ward

Admitted with left sided lumbosacral Admitted with left sided lumbosacral pain pain

Relevant questions/thoughts?Relevant questions/thoughts?

Case of Back PainCase of Back Pain

44thth pregnancy, uncomplicated pregnancy, uncomplicated delivery, no epiduraldelivery, no epidural

Night and rest pain, left thigh Night and rest pain, left thigh radiation, worse with movement, radiation, worse with movement, unable to walk or weight bearunable to walk or weight bear

Episode of feeling cold and shivery 4 Episode of feeling cold and shivery 4 days previouslydays previously

Case of Back PainCase of Back Pain

OE in pain, not unwell, afebrile, OE in pain, not unwell, afebrile, haemodynamically stablehaemodynamically stable

Tender left lumbosacral region, unable to Tender left lumbosacral region, unable to do SLRdo SLR

Hip ok Hip ok

No neurology, bladder and normal PR No neurology, bladder and normal PR

Case of Back PainCase of Back Pain

Case of Back PainCase of Back Pain

ESR 101, CRP 201ESR 101, CRP 201 ALP 489, ALB 19ALP 489, ALB 19 Hb 9.8 MCV 76Hb 9.8 MCV 76 Differential diagnosis and further Differential diagnosis and further

investigations? investigations?

MRIMRI

septic  arthritis  of  left  SIJ  with  an  abscess  in  thegreater  sciatic  notch

Blood cultures Beta-haemolytic Blood cultures Beta-haemolytic Strep.Strep.

IV AntibioticsIV Antibiotics Orthopaedic review Orthopaedic review CT guided aspirationCT guided aspiration Few weeks later CRP 28Few weeks later CRP 28 Repeat MRI Repeat MRI

MRIMRI

Some resolution of Some resolution of abscess, marrow abscess, marrow oedema, some oedema, some destruction of SIJ destruction of SIJ

CausesCauses

Simple mechanical eg ligamentous strainSimple mechanical eg ligamentous strain Degenerative disease with/without neural, Degenerative disease with/without neural,

cord or canal compromisecord or canal compromise Metabolic – osteoporosis, Pagets Metabolic – osteoporosis, Pagets Inflammatory – Ankylosing spondylitisInflammatory – Ankylosing spondylitis Infective – bacterial and TBInfective – bacterial and TB NeoplasticNeoplastic Others, (trauma, congenital)Others, (trauma, congenital) VisceralVisceral

Triggers to investigate/ referTriggers to investigate/ refer

Red Flags ?Red Flags ?

Red flagsRed flags

– Age <20 or >50 with back pain Age <20 or >50 with back pain for the 1for the 1stst time time

– Thoracic pain >50 yrsThoracic pain >50 yrs- Pain following a violent Pain following a violent

injury/traumainjury/trauma- Unremitting, progressive painUnremitting, progressive pain

Red flagsRed flags

- Past or current history of cancerPast or current history of cancer- On Steroids or On Steroids or

immunosuppressantsimmunosuppressants- Drug abuser or +ve HIVDrug abuser or +ve HIV- Systemic symptoms - fever, Systemic symptoms - fever,

appetite and weight loss, malaise appetite and weight loss, malaise

Red flagsRed flags

- Bilateral leg radiation, Bilateral leg radiation, sensory/motor/sphincter symptoms sensory/motor/sphincter symptoms

- Pain predominantly at nightPain predominantly at night

Inflammatory flags ?Inflammatory flags ?

Inflammatory flagsInflammatory flags

- Morning stiffness and pain >30 mins -1 hrMorning stiffness and pain >30 mins -1 hr- Better with activityBetter with activity- Peripheral joint involvementPeripheral joint involvement- Anterior uveitisAnterior uveitis- PsoriasisPsoriasis- Inflammatory bowel diseaseInflammatory bowel disease- Recent GI or GU infectionRecent GI or GU infection- Family historyFamily history

Myotomes and dermatomes ?Myotomes and dermatomes ?

MyotomesMyotomes

C5 Deltoid, biceps (biceps jerk)C5 Deltoid, biceps (biceps jerk) C6 Wrist extensors, biceps (biceps, C6 Wrist extensors, biceps (biceps,

brachioradialis jerk) brachioradialis jerk) C7 Wrist flexors, finger extensors, C7 Wrist flexors, finger extensors,

triceps (triceps jerk)triceps (triceps jerk) C8 Finger flexor, thumb extensors C8 Finger flexor, thumb extensors

(triceps jerk)(triceps jerk) T1 finger abductorsT1 finger abductors

MyotomesMyotomes

L2 Hip flexionL2 Hip flexion L3 Knee extension (knee jerk)L3 Knee extension (knee jerk) L4 Knee extension, ankle dorsiflexion L4 Knee extension, ankle dorsiflexion

(knee jerk)(knee jerk) L5 toe dorsiflexionL5 toe dorsiflexion S1 foot plantar flexion, eversionS1 foot plantar flexion, eversion

DDEERRMMAATTOOMMEESS

Principles of examinationPrinciples of examination

ExaminationExamination

LOOK – deformity, muscle wasting, LOOK – deformity, muscle wasting, kyphosis, scoliosiskyphosis, scoliosis

LOOK – normal cervical lordosis, LOOK – normal cervical lordosis, thoracic kyphosis, lumbar lordosisthoracic kyphosis, lumbar lordosis

FEEL – spinal processes and FEEL – spinal processes and sacroiliac jointssacroiliac joints

ExaminationExamination

MOVE – Lumbar flexion MOVE – Lumbar flexion Schober’s test – marks at “dimples Schober’s test – marks at “dimples

of Venus” and 10 cm above. Measure of Venus” and 10 cm above. Measure at maximal flexion – usually 5 cm at maximal flexion – usually 5 cm

MOVE – Lumbar lateral flexionMOVE – Lumbar lateral flexion MOVE – Cervical flexion/extension, MOVE – Cervical flexion/extension,

lateral rotation and flexion, thoracic lateral rotation and flexion, thoracic rotation rotation

ExaminationExamination

Sciatic stretch (patient supine) - Sciatic stretch (patient supine) - Straight leg raise and dorsiflexion of Straight leg raise and dorsiflexion of foot - pain in calf and posterior thigh foot - pain in calf and posterior thigh between 30-70between 30-70o o – low lumbar (L5/S1) – low lumbar (L5/S1) lesion or sciatic irritationlesion or sciatic irritation

Femoral stretch (patient prone) – Femoral stretch (patient prone) – knee is flexed and then hip extended knee is flexed and then hip extended – pain in anterior thigh – high lumbar – pain in anterior thigh – high lumbar (L2-L4) lesion(L2-L4) lesion

ImagingImaging

XR XR –– Isotope Bone scan –Isotope Bone scan – MRI – MRI – CTCT

ImagingImaging

XR – tumour, fracture, infection, XR – tumour, fracture, infection, inflammationinflammation

Isotope Bone scanIsotope Bone scan – – MRI –MRI – CT CT

ImagingImaging

XR – tumour, fracture, infection, XR – tumour, fracture, infection, inflammationinflammation

Bone scan – increased turnover eg Bone scan – increased turnover eg infection, metastatic disease, infection, metastatic disease, fractures, Pagetsfractures, Pagets

MRI MRI – – CTCT

ImagingImaging

XR – tumour, fracture, infection, XR – tumour, fracture, infection, inflammationinflammation

Bone scan – increased turnover eg Bone scan – increased turnover eg infection, metastatic disease, infection, metastatic disease, fractures, Pagetsfractures, Pagets

MRI – soft tissue, discs, facet joint, MRI – soft tissue, discs, facet joint, nerve roots, cord, inflammationnerve roots, cord, inflammation

CTCT

Degenerative disease and Degenerative disease and sciaticasciatica

Very commonVery common Facet joint OA, disc disease, Facet joint OA, disc disease,

osteophyteosteophyte Mechanical back painMechanical back pain Sciatica – most resolve NB persistent, Sciatica – most resolve NB persistent,

neurology, bilateral, red flagsneurology, bilateral, red flags Analgesia, PT, pain clinicsAnalgesia, PT, pain clinics

Degenerative disease and Degenerative disease and sciaticasciatica

MalignancyMalignancy

Which cancers associated with bone Which cancers associated with bone mets?mets?

MalignancyMalignancy

Unremittting, progressive and night painUnremittting, progressive and night pain Systemic symtomsSystemic symtoms Past hx CaPast hx Ca Breast, bronchus, thyroid, kidney, prostate Breast, bronchus, thyroid, kidney, prostate

and myeloma/plasmacytoma and myeloma/plasmacytoma Osteolytic (prostate osteoblastic)Osteolytic (prostate osteoblastic) XR can be normal in early stages – further XR can be normal in early stages – further

imaging if suspicion highimaging if suspicion high Predilection for vertebral body and pediclesPredilection for vertebral body and pedicles

Malignancy Malignancy

MalignancyMalignancy

InfectionInfection discitis, osteomyelitis, and epidural discitis, osteomyelitis, and epidural

abscess. abscess. hematogenously spread hematogenously spread most often Staphylococcus aureus.most often Staphylococcus aureus. Gram-negative rods in postoperative or Gram-negative rods in postoperative or

immunocompromised patientsimmunocompromised patients normal skin flora is less commonly isolated normal skin flora is less commonly isolated

in postoperative patients. in postoperative patients. Postoperative patients develop symptoms Postoperative patients develop symptoms

2 to 4 weeks after surgery after an initial 2 to 4 weeks after surgery after an initial improvement in pain. improvement in pain.

InfectionInfection Pseudomonas organisms Pseudomonas organisms Mycobacterium tuberculosis in Mycobacterium tuberculosis in

developing nations and immigrant developing nations and immigrant population. Fungal infections are population. Fungal infections are rare. rare.

Only one third have fever and 3% to Only one third have fever and 3% to 15% present with neurologic deficit.15% present with neurologic deficit.

Infections typically involve the Infections typically involve the intervertebral disc and vertebral intervertebral disc and vertebral body endplatebody endplate

InfectionInfection Radiographic changes at 2 to 4 weeksRadiographic changes at 2 to 4 weeks

bone scan can be positive as early as 2 bone scan can be positive as early as 2 days 75% specificdays 75% specific

MRI appearance is decreased T1- and MRI appearance is decreased T1- and increased T2-weighted signal in the increased T2-weighted signal in the infected disk. Enhancement after infected disk. Enhancement after gadoliniumgadolinium

InfectionInfection Conservative treatment of antibiotics, rigid Conservative treatment of antibiotics, rigid

bracing to prevent deformity and control bracing to prevent deformity and control painpain

Surgery : neurologic deficit, presence of Surgery : neurologic deficit, presence of abscess, extensive bone loss with kyphosis abscess, extensive bone loss with kyphosis and instability, failure of blood work and and instability, failure of blood work and biopsy to isolate any organism, excision of biopsy to isolate any organism, excision of a sinus tract, or no response to a sinus tract, or no response to conservative treatment.conservative treatment.

InfectionInfection

InfectionInfection

OsteoporosisOsteoporosis

Risk factors for osteoporosis? Risk factors for osteoporosis?

Treatment for OP ?Treatment for OP ?

LifestyleLifestyle

MedicationMedication

vertebroplastyvertebroplasty

Spinal stenosisSpinal stenosis

Canal or foraminal narrowing with Canal or foraminal narrowing with possible subsequent neural possible subsequent neural compressioncompression

Cause Cause Ligamanetum flavum hypertrophyLigamanetum flavum hypertrophy, ,

facet joint hypertrophy, vertebral facet joint hypertrophy, vertebral body osteophytes, herniated discbody osteophytes, herniated disc

Rare: Pagets, AS, acromegalyRare: Pagets, AS, acromegaly

Symptoms of spinal stenosis ?Symptoms of spinal stenosis ?

Spinal stenosisSpinal stenosis

SymptomsSymptoms– Age - >50Age - >50– Dull aching pain in the lower back and legsDull aching pain in the lower back and legs– Exertional leg pain/weakness/numbnessExertional leg pain/weakness/numbness– Symptoms relieved leaning forward, sitting or lyingSymptoms relieved leaning forward, sitting or lying

ExaminationExamination– May be normalMay be normal– Normal sensation and powerNormal sensation and power– Reflexes normal or slightly reducedReflexes normal or slightly reduced– Normal foot pulsesNormal foot pulses

Spinal stenosisSpinal stenosis

Spinal stenosisSpinal stenosis

Conservative – analgesics, NSAIDs, Conservative – analgesics, NSAIDs, PT, epiduralPT, epidural

Surgery – laminectomy Surgery – laminectomy (+arthrodesis)(+arthrodesis)

cauda equinacauda equina

Features? Features?

Cauda Equina SyndromeCauda Equina Syndrome

Back pain, lower limb weakness, saddle Back pain, lower limb weakness, saddle anaesthesia, sphincter disturbance, anaesthesia, sphincter disturbance, impotence impotence

Causes – usually disc, rarely tumour, Causes – usually disc, rarely tumour, abscess, advanced AS abscess, advanced AS

Diminished sensation L4 to S2 (sacral Diminished sensation L4 to S2 (sacral numbness), weakness ankle and plantar numbness), weakness ankle and plantar dorsiflexion, loss ankle jerks, urinary dorsiflexion, loss ankle jerks, urinary retention, loss anal toneretention, loss anal tone

Urgent MRI and surgical decompressionUrgent MRI and surgical decompression

Cauda Equina SyndromeCauda Equina Syndrome

Another cause of back pain Another cause of back pain (older)(older)

Another cause of back pain Another cause of back pain (younger)(younger)

Later on…Later on…

ASAS

New hope for ASNew hope for AS

TNF alpha blockade significant and TNF alpha blockade significant and sustained improvement in disease sustained improvement in disease activity, function and quality of lifeactivity, function and quality of life

Role in extra-articular disease, Role in extra-articular disease, enthesitis, dactylitis, peripheral joint enthesitis, dactylitis, peripheral joint diseasedisease

SummarySummary

Multiple causes for back painMultiple causes for back pain

Think of red flagsThink of red flags

Image only when it might change Image only when it might change managementmanagement