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LOW BACK PAINNurul Miftah & Che Nurul Ain

Causes in relation to age15-30 years old30-50 years old> 50 years oldProlapsed discTraumaFractureAnkylosing spondylitisSpondylolisthesisProlapsed discDegenerative spinaldiseaseBone infection or tumour(pyogenic osteomyelitis, spinal TB, spinal metastases)Degenerative spinal disease,osteoporotic vertebralcollapse, malignancy(primaryor secondary fromlung, breast, prostate,thyroid, or kidney Ca),Multiple myeloma, spinal stenosis, TB spineRed Flags!

PATHOPHYSIOLOGY OF DISC DEGENERATION

Lumbar Spondylosis (Degenerative osteoarthritis)Degenerative joint disease affecting lumbar vertebrae and intervertebral discPain and stiffnessSciatic radiation due to nerve root pressure by associated protruding disc or osteophytes

Clinical featuresHx of acute disc ruptured -> recurrent attacks of pain over several yearsIntermittent backache Hard physical work, standing or walking a lot or sitting in one position during a long journeyRelieve by laying downPain referred to buttock and down the leg (like sciatic)Tenderness at back and buttocksLumbar movement limited & painful at extremeDifficult in straightening up from forward bend position

X-raysRadiographic features of intervertebral disc degenerationFlattening of disc spaceMarginal bony spur (osteophytes)OA of facet joints

ManagementAsymptomatic dont need treatmentConservative treatmentModified activitiesExercise aerobic, stretching and muscle strengtheningWearing of a lumbar corsetSmall doses of anti-inflammatory drugPain control failSpinal fusion : immobilize the degenerated vertebrae -> relieve pain

If > 50 y.o., think bone mets > primary malignancy of boneCommonest sources : Ca of breast, prostate, kidney, lung, thyroid, bladder and GIT.Commonest site : vertebrae, pelvis, the proximal half of the femur and the humerus.Spread : hematogenous or directMetastases are usually osteoclastic and pathological fractures are common.Osteoblastic tumours are uncommon, usually occur in prostatic carcinoma.

Spinal MetastasisClinical FeaturesPrevious history of cancerAge 50-70Bone/back pain Sudden collapse of vertebrae bodySymptoms of hypercalcaemiaAnorexia, nausea, thirst, polyuria, abdominal pain, general weakness and depression

Lytic = black hole in the boneBlastic = abnormal white area

discrete rounded sclerotic lesions in right ilium "ivory vertebra" involvingL4 and S1. Bone ScanA nuclear medicine bone scan would show bone mets as dark areas

CTDetermining integrity of vertebral column (if surgery indicated)Management Curative - Radical treatment (surgery + radiotherapy) for both primary and secondary tumor if possiblePrognosis for survival = almost hopelessFocuses on relieving and preventing the suffering of patientsPain management- analgesia or radiotherapyFix fractures intramedullary nailingProphylactic fixationSpinal stabilisation- fitted braces or operative stabilizationHypercalcaemia hydration, reduce Ca intake, biphosphanatesCervical spondylosisCervical myelopathy DefinitionChronic intervertebral disc degeneration Cervical cord compression due to a narrow cervical canal-mainly due to cervical spondylosis.Clinical features-aged > 40-neck pain and stiffness-Gradual onset and worse after waking up.-Radiates to occiput, back of shoulders or one or both upper limbs.-numbness, weakness and clumsiness of hands -neck pain and brachialgia-discomfort varies from aching to sharp pain-gait disturbances, clumsy hand, spasticity, sphincter disturbances, motor weaknes, hypereflexia.X ray Findings-Narrowing of one or more intervertebral disc.-Bony spur formation at the anterior or posterior of disc.-Osteophytes encroaching on the intervertebral foramina.-narrow vertebral canal (