CBL 4 Done by:

Najla Al-Ghabban

Mashael Al-Towairqi

Sumaya Al-Amri

HISTORY

Mr. Ahmed is a 67 years old retired male engineer

presented to primary care clinic complaining of chronic

low back pain radiating to both lower limbs for the last

one year.

KEY FACTORS

• 67 years old retired male engineer

• Chronic low back pain

• Radiating to both lower limbs

• For one year

LOWER BACK PAIN(CHRONIC)

Spinal infection

Spinal tumors

Vertebral fracture

Muscular sprain

Lumbar disc herniation

Degenerative spine

disease, Spinal

stenosis

Dissecting aneurysm

Pyelonephritis

Pancreatitis

Spinal causes : Extra Spinal causes :

HISTORY

•HPI:

-Pain

-Hx of trauma

-Functional level

HISTORY

•Risk factors:

-Genetic predisposition

-Age

-Smoking

-Obesity

-Previous injury, fracture or subluxation (trauma)

-Deformity

-Occupation

-Infections

-PHx of cancer

HISTORY

•Red Flags:

-Loss of weight / appetite

-Fevers, sweats

-Night pain, rest pain

-Immunosuppresion

-Loss of sensation

-Loss of motor function

-Sudden difficulties with urination or defecation

HISTORY

•MSK systemic review:

-Stiffness

-Swelling

-Instability

-Deformity

-Limp

-Altered Sensation

-Loss of function

-Weakness

HISTORY

•PMH: He reported that he is known diabetic but

otherwise has no other health problems

•PSH

•Drug Hx

•Allergy

•Family Hx

•Social Hx

FURTHER HISTORY

• There is no history of trauma

• Pain has been progressing during last year but

there has been milder pain over many years

•Pain is aggravated by walking for long distance

and radiates to legs with numbness

•Patient gets relief on bending or lying down

•Patient has no night pain or urinary symptoms

TO DIFFERENTIATE BETWEEN NEUROGENIC

AND VASCULAR CLAUDICATION

Neurogenic Vascular

palliative

factors

provocative

factors

PHYSICAL EXAMINATION Back examination

VITAL SIGNS

Pulse =90/min normal (60-100/min)

BP=145/95 normal(90-140/60-90) what could

be the cause?

RR=18/min normal (12-18)

Temperature=37

BACK EXAMINATION

o Position: Standing , supine position

o Exposure: Trunk and lower limbs covering the

unneeded area

o Look: Front, side, behind

o Feel

o Move

o Do

STANDING POSITION

1-LOOK:

o Skin changes (café au latte spots in

neurofibromatosis)

o Hairy patch

o Deformity: Scoliosis, kyphosis

o Level of: shoulder ,waist and pelvis

o Swelling

o Gait

GAIT

What are the abnormal gaits you know?

GAIT

1-Standing on heels:

o To test L4-L5

o To test 3 muscles:

tibialis anterior, extensor halluces longus,

extensor dgitorum

2-Standing on tiptoes:

o To test S1

o To test gastrocnemius muscle and soleus

2-FEEL

o Spinous processes (tenderness, stips, gaps)

o Paravertebral muscles (tenderness , spasm)

o Temperature

3-MOVE

Active movement :

Flexion: see the level of fingers tip, normally the

patient can bend reach 10cm from the floor 90

degree reaching the medial malleoli without pain

Extension: up to 30 degree

Lateral bending: 30 degree

Rotation: up to 45degree (stabilize the hip)

During the movement note any limitation and if

there is any pain

If the patient cannot move actively then do

passive range of motion

4-DO SPECIAL TEST

Adam`s forward bending test:

o To see if there is rib hump

o If positive: Sign for scoliosis

SUPINE POSITION

o Look: any muscle wasting in the lower limbs

o Feel : tenderness, hotness

o Do special test : SLR (Straight Leg Raising)

HOW IT`S DONE

o With the leg fully extend , put your hand under

the heel and start to raise it passively and slowly.

o Normally the raising degree should be 80 or more

without pain.

o If there is shooting pain radiates to the lower

part between 30-70 degrees the test is positive

and indicate?

o To confirm the diagnosis we dorseflex the ankle

joint (pain increse) and with knee flexion(pain

relieved).

AT THE END

We finish our examination by neurovascular

examination and rectal examination

NEUROLOGICAL EXAMINATION

1-Dermatoms (sensation)

L1= inguinal ligament

L2= front of the thigh

L3= at knee

L4= medial side of shin

L5= dorsum of the foot

S1= small toe

S2= lateral back of the thigh

S3-S5= saddle area

2-Myotoms(power)

L2= hip flexion

L3=knee extension

L4=dorsal flexion of the

ankle

L5=big toe extension

S1=plantar flexion

VASCULAR EXAMINATION

o Pulse:

Dorsalis pedis

Posterior tibial

Pupliteal

o Capillary refilling

TO DIFFERENTIATE BETWEEN NEUROGENIC

AND VASCULAR CLAUDICATION

Neurogenic Vascular

Pulses

Bicycle test

EXAMINATION FINDINGS

Patient walk with slightly flixed back

Moderate spasm of paravertebral muscles

Tenderness of lumbar spine from L4-S1

Moderate restriction of back movement

Reduced sensation at L5andS1 dermatomes.

No muscle weakness

Reduced ankle jerk reflexes? (diabetic and old age not

important)

Lower limbs pulses are palpable

SLR is negative there is no nerve root compression.

OTHER EXAMINATIONS TO RULE OUT EXTRA

SPINAL CAUSES

Abdomen was soft with no tenderness, masses or

pulsation. No renal tenderness

INVESTIGATIONS

CBC :

Hb=13.4g/dl normal (14-18 gm/dl)

WBC=9800 normal( 4,500-10,000 )

ESR=22 normal (0-20)

Bone profile :

Ca=2.8mmol/l normal 2.2-2.6

Phosphorus=1.3mmol/l normal

Alkaline phosphates= 110units/l

IMAGE STUDY

X-ray

MRI

X-RAY

FINDINGS

In the AP view:

The alignment = normal no scoliosis

Density=normal

There are osteophytes formed at the lateral sides

of the vertebra L3-L4

In the lateral view:

Anterior osteophytes

Decreased lordosis because of the degeneration

MRI

FINDINGS

Normally the disc color in T2 is dark on the

peripheral part and white in the central part

In the previous image the disc appears to be dark

lost hydration and died

Bulging of the disc

Ligamentum flavum and facet joint hypertrophy

spinal cord stenosis

SUMMARY

Slightly flexion when standing

Tenderness at L4-S1

Moderate spasm of paravertebral muscles

Moderate restriction of back movement

Reduced sensation at L5andS1

Reduced ankle jerk reflexes

Normal CBC and bone profile

LOWER BACK PAIN(CHRONIC)

Spinal infection

Spinal tumors

Vertebral fracture

Muscular sprain

Lumbar disc herniation

Degenerative spine

disease, Spinal

stenosis

Dissecting aneurysm

Pyelonephritis

Pancreatitis

Spinal causes : Extra Spinal causes :

DEGENERATIVE SPINE DISEASE,

SPINAL STENOSIS

WHAT IS THE

DIFFERENCE

BETWEEN

BULGING DISC

AND HERNIATED

DISC?

ANATOMY

-Anterior elements:

Vertebral body

vertebral disc-Inter

Degeneration occurs at the the disc

-Posterior elements:

Pedicles, laminae, spinous process, transverse process,

)in each level2 (facet joints

Osteoarthrosis occurs at the facet joints

PATHOPHYSIOLOGY

-Bulging of the disc into the spinal canal

-Increase the load on the facet joint

-Facet and ligaments hypertrophy

-Contributing to spinal stenosis

-Pressure on nerve roots >pain

-Patient will bend forward

MANAGEMENT: LOW BACK PAIN

-It is the first line of

treatment

-Physiotherapy:

core muscle

strengthening,

posture training

-NSAID

-Surgical treatment

indicated for:

• Instability or

deformity

e.g. high-grade

spondylolisthesis

• Failure of

conservative

treatment

Decompression of spinal

stenosis

Conservative Operative

MANAGEMENT: SPINAL STENOSIS

-It is the first line of

treatment

-Activity modification

-Analgesics

-Epidural cortico-steroid

injections

- Surgical treatment

indicated for:

• Motor weakness e.g.

drop foot

• failure of –minimum-

6 months of

conservative

treatment

- Spinal

decompression

(laminectomy) is the

commonest

procedure

conservative operative

PROGRESS

• Patient diagnosis was explained to him

• He was given advise about weight reduction and

back care

• He was prescribed physiotherapy and NSAIDs

• He was told extra-dural steroid injections may be

tried to help in symptoms relief

• Patient was told surgery may be offered if

symptoms continues or worsens

CONCLUSION

•Patient reported some improvement with

NSAIDs, Physiotherapy, weight loss and

modification of DLA ( Daily Life Activities )

•Patient wished to have further treatment and was

given Extra -Dural steroid injection

•Patient's symptoms were reasonably controlled

for a long period

•Surgery in the form of Decompression of spinal

stenosis was still a possibility for future