Low Backache and PIVD

Post an Article
 

LOW BACKACHE AND PIVD



  • 80% of the population suffers from LBA at some time of life.

  • 40% of patients with LBA have sciatica.

  • Risk factors related to work- heavy and repeated lifting ,jack hammers and machine tools .

  • Higher body weight-more prone to LBA.


DIFFERENTIAL DIAGNOSIS



  • primary spine disease 

    • Disk herniation

    • Degenerative arthritis



  • Systemic diseases 

    • Metastatic cancer



  • Regional diseases 

    • Aortic aneurysm.

    • LOW BACK ACHE



  • The majority of patients will improve in 1–4 weeks.

  • Identify those patients with pain caused by

        (1) infection, 

        (2) cancer,

        (3)  ankylosing spondylitis, 

        (4)  nonrheumatologic conditions, especially leaking aortic aneurysm.

  • SCIATICA

    Low back pain radiating down the buttock and below the knee suggests a herniated disk causing nerve root irritation.

    Sacroiliitis, facet joint degenerative arthritis, spinal stenosis, or irritation of the sciatic nerve from a wallet—can also cause this pattern.

  • LOW BACK ACHE

    Low back pain at night, unrelieved by rest or the supine position, 

    malignancy- vertebral body metastasis  (prostate, breast, lung, multiple myeloma, or lymphoma) 

    cauda equina tumor.

    Compression fractures (from osteoporosis or myeloma).

  • LOW BACK ACHE WITH NEUROLOGICAL INV

    Cauda equina tumor

    Epidural abscess

    massive disk herniation- nerve root impingement, pain , numbness and weakness   consistent with compression of a single nerve root. 

    Bilateral leg weakness -from multiple lumbar nerve root compressions- saddle area anesthesia, bowel or bladder incontinence, or impotence  indicates a cauda equina syndrome.


INFLAMMATORY LBA



  • Low back pain that worsens with rest and improves with activity - ankylosing spondylitis or other seronegative spondyloarthropathies, especially with insidious onset , before age of 40.

  • Degenerative back diseases produce precisely the opposite pattern, with rest alleviating and activity aggravating the pain.




SPINAL CLAUDICATION



  • Indicates spinal stenosis. 

  • Bilateral discomfort occurring in the buttock, thigh, or leg that (like true claudication) is brought on by walking but (unlike claudication) can also be elicited by prolonged standing. 

  • Pain is improved with rest or with flexion of the lumbar spine; patients have less difficulty walking uphill than downhill.




SYSTEMIC CAUSES



  • Low back pain causing the patient to writhe occurs in renal colic but can also indicate a leaking aneurysm.

  • Pancreatic pain-radiating pain from the abdomen to back

    Physical Examination of the Back

  • Neurologic examination - detect the small deficits produced by disk disease.

  • Cauda equina tumors- large deficits

  • Positive SLR- nerve root irritation 

  • The test is positive if radicular pain is produced with the leg raised 60 degrees or less. Specificity of 40% but is 95% sensitive in patients with herniation at the L4–5 or L5–S1 level




REVERSE SLR



  • The crossed straight leg sign is only 25% sensitive but is 90% specific for disk herniation and is positive when raising the contralateral leg reproduces the sciatica.




PALPATION OF THE SPINE 



  • Point tenderness over a vertebral body - suggests osteomyelitis, but this association is uncommon.

  • A step-off noted between the spinous process of adjacent vertebral bodies may indicate spondylolisthesis,


SCHOBER’ TEST



  • To perform this test, two marks are made, one 10 cm above S1 and another 5 cm below. The patient then bends forward . Normally, the points distract at least 5 cm.

  • Less indicates reduced lumbar motion, which in the absence of severe pain - ankylosing spondylitis or other seronegative spondyloarthropathies.




INTERVERTEBRAL DISCS



  • Shock absorbers between the vertebrae of the spine

  • Tough, fibrous, outer-shelled discs (the annulus) that are filled with gel (the nucleus).

  • Allow the spine to be flexible.

  • Time, trauma, and inherent weakness in a disc can lead to degeneration of the annulus causing the nucleus of the disc to bulge out or even herniate 




NATURAL HISTORY

STAGE OF DYSFUNCTION 


15 -45 years.

Circumferential and radial tears.

Localized synovitis  of facet joints.


STAGE OF INSTABILITY

    35-70 years

    Internal disruption, disc resorption facet joint degeneration.

STAGE OF STABILIZATION

    Hypertrophic bone around disc and facets.



STAGES OF PIVD

NORMAL ANATOMY


   Annulus fibrosus- composed of numerous concentric rings.

   Nucleus pulposus –loose , collagen framework supporting a network of cells.

   Embedded in a gelatinous matrix.


PIVD

  Classical Disc prolapse is posterolateral .

  The nerve root exits from the superior  part of the neural foramen.

  The nerve root of the inferior level is compressed.


NERVE ROOTS

Neurological testing

         Nerve           Motor                       Reflex                Sensory area

           root

 

             C5    Deltoid and biceps         Biceps               lateral arm

             C6    Biceps,ECRL&B            Biceps,BR          Thumb

             C7    Triceps ,FCR                 Triceps                Middle finger

             C8     FCU,  FDP                     None                 Little finger

             T1      Interosseous                 none                  medial arm  

              L4      Dorsiflexion of foot             Knee jerk   Medial calf

              L5      Dorsiflexion of great      None              Medial forefoot

                           toe

              S1      Eversion of foot                 Ankle jerk            Lateral foot



X RAYS



  • X-rays can provide evidence of vertebral body osteomyelitis, cancer, fractures, or ankylosing spondylitis. 

  • Degenerative changes in the lumbar spine are ubiquitous in patients over 40 and do not prove clinical disease

  •  Plain x-rays have very low sensitivity or specificity for disk disease




MRI 



  • Demonstrate intraspinal tumours.

  • Shows degeneration.

  • Nerve roots are also visible and the amount of compression can be clearly seen.

  • Also shows changes in the cord due to compression




INJECTION STUDIES

DIFFERENTIAL SPINAL


     Patients not relieved – not likely to be helped by spinal surgery.

     All medicines are withdrawn 12 hours before surgery.




 ROOT INFILTRATION

     identifies patients with radicular compression if pain is relieved after block.


 FACET BLOCK 


Therapeutic and diagnostic.


CERVICAL DISC DISEASE



  • UNILATERAL-SOFT DISC WITH NERVE ROOT COMPRESSION.

  • UNILATERAL-HARD DISC WITH FORAMINAL SPUR AND NERVE ROOT COMPRESSION.

  • MEDIAL SOFT DISC PROTRUSION WITH SPINAL CORD COMPRESSION

  • TRANSVERSE RIDGE WITH CORD COMPRESSION.


Previous Article : Knee joint pain- what can be done

Next Article : Cervical Spine Injuries