back pain
TRANSCRIPT
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Back Pain By Mahdi saleh
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Lecture outline Introduction ( anatomy of vertebral Colum )
LBP ( Risk factors , Diagnosis , Differential diagnosis ) Nerve Root PainAnkylosing spondylitisPott diseasePyelonephritis
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intervertebral foramina
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Low back painLBP can be caused by pain in the muscles, ligaments, joints, bones, discs, nerves, or blood vessels.
•In 90% of cases, the specific cause of LBP is unclear.
•In 10% of cases, a specific cause such as an infection, fracture, or cancer is identified.
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RISK FACTORSOlder ageOccupational factors
Psychosocial factorsRisk factors for cancer
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DiagnosisThe diagnosis can be classified into three categories:
1 .Nonspecific back pain—Pain for less than 6 weeks (acute), 6 to 12 weeks (subacute), or more than 12 weeks (chronic); negative straight-leg raise test; absence of red flags.
2 .Radicular syndrome—LBP with radiation down leg; positive straight-leg raise test; absence of red flags.
3 .Serious pathology—Further work-up required for presence of red flags, including age younger than 20 or older than 55 years; significant trauma; fever; unexplained weight loss; neurologic signs of cauda equina; progressive neurologic deficit.
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DIFFERENTIAL DIAGNOSIS
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Osteoporotic vertebral fracture
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Osteoporotic vertebral fracture
Acute onset of pain, typically seen in older patients or those at risk for osteoporosis,
point tenderness at the level of the fracture, confirmation by plain radiographs
demonstrating compression or burst fracture
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Spinal stenosis
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Spinal stenosis
Pain worse with extension, presence of unilateral or bilateral leg symptoms worse
with walking and better with sitting,confirmation by CT or MRI
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Herniated disc
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Herniated disc
Radicular pain that is worse with flexion or sitting, may be accompanied by numbness or
weakness of foot plantar flexion (L5/S1) or dorsiflexion (L4/L5), MRI confirms the level
and shows the type of herniation
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Spinal infection/abscess
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Spinal infection/abscess
•Most commonly seen in patients who use IV drugs, have diabetes mellitus, have cancer, or
have a transplant; symptoms include fever, night pain, night sweats, and elevated ESR. MRI
is the study of choice. If neurologic deficit is present, obtain an urgent MRI to evaluate for
an abscess, which would require hospitalization and consultation with a spinal surgeon.
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Ankylosing spondylitis
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Ankylosing spondylitis
Pain, most commonly in the low back or sacroiliac joints, usually begins in late
adolescence or early adulthood. Pain and stiffness worsen with immobility and improve
with motion. HLA-B27 may be positive. Radiographic findings confirm the diagnosis,
but occur years after symptoms.
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Malignancy
Typically seen in an older patient; symptoms of weight loss and night pain; significant anemia;
history of cancer; nonresponse to therapy. Often seen on plain radiographs. Bone scan is
the most sensitive test.
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Abdominal pathology
•such as pancreatitis, pyelonephritis, and cholecystitis can present as back pain or pain
radiating to the back
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Nerve Root Pain
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One of the complications of osteoarthritis of the vertebral column is the growth of osteophytes,
which commonly encroach on the intervertebral foramina, causing pain along the distribution of
the segmental nerve. The fifth lumbar spinal nerve is the largest of the lumbar spinal nerves, and it exits from the vertebral column through the smallest intervertebral foramen. For this
reason, it is the most vulnerable
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Since the fully developed vertebral body is intersegmental in position, each spinal nerve
leaves the vertebral canal through the intervertebral foramen and is closely related to the intervertebra disc. This fact is of great clinical significance in cases with prolapse of
an intervertebral disc
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Ankylosing spondylitis
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Ankylosing spondylitis causes destruction of articular cartilage and bony ankylosisDisease involving the sacroiliac joints and
vertebrae becomes symptomatic in the second and third decades of life as lower back pain and spinal immobility
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Pott disease
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The infection breaks through intervertebral discs to affect multiple vertebrae and extends into the soft
tissues. Destruction of discs and vertebrae frequently results in permanent compression
fractures that produce scoliosis or kyphosis and neurologic deficits secondary to spinal cord and
nerve compression. Other complications of tuberculous osteomyelitis include tuberculous
arthritis, sinus tract formation, psoas abscess, and amyloidosis.
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Pyelonephritis
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Pyelonephritis is one of the most common diseases of the kidney and is defined as
inflammation affecting the tubules, interstitium, and renal pelvis
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Acute pyelonephritis is generally caused by bacterial infection and is associated with urinary tract infection.
Chronic pyelonephritis is a more complex disorder; bacterial infection plays a dominant role, but other factors (vesicoureteral reflux, obstruction) predispose to repeat episodes of acute pyelonephritis.
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Acute pyelonephritisAcute pyelonephritis usually presents with a sudden onset of pain at the costovertebral angle and systemic evidence of
infection, such as fever and malaise. There are often indications of bladder and urethral irritation, such as dysuria, frequency, and urgency. The urine contains many leukocytes (pyuria) derived from the inflammatory infiltrate, but pyuria
does not differentiate upper from lower urinary tract infection. The finding of leukocyte casts, typically rich in
neutrophils (pus casts), indicates renal involvement, because casts are formed only in tubules. The diagnosis of infection is
established by quantitative urine culture.
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costovertebral angle
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Chronic obstructive pyelonephritis may have a silent onset or present with manifestations of acute recurrent pyelonephritis, such as back
pain, fever, pyuria, and bacteriuria
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Chronic pancreatitis
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Chronic pancreatitis is defined as prolonged inflammation of the pancreas associated with
irreversible destruction of exocrine parenchyma, fibrosis, and, in the late stages,
the destruction of endocrine parenchyma.
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Chronic pancreatitis may present in many different ways. It may follow repeated bouts of
acute pancreatitis. There may be repeated attacks of mild to moderately severe
abdominal pain, or persistent abdominal and back pain.
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