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Case of Back Pain
53
year old, right handed lady, hotelier 3 day history of severe lower back pain and weakness in her legs bending over at work and had noticed a mild back pain, which progressed Night and rest pain, leg radiation, worse with movement. Unable to walk
Case of Back Pain
Sep
05Haematologists shoulder pains, lymphadenopathy and rash, fatigue, 7 kg weight loss in 6 months l-node < 1cm ALP 210 Rheum referral Subsequently admitted Ex In pain restricted spine ? leg weakness and altered sensation feet
Case of Back Pain
ALP
320, ALT 89 CRP 96 XR normal MRI spine normal Symptoms progressed Tingling in upper limbs, noted to have reduced reflexes
Case of Back Pain
CSF
protein 2.55 g ?Guillan-Barre ?Guillan Transferred to neurology IV Ig, Rehab, FVC, vitals monitoring Campylobacter IgG and IgA 160 EBV +ve
GB syndrome
PostPost-infective acute inflammatory demyelinating polyneuropathy 1-3 weeks post viral Distal numbness and weakness evolves over days to weeks ascending Back and leg pain can be a feature 20% severe with autonomic and respiratory complications Weakness, areflexia, sensory loss
GB syndrome
Rare
ocular and ataxia Miller-Fisher Millersyndrome NCS: slowing of conduction or block CSF: 1-3g/l 1 IV Ig, supportive, ventilation, plasmapharesis, rehab
BACK PAIN Jaya Ravindran Rheumatologist
Causes
Simple mechanical eg ligamentous strain Degenerative disease with/without neural, cord or canal compromise Metabolic osteoporosis, Pagets Inflammatory Ankylosing spondylitis Infective bacterial and TB Neoplastic Others, (trauma,congenital) Visceral
Red flags
Age <20 or >50 with back pain for the 1st time Thoracic pain >50 yrs - Pain following a violent injury/trauma - Unremitting, progressive pain
Red flags
-
Past or current history of cancer On Steroids or immunosuppressants Drug abuser or +ve HIV Systemic symptoms - fever, appetitie and weight loss, malaise
Red flags
- Bilateral leg radiation, sensory/motor/sphincter symptoms - Pain predominantly at night
Inflammatory flags
Morning stiffness and pain >30 mins -1 hr Better with activity Peripheral joint involvement Anterior uveitis Psoriasis Inflammatory bowel disease Recent GI or GU infection Family history
Myotomes
C5
Deltoid, biceps (biceps jerk) C6 Wrist extensors, biceps (biceps, brachioradialis jerk) C7 Wrist flexors, finger extensors, triceps (triceps jerk) C8 Finger flexor, thumb extensors (triceps jerk) T1 finger abductors
Myotomes
L2
Hip flexion L3 Knee extension (knee jerk) L4 Knee extension, ankle dorsiflexion (knee jerk) L5 toe dorsiflexion S1 foot plantar flexion, eversion
D E R M A T O M E S
Examination
LOOK
deformity, muscle wasting, kyphosis, scoliosis LOOK normal cervical lordosis, thoracic kyphosis, lumbar lordosis FEEL spinal processes and sacroiliac joints
Examination
MOVE
Lumbar flexion Schober s test marks at dimples of Venus and 10 cm above. Measure at maximal flexion usually 5 cm MOVE Lumbar lateral flexion MOVE Cervical flexion/extension, lateral rotation and flexion, thoracic rotation
Examination
Sciatic
stretch (patient supine) - Straight leg raise and dorsiflexion of foot - pain in calf and posterior thigh between 30-70o 30low lumbar (L5/S1) lesion or sciatic irritation Femoral stretch (patient prone) knee is flexed and then hip extended pain in anterior thigh high lumbar (L2-L4) lesion (L2-
Imaging
XR
tumour, fracture, infection, inflammation Bone scan increased turnover eg infection, metastatic disease, fractures, Pagets MRI soft tissue, discs, facet joint, nerve roots, cord, inflammation
Degenerative disease and sciatica
Very
common Facet joint OA, disc disease, osteophyte Mechanical back pain Sciatica most resolve NB persistent, neurology, bilateral, red flags Analgesia, PT, pain clinics
Degenerative disease and sciatica
Malignancy
Unremittting, progressive and night pain Systemic symtoms Past hx Ca Breast, bronchus, thyroid, kidney, prostate and myeloma/plasmacytoma Osteolytic (prostate osteoblastic) XR can be normal in early stages further imaging if suspicion high Predilection for vertebral body and pedicles
Malignancy
Malignancy
Infection
discitis, osteomyelitis, and epidural abscess. hematogenously spread most often Staphylococcus aureus. GramGram-negative rods in postoperative or immunocompromised patients normal skin flora is less commonly isolated in postoperative patients. Postoperative patients develop symptoms 2 to 4 weeks after surgery after an initial improvement in pain.
Infection
Pseudomonas organisms in intravenous drug users. Mycobacterium tuberculosis in developing nations and immigrant population. Fungal infections are rare. Only one third have fever and 3% to 15% present with neurologic deficit. Infections typically involve the intervertebral disc and vertebral body endplate
Infection
Radiographic changes at 2 to 4 weeks bone scan can be positive as early as 2 days 75% specific. MRI appearance is decreased T1- and increased T1T2T2-weighted signal in the infected disk. Enhancement after gadolinium
Infection
Conservative treatment of antibiotics, rigid bracing to prevent deformity and control pain Surgery : neurologic deficit, presence of abscess, extensive bone loss with kyphosis and instability, failure of blood work and biopsy to isolate any organism, excision of a sinus tract, or no response to conservative treatment.
Infection
Infection
Osteoporosis
DEXA
T scores
Osteoporosis
Diagnostic Criteria for Osteoporosis Established by the World Health Organization Based on Comparison to Young Adult Mean Bone Density* Normal Bone density is within 1 SD of the young adult mean Osteopenia Bone density is within 1 to 2.5 SD below the young adult mean Osteoporosis Bone density is 2.5 SD or more below the young adult mean Severe (established) osteoporosis Bone density is more than 2.5 SD below the young adult mean and there has been one or more osteoporotic fractures
*One standard deviation (SD) represents about a 10% to 12% decline in bone density .
Low bone density
Diff
ti l Di
i
fL w
Densit
t
r r
Pr m r t m t M rr m rf t (eg, m m ,m t t )
Osteoporosis - risks
History
of low trauma # - colles, NOF, vertebral, sacral or pelvic insufficiency Steroids Maternal history of NOF # Gonadal hormone deficiency Ca deficiency Prolonged immobility Low BMI Alcohol and smoking
Causes of low bone density
Secondary Causes of Osteoporosis Endocrine Neoplasm Congenital Miscellaneous Rheumatoid arthritis Gastrectomy Renal failure Malabsorption (sprue)
Hyperparathyroidism Multiple myeloma Osteogenesis Hyperthyroidism Hypopituitarism Hyperprolactinemia Lymphoma Homocystinuria Cushing¶s syndrome Mastocytosis
Gaucher¶s disease Cirrhosis
Vertebral fractures
Osteoporosis
Osteoporosis
Bisphosphonates SERMs Strontium Teriparatide Calcitonin Lifestyle
factors Ca and Vit D
7-dehydrocholesterol (diet)
sunlight
cholecalciferol liver
2525-hydroxycholecalciferol kidney 1E-hydroxylase 1,251,25-dihydroxycholecalciferol
(-)
increased GI Ca2+ absorption oCa2+ Bone resorption Thyroid (-) Parathyroid Gland PTH o Renal Ca2+ () Calcitonin reabsorption
Spinal stenosis
Canal
or foraminal narrowing with possible subsequent neural compression Cause Ligamanetum flavum hypertrophy, facet joint hypertrophy, vertebral body osteophytes, herniated disc Rare: Pagets, AS, acromegaly
Spinal stenosis
Symptoms
Age - >50 Dull aching pain in the lower back and legs Exertional leg pain/weakness/numbness Symptoms relieved leaning forward, sitting or lying
Examination
May be normal Normal sensation and power Reflexes normal or slightly reduced Normal foot pulses
Spinal stenosis
Spinal stenosis
Conservative
analgesics, NSAIDs, PT,
epidural Surgery
laminectomy (+arthrodesis)
Cauda Equina Syndrome
Back pain, lower limb weakness, saddle anaesthesia, sphincter disturbance, impotence Causes usually disc, rarely tumour, abscess, advanced AS Diminished sensation L4 to S2 (sacral numbness), weakness ankle and plantar dorsiflexion, loss ankle jerks, urinary retention, loss anal tone Urgent MRI and surgical decompression
Cauda Equina Syndrome
Pagets
Pagets
Pain,
deformity Skull, long bone, vertebra, pelvis, near hip Neurologic compromise Planned surgery ?ALP 2X ULN Rare: high output failure
AS
The Concept of Spondyloarthropathy Disease Subgroups 1. Ankylosing spondylitis 2. Reactive arthritis (Reiter¶s syndrome) 3. Enteropathic arthritis 4. Psoriatic arthritis 5. Undifferentiated spondyloarthropathy 6. Juvenile spondyloarthropathy All These Diseases Share Rheumatologic Features Sacroiliac and spinal (axial) involvement Enthesitis at long attachments of ligaments and tendons causing: Achilles tendonitis and plantar fasciitis, syndesmophyte formation (³bamboo spine´), sacroiliitis (due to a combination of enthesitis and synovitis), and periosteal reaction (³whiskering´) at gluteal tuberosity and other parts of pelvis and other sites Peripheral, often asymmetric, inflammatory arthritis and dactylitis (³sausage´ digits) Share Extra-articular Features Propensity to ocular inflammation (acute anterior uveitis conjunctivitis) Mucocutaneous lesions, variable for the subgroups Rare aortic incompetence or heart block Lack of association with rheumatoid factor and rheumatoid nodules Share Genetic Predisposition Strong association with HLA-B27 gene Familial clustering
AS
NSAIDs Sulphasalazine PT Anti-TNF Anti-
peripheral joints
AS
AS
AS
THE END
THANKTHANK-YOU
53
year old, right handed lady, hotelier 3 day history of severe lower back pain and weakness in her legs bending over at work and had noticed a mild back pain, which progressed Night and rest pain, leg radiation, worse with movement. Unable to walk
Case of Back Pain
Sep
05Haematologists shoulder pains, lymphadenopathy and rash, fatigue, 7 kg weight loss in 6 months l-node < 1cm ALP 210 Rheum referral Subsequently admitted Ex In pain restricted spine ? leg weakness and altered sensation feet
Case of Back Pain
ALP
320, ALT 89 CRP 96 XR normal MRI spine normal Symptoms progressed Tingling in upper limbs, noted to have reduced reflexes
Case of Back Pain
CSF
protein 2.55 g ?Guillan-Barre ?Guillan Transferred to neurology IV Ig, Rehab, FVC, vitals monitoring Campylobacter IgG and IgA 160 EBV +ve
GB syndrome
PostPost-infective acute inflammatory demyelinating polyneuropathy 1-3 weeks post viral Distal numbness and weakness evolves over days to weeks ascending Back and leg pain can be a feature 20% severe with autonomic and respiratory complications Weakness, areflexia, sensory loss
GB syndrome
Rare
ocular and ataxia Miller-Fisher Millersyndrome NCS: slowing of conduction or block CSF: 1-3g/l 1 IV Ig, supportive, ventilation, plasmapharesis, rehab
BACK PAIN Jaya Ravindran Rheumatologist
Causes
Simple mechanical eg ligamentous strain Degenerative disease with/without neural, cord or canal compromise Metabolic osteoporosis, Pagets Inflammatory Ankylosing spondylitis Infective bacterial and TB Neoplastic Others, (trauma,congenital) Visceral
Red flags
Age <20 or >50 with back pain for the 1st time Thoracic pain >50 yrs - Pain following a violent injury/trauma - Unremitting, progressive pain
Red flags
-
Past or current history of cancer On Steroids or immunosuppressants Drug abuser or +ve HIV Systemic symptoms - fever, appetitie and weight loss, malaise
Red flags
- Bilateral leg radiation, sensory/motor/sphincter symptoms - Pain predominantly at night
Inflammatory flags
Morning stiffness and pain >30 mins -1 hr Better with activity Peripheral joint involvement Anterior uveitis Psoriasis Inflammatory bowel disease Recent GI or GU infection Family history
Myotomes
C5
Deltoid, biceps (biceps jerk) C6 Wrist extensors, biceps (biceps, brachioradialis jerk) C7 Wrist flexors, finger extensors, triceps (triceps jerk) C8 Finger flexor, thumb extensors (triceps jerk) T1 finger abductors
Myotomes
L2
Hip flexion L3 Knee extension (knee jerk) L4 Knee extension, ankle dorsiflexion (knee jerk) L5 toe dorsiflexion S1 foot plantar flexion, eversion
D E R M A T O M E S
Examination
LOOK
deformity, muscle wasting, kyphosis, scoliosis LOOK normal cervical lordosis, thoracic kyphosis, lumbar lordosis FEEL spinal processes and sacroiliac joints
Examination
MOVE
Lumbar flexion Schober s test marks at dimples of Venus and 10 cm above. Measure at maximal flexion usually 5 cm MOVE Lumbar lateral flexion MOVE Cervical flexion/extension, lateral rotation and flexion, thoracic rotation
Examination
Sciatic
stretch (patient supine) - Straight leg raise and dorsiflexion of foot - pain in calf and posterior thigh between 30-70o 30low lumbar (L5/S1) lesion or sciatic irritation Femoral stretch (patient prone) knee is flexed and then hip extended pain in anterior thigh high lumbar (L2-L4) lesion (L2-
Imaging
XR
tumour, fracture, infection, inflammation Bone scan increased turnover eg infection, metastatic disease, fractures, Pagets MRI soft tissue, discs, facet joint, nerve roots, cord, inflammation
Degenerative disease and sciatica
Very
common Facet joint OA, disc disease, osteophyte Mechanical back pain Sciatica most resolve NB persistent, neurology, bilateral, red flags Analgesia, PT, pain clinics
Degenerative disease and sciatica
Malignancy
Unremittting, progressive and night pain Systemic symtoms Past hx Ca Breast, bronchus, thyroid, kidney, prostate and myeloma/plasmacytoma Osteolytic (prostate osteoblastic) XR can be normal in early stages further imaging if suspicion high Predilection for vertebral body and pedicles
Malignancy
Malignancy
Infection
discitis, osteomyelitis, and epidural abscess. hematogenously spread most often Staphylococcus aureus. GramGram-negative rods in postoperative or immunocompromised patients normal skin flora is less commonly isolated in postoperative patients. Postoperative patients develop symptoms 2 to 4 weeks after surgery after an initial improvement in pain.
Infection
Pseudomonas organisms in intravenous drug users. Mycobacterium tuberculosis in developing nations and immigrant population. Fungal infections are rare. Only one third have fever and 3% to 15% present with neurologic deficit. Infections typically involve the intervertebral disc and vertebral body endplate
Infection
Radiographic changes at 2 to 4 weeks bone scan can be positive as early as 2 days 75% specific. MRI appearance is decreased T1- and increased T1T2T2-weighted signal in the infected disk. Enhancement after gadolinium
Infection
Conservative treatment of antibiotics, rigid bracing to prevent deformity and control pain Surgery : neurologic deficit, presence of abscess, extensive bone loss with kyphosis and instability, failure of blood work and biopsy to isolate any organism, excision of a sinus tract, or no response to conservative treatment.
Infection
Infection
Osteoporosis
DEXA
T scores
Osteoporosis
Diagnostic Criteria for Osteoporosis Established by the World Health Organization Based on Comparison to Young Adult Mean Bone Density* Normal Bone density is within 1 SD of the young adult mean Osteopenia Bone density is within 1 to 2.5 SD below the young adult mean Osteoporosis Bone density is 2.5 SD or more below the young adult mean Severe (established) osteoporosis Bone density is more than 2.5 SD below the young adult mean and there has been one or more osteoporotic fractures
*One standard deviation (SD) represents about a 10% to 12% decline in bone density .
Low bone density
Diff
ti l Di
i
fL w
Densit
t
r r
Pr m r t m t M rr m rf t (eg, m m ,m t t )
Osteoporosis - risks
History
of low trauma # - colles, NOF, vertebral, sacral or pelvic insufficiency Steroids Maternal history of NOF # Gonadal hormone deficiency Ca deficiency Prolonged immobility Low BMI Alcohol and smoking
Causes of low bone density
Secondary Causes of Osteoporosis Endocrine Neoplasm Congenital Miscellaneous Rheumatoid arthritis Gastrectomy Renal failure Malabsorption (sprue)
Hyperparathyroidism Multiple myeloma Osteogenesis Hyperthyroidism Hypopituitarism Hyperprolactinemia Lymphoma Homocystinuria Cushing¶s syndrome Mastocytosis
Gaucher¶s disease Cirrhosis
Vertebral fractures
Osteoporosis
Osteoporosis
Bisphosphonates SERMs Strontium Teriparatide Calcitonin Lifestyle
factors Ca and Vit D
7-dehydrocholesterol (diet)
sunlight
cholecalciferol liver
2525-hydroxycholecalciferol kidney 1E-hydroxylase 1,251,25-dihydroxycholecalciferol
(-)
increased GI Ca2+ absorption oCa2+ Bone resorption Thyroid (-) Parathyroid Gland PTH o Renal Ca2+ () Calcitonin reabsorption
Spinal stenosis
Canal
or foraminal narrowing with possible subsequent neural compression Cause Ligamanetum flavum hypertrophy, facet joint hypertrophy, vertebral body osteophytes, herniated disc Rare: Pagets, AS, acromegaly
Spinal stenosis
Symptoms
Age - >50 Dull aching pain in the lower back and legs Exertional leg pain/weakness/numbness Symptoms relieved leaning forward, sitting or lying
Examination
May be normal Normal sensation and power Reflexes normal or slightly reduced Normal foot pulses
Spinal stenosis
Spinal stenosis
Conservative
analgesics, NSAIDs, PT,
epidural Surgery
laminectomy (+arthrodesis)
Cauda Equina Syndrome
Back pain, lower limb weakness, saddle anaesthesia, sphincter disturbance, impotence Causes usually disc, rarely tumour, abscess, advanced AS Diminished sensation L4 to S2 (sacral numbness), weakness ankle and plantar dorsiflexion, loss ankle jerks, urinary retention, loss anal tone Urgent MRI and surgical decompression
Cauda Equina Syndrome
Pagets
Pagets
Pain,
deformity Skull, long bone, vertebra, pelvis, near hip Neurologic compromise Planned surgery ?ALP 2X ULN Rare: high output failure
AS
The Concept of Spondyloarthropathy Disease Subgroups 1. Ankylosing spondylitis 2. Reactive arthritis (Reiter¶s syndrome) 3. Enteropathic arthritis 4. Psoriatic arthritis 5. Undifferentiated spondyloarthropathy 6. Juvenile spondyloarthropathy All These Diseases Share Rheumatologic Features Sacroiliac and spinal (axial) involvement Enthesitis at long attachments of ligaments and tendons causing: Achilles tendonitis and plantar fasciitis, syndesmophyte formation (³bamboo spine´), sacroiliitis (due to a combination of enthesitis and synovitis), and periosteal reaction (³whiskering´) at gluteal tuberosity and other parts of pelvis and other sites Peripheral, often asymmetric, inflammatory arthritis and dactylitis (³sausage´ digits) Share Extra-articular Features Propensity to ocular inflammation (acute anterior uveitis conjunctivitis) Mucocutaneous lesions, variable for the subgroups Rare aortic incompetence or heart block Lack of association with rheumatoid factor and rheumatoid nodules Share Genetic Predisposition Strong association with HLA-B27 gene Familial clustering
AS
NSAIDs Sulphasalazine PT Anti-TNF Anti-
peripheral joints
AS
AS
AS
THE END
THANKTHANK-YOU
