Back Pain Abdullah Ramadan Mohammed Al-Tahat supervised by: Dr. Hussam shraideh

1. Back Pain Abdullah RamadanMohammed Al-Tahat supervised by:Dr. Hussam shraideh

2. Epidemiology 70% life time incidence of LBP. 1% of population are disabled because of LBP. Highest prevalence 40-60 year of age. M = F Overall incidence of LBP 45/1000 person per year.

3. Challenging Definitive diagnosis is difficult, even not made in 85%. Have to distinguish benign, self-limited disease (95%) from serious disease (5%) Have to determine when imaging studies are needed

4. Clinical Approach � Look For (Red flags) Systemic Diseases Neurologic Compromise � Usually, a careful history and physical can answer the questions

5. History: Systemic diseases Age Time and duration of pain Recent trauma Hx of Cancer (prostate, breast, kidney, thyroid, lung) Pain worse at night Weight loss IV drug abuse Immune suppression Chronic infection Response to previous therapy Clinical Approach

6. � History: Neurologic Compromise Sciatica / Pseudoclaudication Numbness / Paresthesia Bowel / Bladder dysfunction Leg weakness Clinical Approach

7. Physical exam: Fever Tenderness Spinal deformity Positive straight leg raising test Loss of reflexes Weakness Sensory changes Clinical Approach

8. After taking good Hx & P/E pts can be categorized into Three Categories: 1. Back Pain Only (Most common) Musculoligamentous, fracture, spondylosis, infection, tumor, non back related 2. Back Pain + Sciatica a. Radiculopathy b. Associated symptoms: bowel, bladder, saddle anesthesia (cauda equina syndrome) 3. Spinal Stenosis; Pain improved when seated or spine is flexed Clinical Approach

9. Back Pain Only Simple Back Pain Trial of NSAIDS and muscle relaxants for six weeks, if not ? MRI or CT Most improve (90% in 3 days) Complicated Back Pain Risk factors; age > 50, known malignancy, infection, trauma, IVDA MRI or CT is indicated Clinical Approach

10. Back pain + Sciatica (Sciatic nerve compression) Sharp radiating pain often associated with numbness or paresthesia weakness and loss of reflexes Aggravated by coughing, sneezing, Valsalva Most common cause is herniated disc L4/5, L5/S1 most common Clinical Approach

11. Diagnostic work for pts with red flags Plain X-ray CT scan - Excellent for defining bony anatomy MRI � Gold Standard CT Myelography � C/I for MRI Bone scan � Malignancy/ Infxn Electromyelography localizes the specific nerve root

12. Imaging Studies Discouraged early on Majority improve with conservative therapy. Radiological findings doesn�t always correlate with symptoms. Imaging studies should not replace a good clinical evaluation! Reserved for those who failed conservative therapy or suspicion for underlying disease.

13. Soft tisuue injury is the damage of muscles, ligaments and tendons throughout the body. . Soft tissue injuries can result in pain, swelling, bruising and loss of function . �P�rotection �R�est �I�ce �C�ompression �E�levation

14. Whiplash injury A range of injuries to the neck caused by or related to a sudden distortion of the neck associated with extension. mainly the anterior longitudinal ligament is stretched or teared. Ex: Rear-end collision and roller coaster.

15. Signs and symptoms pain to the neck and back, referred pain to the shoulders, sensory disturbance (such as pins and needles) to the arms & legs and headaches. Symptoms can appear directly after the injury, but often are not felt until days afterwards

16. Diagnosis History head and neck examination X-rays to rule out bone fractures

17. Treatment manipulation, mobilizations and range of motion exercises. NSAID�s cervical collar should not be used for longer than 72 hours as it may lead to prolonged inactivity.

18. Cauda Equina Syndrome � acute loss of function of the�lumbar plexus, neurologic elements (nerve roots) of the spinal canal below the termination (conus) of the�spinal cord.( compression on both sides)

19. Compression of cauda equina Surgical emergency Urinary retention, saddle anesthesia, reduced sphincter tone, bilateral sciatica Immediate referral for MRI or CT Surgical consultation Compression can be from degenerative changes, trauma, infection, tumor or hematoma

20. Spinal Stenosis Abnormal narrowing of the spinal column (stenosis) that may occur in any of the regions of the spine. The most common forms are�cervical spinal stenosis

21. Disease of older adults Caused by Facet arthropathy Ligamentum flavum enlargement Disc osteophyte complexes Congenitally short pedicles Manifests by: Neurogenic claudication, numbness, tingling Pain improved when seated or spine is flexed Mx: Trial of conservative, nonsurgical treatment If intolerable, MRI/CT and possible laminectomy