DIFFERENTIAL DIAGNOSIS AND TREATMENT OF LOW BACK AND LOWER EXTREMITY PAIN

1. DIFFERENTIAL DIAGNOSIS AND TREATMENT OF LOW BACK AND LOWER EXTREMITY PAIN Prof. Dr. Ece Aydoğ PMR

2. Learning objectives • 1. be able to differentiate mechanical and non-mechanical pain • 2. be able to enumerate the risk factors for low back pain • 3. be able to define spondylosis, spondylolysis, spondylolisthesis and spondylitis • 4. be able to describe clinical presentation and treatment for acute muscular strain, lumbar discopathy, spinal stenosis and spondylolisthesis and spondylolysis. • 5. be able to enumerate non-mechanic causes of low back pain and describe differential diagnosis.

3. Learning objectives • 6. be able to enumerate the red flags of serious low back pain • 7. be able to enumerate the reasons which cause pain in the lower extremity and make the differential diagnosis. • 8. be able to enumerate situations that require emergency surgery for lumbar back pain and surgical indications in lumbar discopathy. • 9. be able to enumerate diagnostic methods, treatment approaches, pharmacological and non pharmacological methods for low back pain.

4. Who gets back pain ? • Almost Everybody • Estimates run as high as 80% of the population. • Only 1-2 % need surgery. • 5-10 % develop chronic pain. • 75 % of patients have relapses. • Peak occurrence is between age 30 and 45.

5. The spine has two basic jobs: 1) to protect the spinal cord 2) to allow us to move Back pain usually involves some loss of ability to move easily.

10. SPİNAL SEGMENT Every level of the spine is composed of a disc in the front and paired facet joints in the back. The disc acts as a shock absorber in between the vertebrae, whereas the paired facet joints restrain motion. They allow the spine to bend forwards (flexion) and backwards (extension) but do not allow for a lot of rotation.

12. Classifications • Transient—duration is hours to days, only brought to medical attention when episodic • Acute—duration is days to weeks; most recover spontaneously • Persistent—lasts more than 3-6 months; does not improve with time; no psychological co-morbidities (often associated with spondylotic disease) • Chronic—lasts more than 6 months; worsens with time, associated with major psychological co-morbidities

13. 90% of low back pain is “mechanical” • Injury to muscles, ligaments, bones, disks • Spontaneous resolution is the rule • Nonmechanicalcauses uncommon but don’t miss them! • Spondyloarthropathy • Spinal infection • Osteoporosis • Cancer • Referred visceral pain

14. Age Sendentary lifestyle Pregnancy Obesity Smoking Injury Preexisting back injury due to: Lifting a heavy object Improper lifting Sudden movement, bending, or twisting Prolonged sitting or standing Bad posture Vibration from vehicles or heavy equipment Prior back surgery Other factors which may negatively influence back pain include: Psychological factors, such as low job satisfaction Fatigue or sleep deficit Drug or alcohol abuse Stress Risk Factors

15. Congenital bone conditions Congenital causes (existing from birth) of low back pain include scoliosis and spina bifida. Scoliosis is a sideways (lateral) curvature of the spine that can be caused when one lower extremity is shorter than the other (functional scoliosis) or because of an abnormal design of the spine (structural scoliosis). Children who are significantly affected by structural scoliosis may require treatment with bracing and/or surgery to the spine. Adults infrequently are treated surgically but often benefit by support bracing.

16. Spina bifida and scoliosis

17. Common Sources of LBP Somatic dysfunction Muscle in “spasm” Nerve root In somatic dysfunction, some muscles become overactive (“spasm”) and other muscles become inactive.

18. There are many more joints in the back than discs. • There are many more muscles than joints. • The most common cause of low back pain is when one or more muscles “forget” to relax. We callthis a somaticdysfunction.

19. Common Sources of LBP Any dysfunction involving thethoracic or lumbar spine, the sacroiliac joint or the hip can createlow back pain.

20. piriformis sciatic nerve Common Sources of LBP Long dorsal si ligament sacrospinous ligament sacrotuberous ligament

22. Role of the sacroiliac joint The sacroiliac joint requires muscle activity to keep it stable. If muscles can’t work correctly, perhaps because of a somatic dysfunction, the joint becomes unstable and painful. 1 3 2

23. The most common causes of low back pain; • Injury or overuseof muscles, ligaments, facet joints, and the sacroiliac joints.

24. Lumbar Strain • stretching injury to the ligaments, tendons, and/or muscles of the low back • microscopic tears of varying degrees in these tissues • one of the most common causes of low back pain • occur because of overuse, improper use, or trauma • "acute" if it has been present for days to weeks • "chronic" lasts longer than three months

25. Symptoms • Pain, mostly in the back and buttocks. • Muscle spasms, cramping, and stiffness. • It is aggravated by weight-bearing or specific movements and is relieved by rest. • The most severe pain usually lasts 48 to 72 hours and may be followed by days or weeks of less severe pain. • The back is easily reinjured during this time.

26. Spondylolysis • Spondylolysis(spondylo = spine; lysis=dissolved) refers to the defect (black arrows) present when the pars interarticularis is fractured. This results is the lamina and inferior facet joints being disconnected from the vertebral body.

27. Spondylolysis • Spondylolysis isn't something that people are born with, but develop in childhood /adolescence. • It is thought to be a stress fracture that doesn't heal. • It is seen most often in football linemen and in gymnasts

28. Spondylolisthesis • Spondylolisthesis (spondylo=spine; listhesis=to slip) occurs in the presence of a spondylolysis when the intervertebral disc stretches and allows the vertebral body to slide forward on the vertebra below. This results in widening of the pars defect. This is known as an isthmic spondylolisthesis.

29. Spondylolisthesis • Displastic (congenital dysplasia between the L5-S1) • Degenerative (elderly people) • Traumatic (fracture in the posterior stractures except isthmus) • Patologic (metabolic bone disease, metastatic Ca..)

30. Spondylolisthesis

31. Spinal Stenosis • Spinal stenosis is a medical condition in which the spinal canalnarrows and compresses the spinal cord and nerves. • This is usually due to the common occurrence of spinal degeneration that occurs with aging. • It can also sometimes be caused by spinal disc herniation, osteoporosis or a tumor. • In the cervical and lumbar region it can be a congenital condition to varying degrees.

32. Spinal Stenosis • Spinal-nerve compression in these conditions can lead to sciatica pain that radiates down the lower extremities. • Spinal stenosis can cause lower-extremity pains that worsen withwalking and are relieved by resting (mimicking poor circulation) (Neurogenic claudication)

33. Acute Back Pain in the Elderly Multiple compression fractures

34. More common among postmenopausal women with osteoporosis, or in men or women after long-term corticosteroid use. No early warning, often occurs with forward flexion during normal activity or with trivial trauma Severe spinal pain Marked muscle spasm Some relief with recumbency Compression fractures

35. Less common spinal conditions that can cause low back pain include • Ankylosing spondylitis • Bacterial infection • Spinal tumors • Paget's disease • Scheuermann's disease

36. Spinal Infections • Acute infection • Bacterial • Fungal • Chronic infection • Bacterial • Fungal • Tuberculosis • Brucellosis • Sites of spinal infection • Vertebral osteomyelitis • Disk space infection • Septic sacroiliitis

37. Historical clues Fever, rigors Source of infection: IV drug abuse, trauma, surgery, dialysis, and skin infection Physical exam clues Focal tenderness with muscle spasm Often cannot bear weight Lab clues Mild anemia, Elevated ESR, and/or CRP Spinal Infection

38. Spondylodiscitis

40. Pain worse at night Often associated local tenderness WBC, ESR, protein electrophoresis if ESR elevated Multiple Myeloma Spinal Malignancy

41. Symptoms of arthritis of the spine generally include pain and stiffness that are worse in the back and hip region. • Arthritis pain starts gradually, gets worse over time, and lasts longer than 3 to 6 months. It is generally worse in the morning or after prolonged periods of inactivity. • Arthritis pain gets better when you move around. • Symptoms caused by arthritis and symptoms due to back injury are often similar and commonly occur together.

42. Other medical conditions that can cause pain that may be similar to low back pain include: • Pelvic inflammatory disease • Aortic aneurysm • Peptic ulcers • Gallbladder disease • Pancreatitis • Urinary disorders such as kidney stones or urinary tract infections. • Prostate disease

43. What Are the Red Flags for Serious Low Back Pain? • Fever, weight loss • Intractable pain—no improvement in 4 to 6 weeks • Nocturnal pain or increasing pain severity • Morning back stiffness with pain onset beforeage 40 • Neurologic deficits

44. Lower extremity pain Causes • MUSCLE CRAMP • Dehydration or low amounts of potassium, sodium, calcium, or magnesium in the blood. • Medications • Diuretics, • Statins, which lower cholesterol and can cause muscle injury • Muscle fatigue or strain from overuse, too much exercise, or holding a muscle in the same position for a long time

45. Pressure on nerve roots in the spinal canal. Nerve root compression can be caused by: • A herniated disk • Osteoarthritis • Spondylolysis and Spondylolisthesis • Spinal stenosis • Fractures of the vertebrae • Spinal deformities scoliosis or kyphosis

46. Lower extremity pain • A torn or overstretched muscle (strain) • Hairline crack in the bone (stress fracture) • Inflamed tendon (tendinitis) • Shin splints - pain in the front of your leg related to overuse or repetitive pounding

47. Other common causes of leg pain • Atherosclerosis that blocks blood flow in the arteries (this type of pain, called claudication, is generally felt when exercising or walking and relieved by rest) • Blood clot (deep vein thrombosis) from prolonged bed rest • Infection of the bone (osteomyelitis) or skin and soft tissue (cellulitis) • Inflammation of the leg joints by arthritis or gout • Nerve damage - common in diabetics, smokers, and alcoholics (symptoms include numbness, tingling, or a sensation of pins-and-needles) • Varicose veins

48. Less common causes • Benign tumors or cysts of the femur or tibia (osteoid osteoma) • Legg-Calve-Perthes disease - poor blood flow to the hip that may stop or slow the normal growth of the leg • Malignant bone tumors (Osteosarcoma, Ewing sarcoma) • Sciatic nerve pain (radiating pain down the leg) caused by a slipped disk in the back. • Slipped capital femoral epiphysis - usually seen in boys and overweight children between 11 and 15 years old

49. Differential diagnosis • Arteriogram to check blood flow • Blood tests for specific diseases • Bone biopsy if tumor is seen on MRI which may be malignant • Bone scan • Duplex Doppler/ultrasound exam to look for a blood clot • MRI if a malignant tumor is suspected • X-ray of your back or legs

50. Sciatic nerve pain A “pinched” nerve ?