Back pain Back pain is a common problem
Back pain • Back pain is a common problem that affects most people at some point in their life. • It usually feels like an ache, tension or stiffness in the back. • The pain can be triggered by: • bad posture while sitting or standing • bending awkwardly • lifting incorrectly
Back pain • is not generally caused by a serious condition and, in most cases, it gets better within few days or weeks • is most common in the lower back, although it can be felt anywhere along your spine, from your neck down to your hips • It can usually be successfully treated by taking keeping mobile, painkillers, physioterapy
Back pain • Dividing by its cause: • nonspecific back pain • back pain with radiculopathy or spinal stenosis (disk herniation, spondylartritis) • back pain associated with another specific cause (such as infection or cancer)
Back pain • Non specific pain indicates that the cause is not known precisely, but is believed to be due from the soft tissues such as muscles, fascia, and ligaments
Back pain • • Other causes of back pain: Postural abnormalities (scoliosis, kyphosis) Congenital malformations (spondylolistesis) Trauma
Back pain • The pain may radiate into the arms and hands as well as the legs or feet • may include symptoms other than pain • tingling, weakness or numbness.
Back pain • Back pain can be divided anatomically: neck pain, middle back pain, lower back pain • By its duration: acute (up to 12 weeks), chronic (more than 12 weeks) and subacute (the second half of the acute period, 6 to 12 weeks)
Spinal anatomy
Spinal anatomy
Spinal Anatomy Ligaments
Spinal Anatomy Spinal pathology
The four stages to a herniated disc include: Disc Degeneration: chemical changes associated with aging causes discs to weaken, but without a herniation. Prolapse: the form or position of the disc changes with some slight impingement into the spinal canal. Also called a bulge or protrusion. Extrusion: the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc. Sequestration or Sequestered Disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP).
Ligaments Facet joints
Osteophytes
Cervical osteophytes
Upper extremities dermatomes
Normally, the cervical spine has a slight anterior curvature (lordosis). The cervical spine is straightened, which may be due to paravertebral muscle spasm
Cervical myelopathy • • • Spastic paraparesis Quadriparesis Difficulties with balance Spasticity – lower extremities Radicular symptoms – upper extremities Incontinence – uncommon, urinary frequency - common
Diagnostics • Plane X-ray • MRI • CT
Fyziological diameters of spinal canal - L 4 1. Interpedicular distance 20– 30 mm 2. výška pedikla 3– 5 mm 3. výška facety 5– 8 mm 4. AP sagital distance 15– 25 mm 5. interfacetarna vzdialenosť 15– 20 mm
Spinal canal stenosis • Borderline anterio-posterior diameter for spinal canal • Cervical – 11 mm • Lumbar – 11 -13 mm
Cervical myelopathy • Cervical myelopathy refers to compression on the cervical spinal cord from either a disc herniation or cervical spinal stenosis. • Generally, it is more common in the elderly population and is a slow process.
Cervical myelopathyk • • • Symptoms include incoordination in the hands a heavy feeling in the legs or numbness and tingling in the legs It is generally a slowly progressive condition. It is usually not painful as compression of the spinal cord does not cause pain.
Cervical myelopathy
Cervical myelopathy
Lower extremities dermatomes
Lumbar nerve root compression
Lassegue root L 5, S 1 Opposite Lassegue root L 4
Lassegue maneuver
Nerve root pain pattern Radiculopathy C 6 Radiculopathy S 1
Sign of toe
Thomayer
Location of Pain and Motor Deficits in Association with Nerve Root Involvement at Each Lumbar Disc Level Disc level T 12 -L 1 Location of pain Motor deficit Pain in inguinal region and medial None thigh L 1 -2 Pain in anterior and medial aspect Slight weakness in quadriceps; of upper thigh slightly diminished suprapatellar reflex L 2 -3 Pain in anterolateral thigh Weakened quadriceps; diminished patellar or suprapatellar reflex L 3 -4 Pain in posterolateral thigh and Weakened quadriceps; anterior tibial area diminished patellar reflex Pain in dorsum of foot Extensor weakness of big toe L 4 -5 and foot L 5 -S 1 Pain in lateral aspect of foot Diminished or absent Achilles reflex
Cauda equina syndrome • L 1 -5 a S 1 -5. • Areflexic and flaccid paraparesis • Back pain that radiates down posterior aspect of both legs • Sensory loss in distribution of involved roots (saddle distribution) • Urinary and fecal incontinence (loss of bladder and bowel function)
Cauda equina syndrom
Fyziological diameters of spinal canal - L 4 1. Interpedicular distance 20– 30 mm 2. výška pedikla 3– 5 mm 3. výška facety 5– 8 mm 4. AP sagital distance 15– 25 mm 5. interfacetarna vzdialenosť 15– 20 mm
Spinal canal stenosis • Borderline anterio-posterior diameter for spinal canal • Cervical – 11 mm • Lumbar – 11 -13 mm
Spinal canal
Lumbar stenosis • medical condition in which the spinal canal narrows and compresses the spinal cord nerves at the level of the lumbar vertebra • Leg pain (proximal to distal pain) • Numbness • Weakness exacerbated by standing or walking and relieved with lumbar flexion
Lumbar stenosis
Lumbar stenosis • Narrowing of the spinal canal or neural foramina that produces root compression • Most common – L 4 -L 5, L 3 -L 4 • Congenitally or degenerative disease • Usually after 60 • Single segment or multiple segments
Plain X-ray
L 4/5 Spondylolisthesis
MRI
Prolapse of the disc - CT Diffuse prolapse of the disc and osteophyte Central prolapse of L 4 -L 5 disc
Dif. dg. radiculopathy • Vertebrate MTS • Boreliosis • Pelvic tumors (LS), lungs (Th, C) and others • Intraspinal tumors • Inflammatory diseases
Dif. dg. radiculopathy
Therapy – acute stage • • • Rest Analgetics Non-steroid antiinflammatory drugs Myorelaxants Local anesthetics Epidural corticosteroides
Therapy - later • • • Analgetics Non-steroid antiinflammatory drugs Myorelxants Local anesthetics Physiotherapy, exercising
Therapy • Neuropathic pain – anticonvulsants (pregabalin) • • Surgery Cauda equina syndrome Pain Peripheral paresis
Therapy - surgery • Cauda equina syndrome with urinary symptoms • Marked muscular weakness pertaining to a nerve roots • Progressive neurologic deficit • Pain that exists more than 4 months
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