Back Pain By Mahdi saleh

Lecture outline Introduction ( anatomy of vertebral Colum )

LBP ( Risk factors , Diagnosis , Differential diagnosis ) Nerve Root PainAnkylosing spondylitisPott diseasePyelonephritis

intervertebral foramina

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.

RISK FACTORSOlder ageOccupational factors

Psychosocial factorsRisk factors for cancer

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.

DIFFERENTIAL DIAGNOSIS

Osteoporotic vertebral fracture

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

Spinal stenosis

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

Herniated disc

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

Spinal infection/abscess

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.

Ankylosing spondylitis

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.

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.

Abdominal pathology

•such as pancreatitis, pyelonephritis, and cholecystitis can present as back pain or pain

radiating to the back

Nerve Root Pain

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

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

Ankylosing spondylitis

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

Pott disease

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.

Pyelonephritis

Pyelonephritis is one of the most common diseases of the kidney and is defined as

inflammation affecting the tubules, interstitium, and renal pelvis

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.

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.

costovertebral angle

Chronic obstructive pyelonephritis may have a silent onset or present with manifestations of acute recurrent pyelonephritis, such as back

pain, fever, pyuria, and bacteriuria

Chronic pancreatitis

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.

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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