Back pain is a “human condition”. In west it is second only to common cold as the most common affection of man kind. It is the most common cause of sickness , related absence from work .
Origin of pain :
* Spinal : all structures of spinal column, other than cartilage, are pain sensitive.
* Referral : the pain can be referred from internal organs.
Etiology : the etiology of back pain can be classified as fallow:
Mechanical Systemic Referral
*strain, sprain *Neoplastic: *pulmonary.
(non specific mechanical pain). (multiple myoloma, lymphoma, *cardiac.
*degenerative process of disks and secondaries, spinal cord tumor, *aortic anurysm.
fascet (usually age related). primary vertebral tumor). *GIT.
*herniated disk. *pancreas.
*spinal stenosis. *Infections : *gall bladder.
*osteoporotic compressive fracture. (septic diskitis, TB, brucellosis, *perforating ulcer.
*traumatic fracture. paravertebral abscess, *renal diseases.
*spondylolysis, spondylolesthesis. epidural abscess, herpetic neuritis). *prostatic.
*congenital disorders. *endometriosis.
*Inflammatory spondarthropathy *chronic pelvic
(ankylosing spondylitis). inflammatory
disorders
*Paget s disease.
The initial assessment (a thorough history & comprehensive physical examination) should exclude a serious causes of back pain that require an urgent intervention like spinal cord compression, cauda equine compression, peripheral nerve (root) compression, referral pain, infection, cancer and trauma.
In mechanical (mechanical induced-sprain and strain "muscle spasm") also termed non-specific mechanical back pain: is the commonest, the age usually between 20-55 years old , usually associated with history of lifting or bending. The onset is acute , the pain mostly is asymmetrical mainly confined to lumbosacral region , could be radiated to buttock , thigh but not beyond knee, with local paraspinal muscle spasm and tenderness with no evidence of nerve root involvement. The pain is often related to activity and generally relived by rest, with absence of constitutional symptoms. This type of pain is usually occur in manually workers (lifting heavy weight and twisting).
The prognosis is good (self-limiting) and up to 90% of patients recover in 6 weeks.
In radicular pain (nerve root) : the pain is severe, sharp, lacinating, radiated down beyond the knee within territory of the nerve root, is aggravated by cough, sneezing, straining usually with unilateral leg pain worse than back ache, with sign of nerve involvement with +ve straight leg raising test , motor and sensory or reflex changes and parasthesia limited to nerve root distribution. While referral pain to leg (no nerve irritation) is dull , deep and poorly localized.
Risk factors or parameters that suggest a poor prognosis or possible, serious underlying causes include :
? Age presentation : under age 20 or over age 50.
? Constitutional features : fever, malaise , wt loss which may associated with infection or malignancy.
? Location : thoracic spine region highly suggestive of systemic illness.
? Past medical history of malignancy , TB, HIV, prolonged systemic steroid use.
? Morning stiffness lasting less than an hour can be present in mechanical pain, in contrast morning stiffness of spine lasting more than an hour up to several hours is a common features of sero-negative spondylitis.
? Presence of neurological deficit as nerve root, cauda equina and spinal cord compression.
? Localized bone pain and tenderness to midline over osseous structures can be associated with bone expansion or pathological fracture as in osteoporosis , hemoglobinopathy, infection (TB), neoplastic process.
? Signs and symptoms that suggested referral pain of internal organs that share segmental innervations with part of the axial skeleton, as in renal, ureteric , gall bladder, gastro-intestinal , exertional (anginal) cardiac, pulmonary, prostatic and endometriosis.
Investigation:
Lab. studies are unnecessary unless a serious underlying cause is suspected.
In the absence of risk factors routine x-ray of spine are rarely indicated in the 1st month of symptoms unless a spine fracture is suspected (trauma, chronic steroid use).
Plain radiograph may be helpful in persistent pain in young patient to confirm a diagnosis of ankylosing spondylitis or in old patients with osteoporotic fracture.
MRI and CT scan are tests of choice for evaluation of most serious disease of spine even if plain radiographs are normal or (inconclusive).
CT scan is inferior to MRI for assessing soft tissue structures and nerve , but it is useful for detecting minor bony abnormalities and when MRI is contraindicated (presence of pacemaker, metallic clips or prosthesis).
Low Hb , elevated ESR, CRP may raise the suspicion of inflammation or malignancy.
Elevated acid phosphatase enzyme and prostate specific antigen (PSA) is associated with secondary metastasis of Ca prostate.
Serum alkaline phosphatase is increased in bone metastasis and paget s disease.
Myeloma is associated with a monoclonal band on imunoelectrophoresis and presence of urine Bence-Jones protein.
EMG and NCS are occasionally required to confirm localization of nerve root lesion.
Management of non-specific mechanical back pain:
Patient education, reassurance , simple analgesia, sometimes use NSAID to improve mobility and facilitate exercise.
Return to work , resuming normal activity as tolerated should take place as soon as possible.
Strict bed rest is not helpful, continuation of ordinary activities as tolerated gives equivalent or faster symptomatic recovery. A program of regular exercises and loss of excess wt. are used later to prevent recurrences.
The management of serious systemic, referral or spinal pathology will be influenced by the underlying cause.
Regional periarticular pain
A- Single regional periarticular pain: usually results from over use, repetitive trauma, sometimes from single an episode or from inflammatory process.
The pain is usually non progressive, localized periarticular tenderness, pain is reproduced by resistance active movement or stress as stretching the involved structure. Sign of inflammation depend on the etiology , in overuse no or mild sign of inflammation while in infection or crystal deposition there is mark sign of inflammation.
Main principle in management :
* pain relief.
* avoiding re-injury or trauma.
* appropriate physiotherapy to restore range of motion and function.
* surgery is only occasionally required for very resistant and disabling lesions.
Shoulder pain: main causes of pain :
* rotator cuff lesion.
* adhesive capsulitis "frozen shoulder".
* subacromial bursitis.
* biceptal (long head) tendonitis.
One should firmly put in mind that the shoulder joint is a common site for referral pain from cervical spine but may also be referred from "intra-thoracic lesion pancost , cardiac (anginal) or from gall bladder , hepatic , diaphragmatic lesions" which need not to be missed.
Hand and wrist pain:
* Tenosynovitis e.g: DeQurvian s disease "tenosynovitis of abd. pol. longus or/and ext. pol. brevis".
* Carpal tunnel syndrome . * Raynaud s phenomena .
* C8, T1 radiculopathy. * Reflexive sympathetic dystrophy.
* Dupuytren s contracture . *Trauma . * Infection.
Hip pain:
The common periarticular pain of hip:
* Trochantric bursitis. * Enthesopathy . * Adductor tendonitis. * Ischeal bursitis.
* Ileopectineal bursitis.
The hip is also the site for referral pain from back ache "radicular pain" (in which root pain worse by cough, strain, often accompanied by sensory disturbances) , from psoas abscess , retroperitoneal hemorrhage, pelvic inflammation, can cause inguinal and lateral thigh pain which is aggravated by resistance hip flexion.
Knee pain: In addition to arthritis the knee joint is a common site for trauma especially sport injury and periarticular pain . Also it is a site for referral pain from hip region.
main causes of periarticular pain :
* Prepatellar bursitis, superficial and deep patellar bursitis, anserine bursitis result from repetitive occupational kneeling in addition to consideration of infection and gout.
* Anterior pain syndrome : is a common problem aggravated by sport ,the pain is worse in down and upstairs , might lead to chondromalacia patellae.
* Anterior tibial compartment syndrome : is characterized by sever pain in front of leg, aggravated by exercises and relieved by rest. The syndrome result from fascial compression of the muscle in the Ant. tibial compartment, may result in foot drop, which need urgent surgical decompression.
Foot and ankle pain:
* Pes planus "flat foot", loss of neural arch, pain is in mid sole. It is often congenital or acquired "trauma , constitutional (hyper mobility), RA, neuropathic arthropathy".
* Pes cavus: (claw foot) , high medial arch, subsequent clawing of toes and metatarsal callosities. Rarely associated with neurological disease as Friedreich s ataxia, spine bifida , poliomyelitis.
* MTP pain is felt below heads of metatarsal bone {metatarsalgia} felt as walking on marbles.
Forefoot pain may be due to loss of transverse arch .
* Hallux valgus deformity with secondary bursitis (bunion) , and OA of the 1st MTP joint.
* Hallux rigidus "restriction" of extension of 1st MTP due to OA , causes pain in walking .
* Morton s neuroma, entrapment neuropathy of inter digital nerve , usually between 3rd and 4th metatarsal heads, in middle aged women.
* Planter fasciatis.
* Subcalcaneal, Retroachillis & Periachillus bursitis.
* Achillis enthesitis & Achillis tendonitis.
B- Multiple regional pain: Multiple regional soft tissue pain mostly due to :
* Fibromyalgia.
other causes:
* Seronegative spondarthropathy through enthesitis.
* Generalized hypermobility.
* Endocrine disease, hyperparathyroidism , hypothyroidism (ill defined wide spread pain).
* Parkinsonism (ill defined regional pain, stiffness, disability, rigidity, tremor, bradykinesia are usually apparent.
* Polymyalgia rheumatica and polymyositis.
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .