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 to12 weeks)

Spinal anatomy

Spinal anatomy

LigamentsSpinal Anatomy

Spinal Anatomy

Spinal pathology

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).

The four stages to a herniated disc include:

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 - L4

1. Interpedicular distance 20–30 mm2. výška pedikla 3–5 mm3. výška facety 5–8 mm4. AP sagital distance 15–25 mm5. 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

Lassegueroot L5, S1

Opposite Lassegueroot L4

Lassegue maneuver

Nerve root pain pattern

Radiculopathy C6 Radiculopathy S1

Sign of toe

Thomayer

Location of Pain and Motor Deficits in Association with Nerve Root Involvement at Each Lumbar Disc Level

Disc level Location of pain Motor deficit

T12-L1 Pain in inguinal region and medial None

thigh

L1-2 Pain in anterior and medial aspect Slight weakness in quadriceps;

of upper thigh slightly diminished suprapatellar

reflex

L2-3 Pain in anterolateral thigh Weakened quadriceps; diminished patellar or suprapatellar reflex

L3-4 Pain in posterolateral thigh and Weakened quadriceps;

anterior tibial area diminished patellar reflex

L4-5 Pain in dorsum of foot Extensor weakness of big toe

and foot

L5-S1 Pain in lateral aspect of foot Diminished or absent Achilles reflex

Cauda equina syndrome

• L1-5 a S1-5.

• 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 - L4

1. Interpedicular distance 20–30 mm2. výška pedikla 3–5 mm3. výška facety 5–8 mm4. AP sagital distance 15–25 mm5. 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 – L4-L5, L3-L4

• Congenitally or degenerative disease

• Usually after 60

• Single segment or multiple segments

Plain X-ray

L4/5 Spondylolisthesis

MRI

Prolapse of the disc - CT

Diffuse prolapse of the disc and osteophyte

Central prolapse of L4-L5 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