THE BACK

د.عادل الهنداويExamination:

Symptoms:

1- pain: is it sudden or gradual ? constant or intermittent ?

Sciatica: is pain radiating from the buttock into the thigh &calf

along the course of sciatic nerve.

2-stiffness;3-deformity;4-paraesthesia &weakness in the lower limb & urinary incontinence.

Signs: standing position: Look: skin →scar or crease;

shape &posture → list (lateral deviation of the spine because of pain); Scoliosis (lateral curvature of spine);

Kyphosis(posterior curvature) or kyphos(sharp angulation).

Feel: the spinous processes & interspinous ligaments.

Move: spine Flexion, Extension, Lateral flexion to the right &left, Rotation then ask to Stand on toes(plantarflexion power) &heels(dorsiflexion power).

Prone position

Supine position: do SLR test(Lasegue's test): elevate the straight

leg → if feel pain(means root tension) and if do ankle dorsiflexion

→ more pain because of more stretching on the nerve root.

Examination of the lower limbs: for neurological deficit & vascular problems.

Investigation:

1- plain x-ray: anteroposterior, lateral & oblique views looking at the spine, pelvis &sacroiliac joints.

2- CT: for bone pathology.

3- MRI: for soft tissues pathology.

4- Radio-isotope scan: for secondaries & infection.

5- Discography & facet joint arthrography: inject dye

into disc or facet joint → x-ray.

Vertebral deformities

Scoliosis: is an apparent lateral curvature of the spine but

actually it is a tri plane deformity i.e. there is also rotational

deformity &anteroposterior deformity(lordosis &kyphosis).

Types:

postural(unstructural) scoliosis: is secondary to other condition

outside the spine e.g. short leg will cause tilt of pelvis & spine, if

the patient sit on a table → the pelvic tilt &scoliosis will disappear. Another example is disc prolapse with list of the spine, this will disappear if pain & muscle spasm subside.

Structural scoliosis: here the vertebrae themselves are rotated into fixed non correctable deformity which will not disappear with change in the posture. To differentiate between postural & structural scoliosis → ask the patient to bend forward, if scoliosis disappear it is postural; if scoliosis increase( become more prominent) it is structural.

Types of structural scoliosis: 1- idiopathic; 2- osteopathic (congenital);

3- neuropathic & myopathic.

Clinical features: spine deformity, rib hump, shoulder asymmetry & prominent hip. later→ backache & cardiopulmonary dysfunction.

O/E: ask the patient to bend forward; see if the scoliosis is balanced or not? If balanced, the occiput is over the midline (center of the buttock).

Examine the patient from the side to see if there is kyphosis or lordosis.

Measure the leg length.

Imaging: plain x-ray (full length & in erect position): in structural scoliosis, the vertebrae are rotated & the spinous processes are deviated toward the midline.

How measure the degree of the curve?

First, identify the upper & lower rotated vertebra; then draw a line parallel with the upper border of upper vertebra & another line with the lower border of lower vertebra. The angle between the 2 lines is the angle of the curvature ( Cobb's angle). Usually there is one curve called primary curve balanced by 2 compensatory curves above & below. Sometimes, there is 2 primary curves.

CT & MRI: are needed if there is vertebral abnormality or cord compression.

Skeletal maturity: should be determined because scoliosis will ↑ during growth period & stop after maturity. How ? take x-ray of iliac crest: the iliac apophysis starts ossification at puberty &extends medially; once fusion is complete(at the same time, vertebral ring apophysis complete) further progression of the scoliosis will not occur( Risser's sign).

Prognosis: is bad if

1- scoliosis starts at early age; 2- if the curve

is severe; 3- Riser's sign is incomplete.

Idiopathic scoliosis: 80% of all scoliosis

Incidence of 30ᵒ curve is 3/1000.

According to age at onset:

A- Adolescent scoliosis: presents at over 10 years of age. 90% girls. Usually, primary thoracic curve to the right(convex to right) or lumbar curve or thoraco-lumbar or 2 primary curves.

→ the aim is to prevent the deformity from becoming severe Ŗ

& to correct unacceptable one. So observe the patient every

4 months & x-ray her to measure progression.

If the curve ˂ 20ᵒ→no Ŗ because it either resolves or remains unchanged.

If the curve 20ᵒ-30ᵒ (balanced & not progressing)→ no Ŗ but if progressing→ use Milwaukee brace(thoracic) or Boston brace (lumbar). The brace will not correct the curve but it may prevent progression.

Operative Ŗ is indicated if the curve is ˃ 30ᵒ especially if unacceptable, unbalanced & has been progressing significantly despite conservative Ŗ or liable to progression if the patient presents before puberty.

B- Juvenile scoliosis: presents between 4-9 years; similar to adolescent scoliosis but prognosis is worse. Ŗ→ brace till 10 years old → surgery.

C- Infantile scoliosis: affects ˂ 3 years, more in boys, usually thoracic curve to the left. It corrects spontaneously in 90% of cases. If progress →use brace then after maturity can do operative Ŗ if needed like

adolescent type.

Osteopathic (congenital) scoliosis: is due to congenital vertebral abnormality like hemi vertebra, wedged vertebra, fused vertebra &

fused or absent ribs. The scoliosis usually remains mild but if become severe→ posterior fusion.

Neuropathic &myopathic scoliosis: is due to neuromuscular disorder like

poliomyelitis, cerebral palsy or syringomyelia. The paralytic curve is long &convex toward weak muscle. Ŗ→ similar to idiopathic scoliosis.

Kyphosis:

Is excessive dorsal curvature or straightening out of normal cervical or lumbar lordotic curve.

Types: Unstructural kyphosis (either postural or compensatory) or

Structural kyphosis.

Postural kyphosis: is voluntarily correctable. It is due to bad posture. Ŗ→ posture training &exercise.

Compensatory kyphosis: is secondary to other deformity like

fixed flexion of the hip or ↑ lumbar lordosis. It is also correctable.

Structural kyphosis: is fixed(uncorrectable)

&associated with change in the shape of

the vertebrae.

Causes: 1- osteoporosis;

2- ankylosing spondylitis; 3- TB;

4- fracture & fracture–dislocation.

5- congenital abnormality → the anterior part of the vertebrae

are missing or fused. It is progressive& may cause paraplegia.

Ŗ→ early operative correction.

.

6- Adolescent kyphosis(Scheuermann's disease): is a growth disorder

of the spine in which there is fixed thoracic kyphosis with wedging of several thoracic vertebrae. The cause is unknown but probably due to traumatic infarction of vertebral endplates secondary to repetitive stress.

C.F.: affect boys ˃ girls. Age: puberty. They present

because of increasing thoracic kyphosis, backache &fatigue.

O/E: there is smooth thoracic kyphosis with compensatory

lumbar lordosis. The patient cannot correct the deformity.

Complication: rarely, spastic paresis of the lower limbs.

X-ray: on lateral view, the vertebral endplates( usually T6-T10)

are irregular & fragmented anteriorly more than posteriorly &

sometimes wedge shaped.

Differential diagnosis: 1- postural kyphosis: no pain &the

deformity is correctable by the patient himself; x-ray is normal.

2- TB: causes kyphos; X-ray→ 2 destructed vertebrae with narrow disc in between.

Ŗ→ posture training & back strengthening exercise or bracing for 1-2 years in children to hold thoracic spine extended. rarely require surgical correction

Kyphosis in the elderly:

1- postmenopausal osteoporosis: affects women ˂ 75 years. X-ray:

one or more compression fracture of thoracic spines; she has pain

because of lumbar lordosis.

2- Senile osteoporosis: affect male &female ˃ 75 years. The kyphosis

is more severe. Ŗ→ symptomatic after exclusion of multiple myeloma

&secondary metastases.