LOW BACK PAIN (5).pptx ....................

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1. LOW BACK PAIN DR.K.HARISHMA DR.C.YOGESWARI DR.K.ARIHARI KRISHNAN

2. ORIGINATES FROM SPINAL CORD NERVE ROOTS VERTEBRAL COLUMN MUSCLES & LIGAMENTS (NON SPECIFIC) ABDOMINAL ORGANS

3. CATEGORIES 1.DEGENERATIVE DISORDER 2.MECHANICAL DISORDER (Disk herniation, Lumbar spinal stenosis) 3.INFECTIONS (Osteomyelitis, Spinal epidural abscess) 4.SPINAL EPIDURAL HEMATOMA 5.INFLAMMATORY DISORDERS (Ankylosis spondylosis) 6.CANCER (Multiple myeloma)

4. HX TAKING T RAUMA U NEXPLAINED WEIGHT LOSS [ ? CANCER ] N EUROLOGICAL SYMPTOMS (SENSORY LOSS, PAIN / WEAKNESS IN LEGS, LOSS OF SENSATION IN PERINEAL AREA/ BOWEL/ BLADDER OR SEXUAL DYSFUNCTION) A GE >50 [ RISK OF CANCER,DEGENERATIVE DISEASE ] F EVER [ ? INFECTION ] I NTRAVENOUS DRUG USE/ IMMUNOCOMPROMISED STATE [ RISK OF INFECTION] S TEROID USE [ ? SEC. OSTEOPOROSIS, VERTEBRAL FRACTURES ] H X OF CANCER

5. PHYSICAL EXAMINATION ERYTHEMA [ ? INFECTION, PSORIATIC ARTHRITIS ] MIDLINE FOCAL TENDERNESS [ INFECTION, CANCER, FRACTURE ] SLR [ RADICULAR SYMPTOMS – PAIN/PARAESTHESIA ? NEURAL IRRITATION OR COMPRESSION ] PLANTAR REFLEX FNST DEEP TENDON REFLEXES PERPHERAL PULSATION STATE OF BLADDER & CHECK FOR FOOT DROP, PIRIFORMIS SYNDROME HLAB27 (TO RULE OUTSERUM NEGATIVE SPONDYLOARTHROPATHY)

6. NO SPECIFIC FINDINGS NON-SPECIFIC MUSCULOSKELETAL PAIN STRAINED MUSCLES OR LIGAMENTS; NO SENSORY & MOTOR DEFICITS UNILATERAL, DULL PAIN, TENDERNESS RADIATES DOWN TO THIGH BUT NOT BEYOND THE KNEE WORSEN BY MOVEMENT RELIEVED BY REST PT CAN RECALL WHAT TRIGGERED THE PAIN (EG: LIFTING HEAVY WEIGHT) RESOLVES WITHIN 2 – 4 WEEKS

7. RX ANTI INFLAMMATORY , MUSCLE RELAXANT ( NV DEC, ULUNTHU THYLAM) MOBILITY ( ASANAS,EXERCISE) PHYSICAL MANIPULATION ( THOKKANAM ) APPLY HEAT OR COLD (OTTRADAM )

8. DEGENERATIVE DISORDERS (Age related wear & tear) 1.SPONDYLOSIS (DEGENERATIVE DISK DISEASE) -Intervertebral disk & facet joint gradually degenerates with age -osteophytes compress adjacent nerve roots -radiculopathy & lumbar spinal stenosis (narrowing of intervertebral foramina)

9. SPINAL OSTEOARTHRITIS (Natural Ageing Process)

10. TREATMENT: VATHAM PITHAM IVATTRAI THANIKINRA INIPPU SUVAIULLA MARUNTHUKAL AMK ILAGAM SIDDHATHI ENNAI PURGATION 15 DAYS ONCE WITH MILK ULUNTHU THYLAM LVM THYLAM PATTRU PICHU LOW BACK MUSCLE STRENGTHENING EXERCISE SPINAL EXERCISE

11. 2.SPONDYLOLISTHESIS SLIPPAGE OF VERTEBRAL BODY OVER OTHER (weakness in surrounding ligaments) THIS CAN CAUSE RADICULOPATHY & LUMBAR SPINAL STENOSIS INVESTIGATION : MRI ( degeneration, osteophytes, slippage) OSTEOARTHROSIS OF F ACET JOINT DEGENRATIVE D ISC DISEASE F ORWARD D ORSALLY

12. RX PAIN MANAGEMENT PHYSICAL MANIPULATION LUMBAR SUPPORT BACK EXERCISE

13. MECHANICAL DISORDERS 1.DISC HERNIATION (POS.LAT – RT OR LT) SPONDYLOSIS AT RISK OF DISC HERNIATION ( postero lateral) MECHANICAL COMPRESS NERVE ROOT INFLAMMATORY IRRITATES NERVES [L4 - L5 & S1 – S3] Cause unilateral shooting or electrical pain – radiates from back down below the knee SCIATICA

14. MRI FINDINGS COMPRESS THE NERVE ROOT BELOW IT(- SENSORY OR MOTOR LOSS) L3 – L4 VERTEBRA L4 NERVE –ANTERO MEDIAL ASPECT OF THIGH DIMINISH QUADRICEP OR KNEE JERK REFLEX (Weakness in knee extension) L4 – L5 VERTEBRA L5 NERVE –LAT LOWER LEG & DORSAM OF FOOT WEAKNESS IN DORSIFLEXION OF FOOT & HIP ABDUCTION L5 – S1 VERTEBRA S1 NERVE – LAT FOOT & ANKLE WEAKNESS IN PLANTAR FLEXION OF FOOT DIMINISH ACHILLES REFLEX

15. DISC HERNIATION - QUICK ASCESS L4 - SQUAT L5 – HEEL WALK S1 – TOE WALK

16. SLR SUPINE, RAISE LEG TO 30 – 70 DEGREE + VE PAIN RADIATES TO KNEE LUMBAR DISC HERNIATION.. PROCEED WITH MRI ( TO CONFIRM ) BACK PAIN IS NOT POSITIVE

17. SCIATICA (VATHASTHAMBAM) VATHA KABATHAI KORAIKUM USHNA MARUNTHUKAL KVC 2BD THIPPILI RASAYANAM 5G BD SIDDHADHI ENNAI 10 DROPS WITH HOTWATER AMK CHOOR CHITRAMUTI MADAKU THYLAM 10 DROPS WITH MILK LVM THYLAM SITTARATHAI PATTRU (2 DAYS) – START WITH DRY TREATMENT FOR IMMEDIATE PAIN RELIEVE VARMAM

18. LUMBAR SPINAL STENOSIS NARROWING OF CENTRAL CANAL LATERAL RECESS NEURAL FORAMEN CAUSES SPONDYLOSIS SPONDYLOLISTHESIS TRAUMA PAGET DISEASE OF BONE ACHONDROPLASIA

19. SPONDYLOSIS OSTEOPHYTES / THICKENED LIGAMENTUM FLAVUM / FACET OSTEOARTHROSIS / DISC BULGING CAUSE MECHANICAL COMPRESSION OR VENOUS CONGESTION EDEMA OR SWELLING PSEUDOCLAUDICATION: (POSITIONAL PAIN) PAIN INDUCED BY POSITION THAT EXTEND THE SPINE (WALKING, STANDING) PAIN RELIEVED BY POSITION THAT FLEX THE SPINE (SITTING OR BENDING FORWARD) (SHOPPING CART SIGN) VASCULAR CLAUDICATION: EXERTIONAL PAIN SENSORY LOSS OR WEAKNESS: TYPICALLY BILATERAL DOES NOT FOLLOW A DERMATOMAL OR MYOTOMAL PATTERN

20. DIAGNOSIS: MRI- NARROWING OF SPINAL CANAL

21. INFECTIONS: 1.VERTEBRAL 0STEOMYELITIS [ORGANISM INVADE BONES] STAPHYLOCOCCUS AUREUS – COMMON IN BOTH STREPTOCOCCUS GRAM NEGATIVE ENTERIC BACILLI PSEUDOMONAS AERUGINOSA – COMMON IN INTRAVENOUS GRUG USERS MYCOBATERIUM TUBERCULOSIS I.E : POTTS DISEASE 2.SPINAL EPIDURAL ABSCESS INFECTION SPREAD FROM VERTEBRA TO EPIDURAL SPACE

22. VERTEBRAL OSTEOMYELITIS SPINAL EPIDURAL ABSCESS – COMPRESS ADJACENT NERVE ROOT

23. RISK FACTORS DM INTRAVENOUS DRUG USE IMMUNOSUPPRESSION – HIV OR CHRONIC STEROID USE PRESENCE OF INDWELLING DEVICES ENDOCARDITIS UTI

24. LAB INVESTIGATIONS CBC (? LEUKOCYTOSIS) ESR & CRP BLOOD & URINE CULTURE , X-RAY MRI BIOPSY

25. SPINAL EPIDURAL HEMATOMA WHICH IS BLEEDING IN EPIDURAL SPACE CAUSE: DISC HERNIATION TRAUMA RECENT SURGERY BLEEDING DISORDER OR ANTI COAGULATION THERPY BACK PAIN IS USUALLY SEVERE & WELL LOCALIZED

26. LAB INVESTIGATION CBC (THROMBOCYTOPENIA & PROTHROMBIN TIME) PARTIAL THROMBOPLASTIN TIME (COAGULATION PROBLEM) MRI (ENTIRE SPINE) SHOW SAC OF BLOOD IN EPIDURAL SPACE EXTEND ACROSS MULTIPLE SPINAL LEVEL MAY COMPRESS ADJACENT SPINAL CORD

27. VERTEBRAL FRACTURES: CAUSE: OSTEOPOROSIS (LOW BONE DENSITY) OSTEOGENESIS IMPERFECTA (BRITTLE BONE DISEASE) LESIONS FROM METASTATIC OR PRIMARY TUMOUR OR INFECTION POSTMENOPAUSAL FEMALES STEROID USE OTHER PATHOLOGICAL CAUSE (TB,CANCER) COMMON: VERTEBRAL COMPRESSION FRACTURE (FRAGILITY FRACTURE) MAY BE DUE TO MILD TRAUMA (PT MAYNOT REMEMBER)

28. COMPRESSION FRACTURE

29. INVESTIGATION ESR & BLOOD SUGAR ,BP SHOULD BE MONITORED X RAY CT SCAN MRI BONE DENSITY STUDY(TO ACCESS FUTURE RISK) VIT D LEVEL

30. TREATMENT BRACING TECHNIQUE VATHAM, PITHAITHAI KURAIKUM MATTRUM ASTHIYIN KANATHANMAIYAI KOOTUM MARUNTHUKAL AMK ILAGAM PIRANDAI CHOOR MUTHU PARPAM

31. METASTATIC MALIGNANCY SPINAL METASTASIS OFTEN OCCUR IN EPIDURAL SPACE SYMPTOMS: CONSTANT PAIN – WORSE AT NIGHT –UNRELIEVED BY REST FOCAL NEUROLOGICAL SYMPTOMS (Lower extremity weakness, numbness, bladder & bowel dysfunction, paralysis) FEVER NIGHT SWEATS, FEVER, CHILLS UNEXPLAINED WEIGHT LOSS

32. METASTASIS COMMON CANCER THAT METASTASIS TO SPINE PROSTATE BREAST KIDNEY THYROID &LUNG CANCER MULTIPLE MYELOMA START IN SPINE & CAUSE BACKPAIN INVESTIGATION: MRI, CT, BIOPSY

33. MULTIPLE MYELOMA NEOPLASTIC PROLIFERATION OF PLASMA CELLS WITHIN BONE MARROW COMMON IN 60 + AGE

34. CAUDA EQUINA SYNDROME SOME CONDITIONS LIKE HERNIATED DISK, SPINAL EPIDURAL ABSCESS & HEMATOMA, VERTEBRAL FRACTURES & MALIGNANCY CAN COMPRESS CAUDA EQUINA IT IS THE COLLECTION OF LUMBAR & SACRAL NERVE ROOTS AFTER THE SPINAL CORD ENDS AT L2 LEVEL (CONUS MEDULLARIS) ONCE FOOT DROP IS ESTABLISED THERE IS NO RECOVERY FOR THIS CONDITION PT NEED FAST TREATMENT TO PREVENT LASTING DAMAGE LEADING TO INCONTINENCE & PERMANENT PARALYSIS TO LEGS

35. SYMPTOMS UNILATERAL ASYMMETRIC SENSORY LOSS BACK PAIN/ WEAKNESS IN THE EXTREMITIES LOSS OF REFLEXES (KNEE & ANKLE) SADDLE ANESTHESIA BOWEL,BLADDER OR SEXUAL DYSFUNCTION URINARY RETENTION, URINARY INCONTINENCE

36. INVESTIGATION BLADDER ULTRASOUND (POST VOID RESIDUAL <30 NORMAL) >100 – SIGNIFICANT NEUROLOGICAL COMPROMISE DIGITAL RECTAL EXAM (FECAL RETENTION, FECAL INCONTINENCE) AFFECTED MALES MAY ALSO HAVE ERECTILE DYSFUNCTION

37. OORUSTHAMBAVATHAM –CAUDA EQUINA SYNDROME VARATCHI UNDAKKUM SIKKICHAIKU PIN POSHAKKU ALIKKUM SIKKICHAI KVC 2 BD CMC 50MG BD ALTERNATE DAYS CHITAMUTTI MADAKU THYLAM10 ML WITH MILK OD AT NYT AMK ILAGAM 5G BD AMUKKURA PAL KASHAYAM 60 ML BD NOTHI KUDINEER 60 ML BD KABASURA KUDINEER 60 ML BD LVM THAYLAM CHITRAMUTI MADAKKU THYLAM AVOID LYING IN FLOOR

38. CONUS MEDULLARIS SYNDROME SIMILAR TO CAUDA EQUINA DIFFERENCE? BILATERAL AND SYMMETRIC PATTERN URINARY & FECAL INCONTINENCE ARE EARLY SYMPTOMS

39. SPINAL CORD COMPRESSION AFFECTING CORTICOSPINAL TRACT UPPER MOTOR NEURON SIGNS + BELOW THE LEVEL OF LESION BRISK & HYPERACTIVE REFLEX SPASTICITY BABINSKI REFLEX (EXTENSOR PLANTAR RESPONSE) INVESTIGATION:MRI

40. SERONEGATIVE SPONDYLOARTHROPATHIES INFLAMMATORY CONDITION ABSENCE OF RF ASSOCIATION WITH HLA-B27: MHC CLASS 1 MOLECULE COMMEN IN MEN <45 PAIN WORSE AT NIGHT & MORNING STIFFNESS > 30 MIN & IMPROVES WITH MOVEMENT & EXERCISE

41. SYMPTOMS: PERIPHERAL ARTHRITIS ENTHESITIS (TENDON & LIGAMENT INSERT) UVEITIS ( INFLAMMATION OF UVEA) DACTYLITIS ( SAUSAGE FINGERS)

42. PSORIATIC ARTHRITIS ASYMMETRIC INFLAMMATION OF JOINTS (HANDS & FEET, SPINE) < 30% WITH PSORIASIS DEVELOP PSORIATIC ARTHRITIS FINDINGS: DACTYLITIS PENCIL IN CUP DEFORMITY

43. ANKYLOSIS SPONDYLOSIS CHRONIC SYMMETRICAL INFLAMMATION PATIAL OR COMPLETE FUSION (“ANKYLOSIS”) COMMONLY AFFECT YOUNG MALES CAUSE PAIN IN SPINE, SACROILIAC JOINTS & THE ENTHESES PAIN IS GRADUAL ONSET ASSOCIATED WITH MORNING STIFFNESS, IMPROVES WITH EXERCISE & DOESN’T IMPROVES WITH REST EXTRA ARTICULAR MANIFESTATIONS INCLUDE UNILATERAL ANTERIOR UVEITIS, PSORIASIS & AORTIC ROOT DILATATION (WHICH MAY INCREASE THE RISK OF AORTIC DISSECTION) I.E : AORTIC REGURGITATION AND RESTRICTIVE PULMONARY DISEASE DUE TO COSTOVERTEBRAL & COSTOSTERNAL ANKYLOSIS SEVERITY: MONITOR CHEST WALL EXPANSION

44. INVESTIGATION CBC (MICROCYTIC MICROCHROMIC ANEMIA) ELEVATED ESR & CRP HLA B27 X – RAY MRI OF SACROILIAC JOINT (SHOWS EROSION, SCLEROSIS & NARROWING OF JOINT SPACE. WHEN THE NARROWING REACHES A POINT OF COMPLETE FUSION ITS CALLED ANKYLOSIS) MRI SPINE (BAMBOO SPINE – BCOZ THE VERTEBRA ARE ABNORMALLY CONNECTED THROUGH REACTIVE BONY GROWTHS CALLED SYNDESMOPHYTES)

45. REACTIVE ARTHRITIS REITER SYNDROME AUTO IMMUNE – AFFECT YOUNG MEN BACTERIAL INFECTION (SHIGELLA, YERSINIS, CHLAMYDIA, CAMPYLOBACTER, SALMONELLA) HERE THE ORGANISM NOT ENTER THE BONES

46. ABDOMINAL AORTIC ANEURYSM (AAA) RISK FACTORS: HYPERTENSION DIABETES TOBACCO USE CORONARY ARTERY DISEASE AAA CAUSE VAGUE BACK OR FLANK PAIN ALONG WITH A PULSATILE ABDOMINAL MASS OCCASIONALLY PERSON BECOME HYPOTENSIVE DUE TO BLOOD LOSS INVESTIGATION ABDOMINAL ULTRASOUND

47. RETROPERITONEAL HEMORRHAGE ANOTHER CAUSE OF BACK PAIN IS RETROPERITONEAL HEMORRHAGE, DEVELOPED DUE TO ANTI COAGULATION THERAPY OR AFTER HAVING CANNULATION OF FEMORAL ARTERY DURING CARDIAC CATHETERIZATION PROCEDURE WHICH SOMETIMES LEAD TO BILATERAL FLANK HEMATOMAS CALLED GREY TURNER SIGN

48. OTHER POTENTIAL EXTRA SPINAL CAUSES AORTIC DISSECTION POLYNEPHRITIS RENAL COLIC PANCREATITIS PID ENDOMETRIOSIS PROSTATITIS

49. THANK YOU!