Скачать или смотреть Orthopedics | Approach to low back pain | Made Easy by Dr. Pramod Baral | DIP Medical Video | Part 2

Back pain in children and adolescents
10-30% of normal pediatric population will experience back pain at some point by the time they reach adolescence.

Detailed history (with red flags) and physical examination ( along with deformity, Adam’s forward bending test) of spine important.

Examine foot (eg cavus), hip, pelvic obliquity, LLD


D/D:

Nonspecific/mechanical LBP
Spondylolysis and Spondylolisthesis
Scheuermann kyphosis
Scoliosis
Disc herniation
Trauma

Infection,
Neoplasms
Benign: ABC, Osteoblastoma, histiocytosis, osteoid osteoma
Malignant: Ewing’s sarcoma, Osteosarcoma, Leukemia Chondrosarcoma

Back pain in Adults
Problems of Aging spine: Osteoporotic Compression Fractures and Degeneration of Spinal Structures.


Disorders associated with aging producing back pain
Disc degeneration, Osteochondrosis, PIVD
Facet degeneration
Degen. Spondylolisthesis
Spinal Stenosis
Spinal Deformities
Osteoporosis with VCFs
Pathological fractures- Mets
Infections

Case 1
19yrs/F
Low Back Pain x 3 years
-gradual onset, increased with activity (esp. with bending forward)
-no radiation
-Bowel/Bladder – normal
-Normal Apatite, No fever, No weight Loss
-Works in a bakery shop
VAS: Max 6/10, Now-4/10
O/E:
Curvature/Deviation of the midline furrow of spine at midback
List 2 cm to right
B/L shoulders: equal
Left hip- Prominent
ATR: 20 degrees- Thoracic (right), 13 degrees –Lumbar (right)
Abdominal reflexes: symmetrical
B/L LL Neurology: Intact

Case 2
38yrs/M
Low Back pain- 7 days
-sudden onset while lifting weight
Radiating to Left LL 4 days, with tingling/numbness of foot, aggravated with standing/walking/coughing, reduced with lying down/painkiller.
VAS: max 7/10, now-5/10
-Bowel/Bladder: Normal
O/E:
-List to left side
R L
-SLRT: 80 degrees 40 degrees

-Power: L2 5/5 5/5
L3 5/5 5/5
L4 5/5 5/5
L5 5/5 2/5
S1 5/5 5/5

-Sensory N L5 1/2, others Normal

Case 3: 56yrs/M
Low Back Pain x 2 months
-Severe intensity, started after dragging a mattress
-Radiation to Left foot
-Increased with activity and on lying down as well.
-Bowel/Bladder: Normal
-No Perineal numbness/tingling
-No fever/constitutional symptoms, No H/O trauma
O/E:
Tenderness Lower lumbar spines (L3-L5)
-SLRT: 70 degrees B/L
Neurology Intact Bilateral
-Reflexes: Normal

Imaging in Back Pain
Referral note from clinician: A clinical summary including relevant findings and suspected pathology in very important.

Xrays:
Lumbar spine X-ray: AP and lateral view

standing– T11 to head of femur.
Gives Information about lumbar spine, plus hips, SI joints, Lumbopelvic parameters.



Flexion-Extension Views: Standing or Lying







Whole Spine Imaging: Alignment (AP:C3 to Femoral Head, Lat: Acoustic foramina to 15cm of femur)
EOS Imaging system: reduced radiation- one tenth dose, simultaneous AP and Lateral

MRI
Detects both bone and soft structures with precision of anatomy and tissue quality.
C/I: metallic foreign bodies, Claustrophobia

Sequences: Sagittal (T1, T2) and Axial T2 (T11 to S2/3)
Coronal T1 or T2:
STIR/FAT SAT (fat-suppressed sequences)- fracture, tumor, inflammatory process.

Gadolium (contrast) – discitis or neoplastic lesion.
-differentiate scar tissue and disc herniation recurrence.

CT Scan
Keep dose at minimal level : “ALARA”
Indications: Study of vertebral bone for facet arthritis, bony component of central and lateral stenosis, vertebral fracture, implants, focal bony lesion (eg. osteoid osteoma).
Axial, Sagittal, Coronal with bone and soft tissue algorithm.

Electromyogram/Nerve conduction Tests
NCT: To evaluate nerve entrapments.

EMG: studying electrical activity of individual motor units of muscle.
Useful for diagnosing Neuropathies and Myopathies.

Degenerative Disc Disease (DDD):
DISC
15-20% of length of spine
Flexibility to spine
Nucleus pulposus at the center, circumferentially constrained by annulus fibrosus.
Cartilagenous End plate

Degenerative Processes: altered matrix components, changes in cell number, cell phenotype and metabolic activity.
Resulting in reduced disc height, disc bulging, loss of NP/AF demarcation

PIVD Degenerative spondylolisthesis Lumbar Stenosis/Adult Deformity

Conservative Treatment of Back Pain