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Neck and Back Pain
By Kubra Al Sayed
&
Enas Al Ekri
Monday, April 4, 2005
Back Pain
• Differential Diagnosis
_Musculoligamentous strain
_Sciatica
_Spinal stenosis
_spondylolisthesis
_vertebral compression fracture
_Neoplasms
_Infections
_ankylosing spondylitis
_Psychogenic disease
_cauda equina syndrome
2
Spinal Stenosis
•
•
•
•
Predominant in elderly
Narrowing of lumbar spinal canal
Pain worsened by standing,walking
Relieved by rest,sitting and lying
down
• Numbness or weakness in
legs(psudoclaudication)
3
Neoplasms
• Most common is metastatic Ca
• Waist –level or midback pain not relieved
by lying down
• Increasing in severity & aggravated by
activity
• Past hx of Ca :
breast,lung,prostate,GIT,GUT
• Myeloma is the commonest primary
tumor
4
Infections
• Vertebral osteomyelitis
• Secondary to spinal procedures
:LP,disk surgery
• Tenderness to percussion of
affected vertebrae
• Fever absent in up to half of pts.
5
Ankylosing Spondylitis
• Seronegative spondyloarthropathy
• Morning spinal stiffness
• Symptomatic improvement with
exercise
• HLA-B27 positive (immune disease)
• Films of sacroiliac joint may show
narrowing of the joint space and
active sclerosis (sacroiliitis)
6
Psychogenic Disease
•
•
•
•
Depression
Somatization
Malingering
Normal Physical Examination
7
Cauda Equina Syndrome
• Injury by any process that
compromises the spinal canal
below the L-1 level.
• Massive midline disk herniation is
the most common cause.
• In 90% urinary retention.
• Saddle anesthesia: reduction in
sensation over the buttocks, upper
posterior thighs and perineum.
8
Workup
•
•
•
•
•
•
History
Physical Examination
Neurologic Examination
Radioimmaging
Management
Back exercises
9
History
• Pain characteristics: quality,
location, onset, radiation.
• Fever, Neurological deficits: Bladder
dysfunction, saddle anesthesia.
• Hx of recent injury.
• Prior hx of cancer.
• Hx of recent lumbar puncture.
• Hx of prolonged use of
corticosteriod.
10
• Aggravating and relieving factors.
• Impact of back pain on daily
activities.
• Emotional and social stressors.
• Check for depression.
11
Physical Examination
• Examine the back with patient
standing and back uncovered.
• Inspect for asymmetry, muscle
bulk, posture, spinal curvature.
• Assess flexibility.
• Palpate for focal tenderness,
masses.
• SLR Test.
12
Neurologic Examination
• Test for S1 root function (L5-S1
disk): Plantar flexion against
resistance, ankle deep tendon
reflexes and lateral foot sensation.
• Test for L5 root function (L4-L5
disk): dorsiflexion of the ankle and
big toe against resistance and
sensation on the anterior, medial
dorsal foot.
13
14
15
16
17
18
19
20
21
22
Radioimmaging
• Lumbo-sacral spine films.
• CT
• MRI
23
L-S Spine Films
• Neither cost-effective nor useful in
decision making
• When suspected :





Malignancy
compression fracture
ankylosing spondylitis
chronic osteomyelitis
major trauma
24
Management
• Bed rest xxx continuing activity
• Local application of heat or warm
compresses
• NSAIDs
• Physiotherapy
• Pt. Education
• Back care & hyeigiene
• Refer
25
26
Evaluation of neck
pain
27
Pathophysiology and Clinical
Presentation
•
•
•
•
•
Neck strain
Degenerative disease
Inflammatory disease
Malignancy
Referred pain
28
Neck Strain
• Most common form of neck pain
• Caused by paraspinal muscle spasm
• Self limited if aggravating activities is
avoided
29
Severe neck strain
• Seen in cervical hyperextension
(whiplash) injury
• Results in
musculoligamentous strain
muscle fibers tear
• Symptoms become most severe the
day after the acute event
30
Cont…
• Neurologic deficits rare (unless #
of spine is present)
• Refractory pain > 6months
represent zygapophyseal joint
injury
31
Degenerative disease
• Recurring neck stiffness
• Mild aching discomfort
• Progressive limitation of neck
motion
• Lateral rotation & lateral flexion
are restricted
32
Cont…
• Usually localized to lower cervical
levels
• Narrowing of neural foramina
causes root impingement & pain
• Radiating pain of affected root,
paresthesia, numbness & weakness
may be associated
33
Cont…
C-5 root compression:
• Involves anterosuperior shoulder &
anterolateral aspect of upper arm
& forearm
• Decreased biceps jerk & weakness
of elbow flexion found in
examination
34
Cont…
C-6 root compression:
Affects the dorsoradial aspect of
forearm & thumb
C-7 root compression
Alters sensation in the middle of
hand
35
Inflammatory disease
(Rheumatoid)
• Pain worsening in the morning
• Symmetric polyarthropathy &
subluxation at C1-2 are
charactiristic
• In spondyloarthropaties , neck pain
occurs as diffuse back & sacroiliac
discomfort
36
Cont…
• In polymyalgia rheumatica neck
pain accompanies aching
discomfort & stiffness of shoulder
& hip girdle
37
Malignancy
• Metastasis to spinal cord or
vertebral bodies may produce pain
that is worse at night or while
bending down
38
Referred pain
• Coronary ischemia, pain worsen by
physical activity
• Concurrent arm pain, simulate
cervical radiculopathy
• Esophageal disease, referred pain
to neck
39
Differential Diagnosis
•
•
•
•
Lymphadenopathy
Thyroditis
Angina pectoris
Meningitis
40
Work up
History:
Precipitating events
Aggravating & alleviating factors
Area of maximal tenderness
Radiation
Numbness or weakness in the
extremities
41
Cont…
Coarse of the disease
Past history of similar problem
Previous medication
Symptoms of coronary artery
disease or meningeal irritation
42
Examination
Visualization of neck, thorax, &
upper extremities
Assessment of neck motion (
flexion, extension, left & right
lateral flexion & left & right
rotation)
Palpation of the neck ( point of
local tenderness)
43
44
45
Cont…
Examination of upper extremities
(tendon reflexes, strength,
sensation, range of motion, &
pulses)
Meningeal signs (patient with fever
& neck pain)
46
47
48
49
Laboratory studies
• Traumatic neck strain: cervical spine
films (rule out structural damage)
• Clinical evidence of root compression:
MRI is indicated; CT with myelography
if MRI not available
50
Cont..
• Degenerative disease & ankylosing
spondylitis: neck plain film
• Tumors: bone scan or CT if bony
involvement; MRI if marrow or
cord compression of concern
51
Symptomatic management
• Strain:
Heat, ice & gentle massage
Muscle relaxants: useful in shortterm basis
NSAIDS:( e.g., aspirin, ibuprofen)
with small nighttime dose of
diazepam(5mg)
52
Cont…
Strengthening & range of motion
exercise
Soft cervical collar to rest sore neck
muscle, avoid prolonged use (disuse
atrophy)
53
Cont…
• Degenerative disease:
NSAIDS( ibuprofen or naproxen)
Cervical collar (minimize
compression)
Home cervical traction( severe,
chronic, or recurrent neck
pain)applied 20-30 min 2-4
times/day
54
Cont…
Surgical management in refractory
disease, when neurologic
compromise is present
55
56
Indication for referral and
admission
• Meningeal signs
• Chronic pain unresponsive to
conservative measures
• Significant weakness of upper
extremity
57
Cont…
• Signs of cord injury
hyperreflexia
incontinence
retention
bilateral neurologic deficits
58
Thank You
59