1. Neck and Back Pain By Kubra Al Sayed & Enas Al Ekri Monday, April 4, 2005

2. 2 Back Pain Differential Diagnosis _Musculoligamentous strain _Sciatica _Spinal stenosis _spondylolisthesis _vertebral compression fracture _Neoplasms _Infections _ankylosing spondylitis _Psychogenic disease _cauda equina syndrome

3. 3 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)

4. 4 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

5. 5 Infections Vertebral osteomyelitis Secondary to spinal procedures :LP,disk surgery Tenderness to percussion of affected vertebrae Fever absent in up to half of pts.

6. 6 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)

7. 7 Psychogenic Disease Depression Somatization Malingering Normal Physical Examination

8. 8 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.

9. 9 Workup History Physical Examination Neurologic Examination Radioimmaging Management Back exercises

10. 10 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.

11. 11 Aggravating and relieving factors. Impact of back pain on daily activities. Emotional and social stressors. Check for depression.

12. 12 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.

13. 13 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.

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23. 23 Radioimmaging Lumbo-sacral spine films. CT MRI

24. 24 L-S Spine Films Neither cost-effective nor useful in decision making When suspected : Malignancy compression fracture ankylosing spondylitis chronic osteomyelitis major trauma 

25. 25 Management Bed rest xxx continuing activity Local application of heat or warm compresses NSAIDs Physiotherapy Pt. Education Back care & hyeigiene Refer

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27. 27 Evaluation of neck pain

28. 28 Pathophysiology and Clinical Presentation Neck strain Degenerative disease Inflammatory disease Malignancy Referred pain

29. 29 Neck Strain Most common form of neck pain Caused by paraspinal muscle spasm Self limited if aggravating activities is avoided

30. 30 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

31. 31 Cont… Neurologic deficits rare (unless # of spine is present) Refractory pain > 6months represent zygapophyseal joint injury

32. 32 Degenerative disease Recurring neck stiffness Mild aching discomfort Progressive limitation of neck motion Lateral rotation & lateral flexion are restricted

33. 33 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

34. 34 Cont… C-5 root compression: Involves anterosuperior shoulder & anterolateral aspect of upper arm & forearm Decreased biceps jerk & weakness of elbow flexion found in examination

35. 35 Cont… C-6 root compression: Affects the dorsoradial aspect of forearm & thumb C-7 root compression Alters sensation in the middle of hand

36. 36 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

37. 37 Cont… In polymyalgia rheumatica neck pain accompanies aching discomfort & stiffness of shoulder & hip girdle

38. 38 Malignancy Metastasis to spinal cord or vertebral bodies may produce pain that is worse at night or while bending down

39. 39 Referred pain Coronary ischemia, pain worsen by physical activity Concurrent arm pain, simulate cervical radiculopathy Esophageal disease, referred pain to neck

40. 40 Differential Diagnosis Lymphadenopathy Thyroditis Angina pectoris Meningitis

41. 41 Work up History: Precipitating events Aggravating & alleviating factors Area of maximal tenderness Radiation Numbness or weakness in the extremities

42. 42 Cont… Coarse of the disease Past history of similar problem Previous medication Symptoms of coronary artery disease or meningeal irritation

43. 43 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)

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46. 46 Cont… Examination of upper extremities (tendon reflexes, strength, sensation, range of motion, & pulses) Meningeal signs (patient with fever & neck pain)

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50. 50 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

51. 51 Cont.. Degenerative disease & ankylosing spondylitis: neck plain film Tumors: bone scan or CT if bony involvement; MRI if marrow or cord compression of concern

52. 52 Symptomatic management Strain: Heat, ice & gentle massage Muscle relaxants: useful in short- term basis NSAIDS:( e.g., aspirin, ibuprofen) with small nighttime dose of diazepam(5mg)

53. 53 Cont… Strengthening & range of motion exercise Soft cervical collar to rest sore neck muscle, avoid prolonged use (disuse atrophy)

54. 54 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

55. 55 Cont… Surgical management in refractory disease, when neurologic compromise is present

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57. 57 Indication for referral and admission Meningeal signs Chronic pain unresponsive to conservative measures Significant weakness of upper extremity

58. 58 Cont… Signs of cord injury hyperreflexia incontinence retention bilateral neurologic deficits

59. 59 Thank You