Case of Back Pain
53 year old, right handed lady, hotelier
 3 day history of severe lower back pain
and weakness in her legs
 bending over at work and had noticed a
mild back pain, which progressed
 Night and rest pain, leg radiation, worse
with movement. Unable to walk
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Case of Back Pain
Sep 05Haematologists shoulder pains,
lymphadenopathy and rash, fatigue, 7 kg
weight loss in 6 months
 l-node < 1cm ALP 210 Rheum referral
 Subsequently admitted
 Ex In pain restricted spine ? leg weakness
and altered sensation feet
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Case of Back Pain
ALP 320, ALT 89 CRP 96 XR normal
 MRI spine normal
 Symptoms progressed
 Tingling in upper limbs, noted to have
reduced reflexes
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Case of Back Pain
CSF protein 2.55 g
 ?Guillan-Barre
 Transferred to neurology
 IV Ig, Rehab, FVC, vitals monitoring
 Campylobacter IgG and IgA 160
 EBV +ve
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GB syndrome
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Post-infective acute inflammatory demyelinating
polyneuropathy
1-3 weeks post viral
Distal numbness and weakness – evolves over
days to weeks ascending
Back and leg pain can be a feature
20% severe with autonomic and respiratory
complications
Weakness, areflexia, sensory loss
GB syndrome
Rare – ocular and ataxia – Miller-Fisher
syndrome
 NCS: slowing of conduction or block
 CSF: 1-3g/l
 IV Ig, supportive, ventilation,
plasmapharesis, rehab
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BACK PAIN
Jaya Ravindran
Rheumatologist
Causes
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Simple mechanical eg ligamentous strain
Degenerative disease with/without neural, cord
or canal compromise
Metabolic – osteoporosis, Pagets
Inflammatory – Ankylosing spondylitis
Infective – bacterial and TB
Neoplastic
Others, (trauma,congenital)
Visceral
Red flags
– Age <20 or >50 with back pain for the
1st time
– Thoracic pain >50 yrs
- Pain following a violent injury/trauma
- Unremitting, progressive pain
Red flags
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Past or current history of cancer
On Steroids or immunosuppressants
Drug abuser or +ve HIV
Systemic symptoms - fever, appetitie
and weight loss, malaise
Red flags
- Bilateral leg radiation,
sensory/motor/sphincter symptoms
- Pain predominantly at night
Inflammatory flags
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Morning stiffness and pain >30 mins -1 hr
Better with activity
Peripheral joint involvement
Anterior uveitis
Psoriasis
Inflammatory bowel disease
Recent GI or GU infection
Family history
Myotomes
C5 Deltoid, biceps (biceps jerk)
 C6 Wrist extensors, biceps (biceps,
brachioradialis jerk)
 C7 Wrist flexors, finger extensors, triceps
(triceps jerk)
 C8 Finger flexor, thumb extensors (triceps
jerk)
 T1 finger abductors
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Myotomes
L2 Hip flexion
 L3 Knee extension (knee jerk)
 L4 Knee extension, ankle dorsiflexion
(knee jerk)
 L5 toe dorsiflexion
 S1 foot plantar flexion, eversion
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D
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Examination
LOOK – deformity, muscle wasting,
kyphosis, scoliosis
 LOOK – normal cervical lordosis, thoracic
kyphosis, lumbar lordosis
 FEEL – spinal processes and sacroiliac
joints
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Examination
MOVE – Lumbar flexion
 Schober’s test – marks at “dimples of
Venus” and 10 cm above. Measure at
maximal flexion – usually 5 cm
 MOVE – Lumbar lateral flexion
 MOVE – Cervical flexion/extension, lateral
rotation and flexion, thoracic rotation
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Examination
Sciatic stretch (patient supine) - Straight
leg raise and dorsiflexion of foot - pain in
calf and posterior thigh between 30-70o –
low lumbar (L5/S1) lesion or sciatic
irritation
 Femoral stretch (patient prone) – knee is
flexed and then hip extended – pain in
anterior thigh – high lumbar (L2-L4) lesion
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Imaging
XR – tumour, fracture, infection,
inflammation
 Bone scan – increased turnover eg
infection, metastatic disease, fractures,
Pagets
 MRI – soft tissue, discs, facet joint, nerve
roots, cord, inflammation
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Degenerative disease and sciatica
Very common
 Facet joint OA, disc disease, osteophyte
 Mechanical back pain
 Sciatica – most resolve NB persistent,
neurology, bilateral, red flags
 Analgesia, PT, pain clinics
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Degenerative disease and sciatica
Malignancy
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Unremittting, progressive and night pain
Systemic symtoms
Past hx Ca
Breast, bronchus, thyroid, kidney, prostate and
myeloma/plasmacytoma
Osteolytic (prostate osteoblastic)
XR can be normal in early stages – further
imaging if suspicion high
Predilection for vertebral body and pedicles
Malignancy
Malignancy
Infection
discitis, osteomyelitis, and epidural abscess.
hematogenously spread
most often Staphylococcus aureus.
Gram-negative rods in postoperative or
immunocompromised patients
 normal skin flora is less commonly isolated in
postoperative patients.
 Postoperative patients develop symptoms 2 to 4
weeks after surgery after an initial improvement
in pain.
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Infection
Pseudomonas organisms in intravenous drug
users.
 Mycobacterium tuberculosis in developing
nations and immigrant population. Fungal
infections are rare.
 Only one third have fever and 3% to 15%
present with neurologic deficit.
 Infections typically involve the intervertebral disc
and vertebral body endplate
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Infection
Radiographic changes at 2 to 4 weeks
bone scan can be positive as early as 2 days
75% specific.
 MRI appearance is decreased T1- and increased
T2-weighted signal in the infected disk.
Enhancement after gadolinium
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Infection
Conservative treatment of antibiotics, rigid
bracing to prevent deformity and control pain
 Surgery : neurologic deficit, presence of
abscess, extensive bone loss with kyphosis and
instability, failure of blood work and biopsy to
isolate any organism, excision of a sinus tract, or
no response to conservative treatment.
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Infection
Infection
Osteoporosis
DEXA
T scores
Osteoporosis
Diagnostic Criteria for Osteoporosis Established by the World Health Organization Based on
Comparison to Young Adult Mean Bone Density*
Normal
Bone density is within 1 SD of the young adult mean
Osteopenia
Bone density is within 1 to 2.5 SD below the young adult mean
Osteoporosis
Bone density is 2.5 SD or more below the young adult mean
Severe (established) osteoporosis
Bone density is more than 2.5 SD below the young adult mean and there has been one or more
osteoporotic fractures
*One standard deviation (SD) represents about a 10&percnt; to 12&percnt; decline in bone density .
Low bone density
Differential Diagnosis of Low Bone Density
Osteoporosis
Primary
Secondary
Osteomalacia
Osteogenesis imperfecta
Marrow-based diseases (eg, myeloma, mastocytosis)
Osteoporosis - risks
History of low trauma # - colles, NOF,
vertebral, sacral or pelvic insufficiency
 Steroids
 Maternal history of NOF #
 Gonadal hormone deficiency
 Ca deficiency
 Prolonged immobility
 Low BMI
 Alcohol and smoking
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Causes of low bone density
Secondary Causes of Osteoporosis
Endocrine
Neoplasm
Congenital
Miscellaneous
Hyperparathyroidism Multiple myeloma Osteogenesis
Rheumatoid arthritis
Hyperthyroidism
Gastrectomy
Lymphoma
Cushing’s syndrome Mastocytosis
Homocystinuria
Gaucher’s disease Cirrhosis
Hypopituitarism
Renal failure
Hyperprolactinemia
Malabsorption (sprue)
Vertebral fractures
Osteoporosis
Osteoporosis
Bisphosphonates
 SERMs
 Strontium
 Teriparatide
 Calcitonin
 Lifestyle factors
 Ca and Vit D
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7-dehydrocholesterol
(diet)
sunlight
25-hydroxycholecalciferol
kidney 1-hydroxylase
1,25-dihydroxycholecalciferol
cholecalciferol
liver
(-)
increased GI Ca2+ absorption
Ca2+
Bone resorption
Thyroid
(-)
Parathyroid Gland
PTH
 Renal Ca2+
()
Calcitonin
reabsorption
Spinal stenosis
Canal or foraminal narrowing with possible
subsequent neural compression
 Cause
 Ligamanetum flavum hypertrophy, facet
joint hypertrophy, vertebral body
osteophytes, herniated disc
 Rare: Pagets, AS, acromegaly
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Spinal stenosis
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Symptoms
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Age - >50
Dull aching pain in the lower back and legs
Exertional leg pain/weakness/numbness
Symptoms relieved leaning forward, sitting or lying
Examination
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May be normal
Normal sensation and power
Reflexes normal or slightly reduced
Normal foot pulses
Spinal stenosis
Spinal stenosis
Conservative – analgesics, NSAIDs, PT,
epidural
 Surgery – laminectomy (+arthrodesis)
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Cauda Equina Syndrome
Back pain, lower limb weakness, saddle
anaesthesia, sphincter disturbance, impotence
 Causes – usually disc, rarely tumour, abscess,
advanced AS
 Diminished sensation L4 to S2 (sacral
numbness), weakness ankle and plantar
dorsiflexion, loss ankle jerks, urinary retention,
loss anal tone
 Urgent MRI and surgical decompression
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Cauda Equina Syndrome
Pagets
Pagets
Pain, deformity
 Skull, long bone, vertebra, pelvis, near hip
 Neurologic compromise
 Planned surgery
 ?ALP 2X ULN
 Rare: high output failure
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AS
The Concept of Spondyloarthropathy
Disease Subgroups
1. Ankylosing spondylitis
2. Reactive arthritis (Reiter’s syndrome)
3. Enteropathic arthritis
4. Psoriatic arthritis
5. Undifferentiated spondyloarthropathy
6. Juvenile spondyloarthropathy
All These Diseases Share Rheumatologic Features
• Sacroiliac and spinal (axial) involvement
• Enthesitis at long attachments of ligaments and tendons causing: Achilles tendonitis and plantar fasciitis,
syndesmophyte formation (“bamboo spine”), sacroiliitis (due to a combination of enthesitis and synovitis),
and periosteal reaction (“whiskering”) at gluteal tuberosity and other parts of pelvis and other sites
• Peripheral, often asymmetric, inflammatory arthritis and dactylitis (“sausage” digits)
Share Extra-articular Features
• Propensity to ocular inflammation (acute anterior uveitis conjunctivitis)
• Mucocutaneous lesions, variable for the subgroups
• Rare aortic incompetence or heart block
• Lack of association with rheumatoid factor and rheumatoid nodules
Share Genetic Predisposition
• Strong association with HLA-B27 gene
• Familial clustering
AS
NSAIDs
 Sulphasalazine – peripheral joints
 PT
 Anti-TNF
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AS
AS
AS
THE END
THANK-YOU