Sunteți pe pagina 1din 128

Regional syndromes-

Neck and low back pain



Neck pain
Cervicalgia the importance of the problem

Cervicalgia (pain in the cervical region) is very common in clinical
practice.

The annual incidence of neck pain is 15%.

Woman complaint more often of neck pain and have a higher risk to
develop chronic cervicalgia than men.

Young people are often affected by episodes of acute neck pain, which
are usually transient.

The most common condition is chronic pain with acute, recurring
episodes in adults and the elderly
Functional anatomy
Atlas
Axis
The structure of vertebrae

A Vertebral body
B Vertebral disk
C Facet joint
D Intervertebral foramina
E Spinal cord and nerve
roots
http://www.neurospineinstitute.org/procedures/spine-anatomy-physiology/
Functional anatomy
- nerve roots
Nerve roots exits
C1
C2
C4
C3
C5
C6
C7
C8
Sensory territory of nerve roots dermatomes
Common causes of neck pain
Trauma
- History of trauma
- Occupational factors, bad posture
Often causes acute attacks in young people
Diagnostic tests usually normal
Spondyloarthrosis
Pain usually mechanical
- Chronic or recurring pain
- Can be associated with neurogenic manifestations, arising from the nerve
roots or spinal cord
The most common cause of neck pain in adults and the elderly
Suggestive x-ray features
Inflammatory joint
disease
Pain tends to be inflammatory
- Usual association of manifestations of arthritis in other locations
Rheumatoid arthritis, seronegative spondyloarthropathies and juvenile
idiopathic arthritis often affect the cervical spine
Infection
Acute or chronic infections of the vertebral bones or disks, like tuberculosis
or brucellosis, may, on rare occasions, affect the neck
Metastases
Tumors in the thyroid, lung, breast, kidney and prostate may metastasize
to the cervical spine
- Multiple myeloma can affect this region
- Primary bone tumors are rare
Referred pain
Special attention to the shoulder, pulmonary vertex and heart
Risk factors


Age is an important factor when identifying the cause of cervicalgia
Risk factors

http://www.activecarewilm.com/2012/05/23/poor-posture/
Clinical case 1
Maria was 68 years old. She was a housewife and farm worker. She went to the
doctor because of pain affecting the cervical and upper thoracic region.
The pain had begun insidiously when she was about 40 and had been getting
progressively worse. In the first years of the disease, the pain appeared
occasionally at times of strenuous physical work. As the years went by, it
became more frequent and appeared with less and less effort until it was almost
constant, with flares. During such exacerbations, which lasted up to a week, the
pain extended to the whole cervical area, and also involved the shoulders. The
pain was worse with exercise (such as carrying heavy items in her arms) and
was relieved by rest. She had no pain at night except when she moved in bed.
She takes NSAIDs, with inconsistent effect.
When asked, she described occasional pain and tiredness in her arms but
denied any paresthesia or weakness. The pain was not exacerbated by Valsavas
maneuver. Maria also had similar pain in the lumbar region and in her knees.
She had a history of peptic ulcer and arterial hypertension (under control with
Prestarium and Tertensif).


Taking history
What kind of pain?

A history of recent trauma or the appearance of pain as a result of a
prolonged, forced position acute cervicalgia

An inflammatory rhythm - infection, inflammation or neoplasm.
It is important to look for symptoms and signs of arthritis in other
locations.
The systematic enquiry will try to identify signs of systemic disease

Mecanical pain spondyloarthrosis

Real neurogenic pain - root compression
intense, dysesthesic (electric shock or pins and needles) and
follows a dermatome distribution



Taking history


The location of the pain
gives an indication of its
most likely point of origin

Where is the pain localized?
Regional clinical examination
Observation
Accentuation or attenuation of physiological lordosis, localized kyphosis,
scoliosis
Atrophy of the shoulder muscles
Localized swelling

Palpation
Nonspecific should be interpreted with caution
Muscle spasm associated with a stiffness! Pain that is clearly located over one
or two spinous processes may suggest infection or neoplasm.
Regional clinical examination

Mobilization

Amplitude of movement varies
considerably from one person to
another.
Measurements of the range of
movement tend to be
qualitative, looking for a
significant reduction in mobility
associated with functional
impact and local pain, or for
pain radiating with movement

Physical examination
H = 155 cm, W = 80 kg
Reduced lateral inclination and rotation of the neck, with
pain at the extremes of movement.
Pain on palpation of different muscular points on the
posterior and lateral aspects of the neck
Normal power, reflexes and pain sensation.
No muscle atrophy.


What is the probable diagnose?

1. Cervicobrachial neuralgia

2. Nonspecific chronic cervicalgia

3. Cervical disk herniation
What is the probable diagnose?

1. Cervicobrachial neuralgia

2. Nonspecific chronic cervicalgia

3. Cervical disk herniation
What diagnostic tests would you request?

1. Lateral x-ray of the cervical spine

2. CT

3. MRI


What diagnostic tests would you request?

1. Lateral x-ray of the cervical spine

2. CT

3. MRI


Lateral x-ray of the cervical spine
1. Reduction in the
intervertebral space
Scleroza platoului vertebral
2. Sclerosis of the vertebral
endplates
3. Osteophytes

1
1
4
2
2
2
3
3
3
Treatment
Nonfarmacological treatment
encourage her to stay active - regular relaxation exercises, mobilizing and
stretching the muscles
avoid strenuous activities that put a strain on her neck, such as carrying heavy
loads and effort in forced positions.
Progressive loss of weigh
A low, well-adjusted pillow
Physiotherapy
Local heat applied at home during exacerbations
The cervical collar, properly adjusted that it is comfortable but effective

Medication
NSAIDs - COX2 selective (Celecoxib or Etoricoxib)
Analgesics (Paracetamol +/- Codeine or Tramadol)
Myorelaxants

CHRONIC NON-SPECIFIC NECK PAIN
MAIN POINTS
This is a very common condition in the elderly.
The pain is usually insidious and chronic, with exacerbations.
It may also involve the scapular region though it has no neurogenic
characteristics.
Neck movements are limited (especially rotation and lateral inclination).
Spondyloarthrosis is the most common underlying cause, but the correlation
between x-ray and clinical examination is very unreliable.
!Investigation should be limited to the essential cervical x-ray maybe (NO need
to repeat them often)

Treatment is conservative.
Avoidance of excessive effort should be combined with a program of regular
mobilization and relaxation exercises
Analgesics, mild anti-inflammatories and muscle relaxants may be necessary
during flare-ups
Prognosis varies but the pain tends to become chronical.
Clinical case 1 - evolution
During 3 years of follow-up, Maria, our previous patient, was very
pleased with her response to treatment. Although she still had some
pain, it was more tolerable. Exacerbations were now rare and related to
effort.
This time, she came back to us because of exacerbation of the pain,
which was no longer responding to the usual measures. The pain was
particularly intense and involved the left arm and forearm as far as the
thumb. She described this radiated pain as an electric shock and had
noticed that it appeared especially when she turned her neck to the
right.
A slight cough that she had had for a few days made the pain
unbearable, as it increased the radiated pain, causing the pins and
needles to last longer.

Taking history
What kind of pain?

A history of recent trauma or the appearance of pain as a result of a
prolonged, forced position acute cervicalgia

An inflammatory rhythm - infection, inflammation or neoplasm.
It is important to look for symptoms and signs of arthritis in other
locations.
The systematic enquiry will try to identify signs of systemic disease

Mecanical pain spondyloarthrosis

Real neurogenic pain - root compression
intense, dysesthesic (electric shock or pins and needles) and
follows a dermatome distribution



Taking history


Where is the pain localized?
Regional physical examination
Cervical Lasgue test
Forced lateral flexion of the neck to
the right caused the pain to radiate to
the lateral aspect of the left forearm
Spurlings maneuver
Vertical compression of the head
towards the neck caused local pain
without radiation
Regional physical examination
- neurological examination
If we suspect root or spinal cord compression, a detailed neurological
examination of the upper limbs is called for.
Evaluation of touch and pin-prick sensation will follow the dermatomes
Muscle strength and reflexes can be assessed as shown in table
Nerve root Muscle strength
Abnormal
OT Reflexes
C5 Shoulder - abduction Biceps reflex
C6 Wrist- extension,
Elbow- supination, flexion
Radial reflex
C7 Elbow - extension,
Wrist flexion
Triceps reflex
C8 Fingers - flexion NA
Local examination
The pain worsened during active and passive mobilization of the neck,
which was more limited, with associated muscle spasm.

Forced lateral flexion of the neck to the right (cervical Lasgue) caused
the pain to radiate to the lateral aspect the left forearm

Neurological examination showed reduced pin-prick sensation over the
thumb and radial side of the left forearm;

There were no apparent changes in muscle strength. Tinels and
Phalens signs for carpal tunnel syndrome were negative

What is the probable diagnose?

1. Nonspecific chronic cervicalgia

2. Cervico-brachial neuralgia (Cervical nerve root
compression)

3. Cervical spondylodiscitis




What is the probable diagnose?

1. Nonspecific chronic cervicalgia

2. Cervico-brachial neuralgia (Cervical
nerve root compression)

3. Cervical spondylodiscitis




Investigations
Cervical radiography
It enables us to discover the cause of nerve root compression:
spondylarthrosis, spondylolistheses, destructive lesions of the vertebrae

MRI of cervical spine
The most accurate examination for nerve root compression
Are indicated only if surgery is contemplated

CT myelography
Recommended for those with pacemaker or surgical devices in the cervical
region

Electromyogram of upper limbs
Can be decisive in the case of inconclusive abnormalities in the neurological
examination as it clarifies the existence of and aids in the location of lesions.
MRI in compression nerve root syndrome

T2-weighted MRI in a patient with right-sided C6 radiculopathy.
A. Sagittal view showing spondylosis at C5-C6 and C6-C7 disk levels (ARROWS)
B. Axial view showing a right-sided disk-osteophyte complex at C5-C6 disk level (ARROW) that is putting
pressure on the C6 nerve root.


Treatment
Conservative treatment
Cervical collar
Physical therapy for muscle relaxation treatment and careful traction
of the cervical spine after flare-up
Physiotherapy
NSAIDs, analgesics, muscle relaxants
Epidural steroid infiltration (CT guided)
Surgical treatment
If symptoms persist > 6 weeks or worsen (especially neurological)
despite conservative treatment neurosurgical assessment
CERVICAL NERVE ROOT COMPRESSION
MAIN POINTS
Cervical nerve root compression should be suspected whenever there is
dysesthesic pain in the territory of a root and exacerbated by cervical
movements. Sensory or motor deficiencies may ensue.
The roots C5C7 are most often affected.
Root compression may accompany the onset of cervical pain, especially in young
people, suggesting a disk lesion, or develop insidiously in the presence of a
chronic degenerative condition such as spondyloarthropathy.
Lasgues cervical maneuver, Spurlings maneuver and a neurological
examination of the upper limbs are the key to the diagnosis.
Electromyography and MRI (Magnetic Resonance Imaging) may be indicated
when the persistence or severity of the situation may warrant surgery.
The prognosis is usually favorable with conservative treatment.
The persistence of incapacitating symptoms or progressive neurological
alterations >6 weeks in spite of appropriate conservative treatment may justify
assessment by an experienced surgeon.

Clinical case 2
Ana, 49 years old, is being followed up at the Rheumatology Clinic Cluj Napoca
for rheumatoid arthritis that had begun 10 years before. Is being treated with
Methotrexate and NSAIDs with highly satisfactory results on her peripheral
arthritis.
She complaint of neck pain for the first time. She put it down to working
long hours at the computer and some stress.
A more detailed enquiry revealed that the pain was in the upper cervical area
and sometimes involved the occipital region.
It got worse in the last 2 weeks. It was worse at the end of the working day and
didnt improve with rest. The pain was there when she woke up, and she
experienced moderate morning stiffness of the neck lasting for about 2 hours.
She denied any neurogenic manifestations in the upper limbs or her body.
Our examination revealed painful restriction of neck movements, but
neurological examination was normal.
Biologic: VSH = 20-40 mm/h, CRP = 1,2 mg/dl

Taking history
What kind of pain?

A history of recent trauma or the appearance of pain as a result of a
prolonged, forced position acute cervicalgia

An inflammatory rhythm - infection, inflammation or neoplasm.
It is important to look for symptoms and signs of arthritis in other
locations.
The systematic enquiry will try to identify signs of systemic disease

Mecanical pain spondyloarthrosis

Real neurogenic pain - root compression
intense, dysesthesic (electric shock or pins and needles) and
follows a dermatome distribution



What diagnostic tests would you request?

1. None

2. Antero-posterior x-ray of cervical spine

3. Dynamic lateral view x-ray of cervical spine
(flexion and extension)

What diagnostic tests would you request?

1. None

2. Antero-posterior x-ray of cervical spine

3. Dynamic lateral view x-ray of cervical
spine (flexion and extension)

Anterior atlantoaxial subluxation in
rheumatoid artrhritis
Anterior atlantoaxial
subluxation
the distance between the
posterior edge of the arch of the
atlas and the anterior edge of the
odontoid process during
flexion>5 mm
As a result of rupture or
distension of the transverse
and cruciate ligaments of atlas
(due to chronic inflammation
of atlantoaxoidian joit).

INFLAMMATORY NECK PAIN
MAIN POINTS
The possibility of cervical involvement should always be borne in mind and
actively investigated in patients with rheumatoid arthritis, juvenile idiopathic
arthritis and seronegative spondylarthropathy. On rare occasions, cervical
involvement may be the first manifestation of these diseases.
Infections of the cervical vertebrae and disks (spondylodiscitis) are relatively
rare but should always be considered, especially in a clinical context suggesting
tuberculosis or brucellosis.
Pain of metastatic origin may have an inflammatory rhythm, although it tends
to be more constant and unrelated to movement or rest.
First line investigations: X-rays and acute-phase reactants measured together
with tests specific to the clinically suspected causes.




A referral to a specialist
- Who ? Where? When? -
Almost all cases of neck pain should be managed by general practitioners
A referral to a specialist
- Who ? Where? When? -
Some situations justify sending patients to a specialist
(rheumatologist, orthopedic surgeon, neurosurgeon, physiatrist
or even a specialist in internal medicine, as the case may be):
Reason to suspect an infectious or neoplastic lesion
Neck pain as part of polyarthritis
Manifest cervical instability or deviation
Neurological signs in the nerve roots or spinal cord
Intense symptoms that are resistant to conservative treatment

Durerea
lombar
Durerea lombar
Importana problemei
Prevalena anual a durerii lombare n SUA 15-20%

Este cea mai frecvent cauz de impoten functional la pacienii < 45 ani i
cea mai frecvent cauz de disabilitate n SUA

85% din populaie va avea cel puin o dat n via experiena unei dureri
lombare

Este a doua cauz ca frecven de adresabilitate n cabinetul medicului de
familie

90% din durerile lombare se amelioreaz i trec n 2 - 6 sptmni, mai ales
dac pacienii rmn activi

Recurena este frecvent: 60-80% din pacieni au recidive n urmtorii 2 ani
Anatomie funcionala


Anatomie funcionala
Anatomie funcionala

Emergena rdcinilor nervoase lombare
Stnga: compresiune rdcin nervoas prin hernie de disc sau osteofit al articulaiei interfaetare
Prezentare caz 1
Teodora, femeie de 35 ani care lucreaz la grdini, are
durere de spate de intensitate mare de 3 zile de cand s-a
aplecat s ridice un copil. A mai avut intermitent dureri de
spate mai ales la sfritul zilei, dupa ce fcea efort mai mare
ridicnd copii i material didactic, dar niciodat durerea nu
a avut aceast intensitate.

A folosit un unguent antiinflamator i a luat ibuprofen
(Nurofen) 200 mg o dat pe zi fr ameliorare.

Ce informaii anamnestice
suplimentare v sunt necesare ?

1. Informaii despre caracterul durerii

2. Informaii despre semnele neurologice i/sau
iradierea n membre (un membru sau ambele
in bascul)

3. Toate cele de mai sus i alte elemente...

Ce informaii anamnestice
suplimentare v sunt necesare ?

1. Informaii despre caracterul durerii

2. Informaii despre semnele neurologice i/sau
iradierea n membre (un membru sau ambele
in bascul)

3. Toate cele de mai sus i alte elemente...

Elemente cheie din anamnez
Durere: localizare, iradiere, caracter (arsur, amoreal, etc), debut,
durat orar (constant/intermitent), severitate, factori declanatori
(traumatisme, poziie, miscri, repaus, etc) si factori de ameliorare

Semne neurologice: parestezii, hipo/hiperestezie, senzaie de
greutate n membru, parez/plegie, tulburri motorii (de mers),
tulburri sfincteriene, etc.

Semne generale: febr, scdere ponderal, frisoane, astenie, etc.

Boli asociate/traumatisme: neoplasme, TBC sau contaci, alte
infecii, boli arteriale periferice, traumatisme majore sau mici etc

Condiii de via i munc: profesie, domiciliu, lifestyle, toxice,
situaie familial, etc

Factori clinici sugestivi
pentru existena unei patologii serioase
Vrsta < 20 ani sau > 50 de ani
Durerea nocturn i de repaus, progresiv
Simptome/semne generale: febr, frisoane, semne
infecioase, sindrom impregnare malign - scdere ponderal,
manifestri de organ
Traumatism/infecie recent
Istoric cancer, osteoporoz, corticoterapie
Semne neurologice: semne de compresiune, iradiere n
membrele inferioare bilateral sau in bascul, modificri ROT,
parestezii, pareze, anestezie n a, retenie urinar


Prezentarea cazului
- completare
Durerea se accentueaz la efort i cedeaz la repaus
Nu are iradiere n membrul inferior
Nu are accentuare la tuse sau strnut, nu are parestezii sau tulburri
de miciune
Nu are semne generale (febr, astenie, sindrom impregnare malign)
Nu a avut nici un traumatism
A mai avut durere lombar moderat (jen sau disconfort), dar
niciodat de aceast intensitate
St mult aezat, dar i n picioare; car i mut greuti: cri,
cataloage, plane; conduce mult (face naveta); este n general sedentar
(nu face miscare, exerciiu fizic, etc)
Este activ, vesel, sociabil, mulumit de viaa, familia i profesia ei


Ce vei cuta n primul rnd la
examenul obiectiv general ?

1. Tulburrile de postur i atitudine

2. Tulburrile de mers

3. Semnele generale
Ce vei cuta n primul rnd la
examenul obiectiv general ?

1. Tulburrile de postur i atitudine

2. Tulburrile de mers

3. Semnele generale
Elemente cheie din examenul obiectiv
Examen coloan vertebral:
Postura, inspecia (curburi fiziologice/ patologice)
Palparea i percuia pentru identificarea punctelor dureroase i
contracturilor musculare
Mobilitatea coloanei vertebrale: toate direciile, toate poziiile
Mersul: antalgic, clcie, vrfuri
Semnele de iritaie radicular: testul Lasegue

Examen neurologic: mers, ROT, hipo/hiperestezie, fora
muscular, hipotrofie muscular, etc

Examen general

Examen obiectiv
= 180 cm, G = 85 kg
Mers clcie i vrfuri posibil (semnul talonului i poantei
negativ)
Contractur muscular paravertebral important
Durere moderat la flexia anterioar a trunchiului la aprox 80
0,
fr durere la percuia SI i manevre pentru SI negative

Schber = 2 cm
Lasegue negativ
ROT simetrice, prezente bilateral, far tulburri de sensibilitate
For muscular pstrat la toate grupurile musculare, fr
hipotrofie muscular


Ce diagnostic vei formula ?

1. Lumbago acut hiperalgic

2. Lumbago subacut

3. Lombalgie cronic recurent
Clasificare criterii de evolutie

Evoluie

Lombalgie acut
< 6 sptmni

Lombalgie subacut
6-12 sptmni

Lombalgie cronic
> 12 sptmni


Lombalgie acut recurent
< 6 sptmni, istoric episoade similare

Ce interpretare clinic avei n aceast
etap ?

1. Hernie de disc

2. Lombalgie comun (nespecific)

3. Osteoporoz cu tasari vertebrale
Lombalgie
acut - cauze
o Mecanice
deranjamente minore n disc,
platouri vertebrale, articulaiile
faetelor, ligamente, fascii,
muchi paravertebrali, vase -
nespecifice !
artroz - spondilartroz, discartroz,
hernie de disc, stenoz spinala,
spondilolisteza, tulburari de static
vertebral
o Boli infecioase
osteomielit, spondilodiscit, sacroiliit
infectioas, herpes zoster, etc.
o Boli neoplazice/infiltrative
osteom osteoid, osteoblastom,
osteocondrom, metastaze osoase
o Reumatisme inflamatorii
spondilita anchilozant, SpA
o Boli endocrine
osteomalacie, osteoporoz
o Dureri iradiate abdominale,
pelviene, toracice
anevrism aort abdominal, afeciuni
gastroIS, endometrioz, boal
inflamatoare pelvin, etc



10 %
Boala Vrsta L0calizarea
durerii
Calitatea
durerii
Agravare/
ameliorare
Semne
Deranjamente
minore
20-40 lombar, fese,
reg. post. coapse
surd,spasm activitatea,
flexia
mobilitate,
sensibilitate +
Hernie de disc 30-50 lombar,iradiere
n membru
ascuit,
arsur,
parestezii
ortostatism
flexie, ezut
Lasegue +
F musc
ROT asimetrice
Spondilartroza
Stenoza spinal
> 50 lombar, iradiere
membre bilat.
surd,
ascuit
parestezii
mers extensie
+/- F musc
ROT asimetrice
Spondilita
anchilozant
15-40 lombar, art. SI profund repaus
activitatea
redoare
mobilitate
sensibilitate +
art. SI
Infecie oricare lombar, sacru surd,
ascuit
variabili febr
sensibilitate +
+/- tulb. neurol
Cancer > 50

osul afectat profund,
persistent,
progresiv
decubit,
tuse
sensibilitate +
+/- tulb. neurol
+/- febr
Clasificare criterii clinice
Durere
lombar
Comun
(Nespecifica)
Asociat cu
radiculopatie
/stenoz spinala
Asociat cu alt
cauz specific
Spondilita
anchilozant
Cancer
Infecii
vertebrale
Fracturi
vertebrale
Sindrom de
coad de cal
Ce investigaii vei solicita ?

1. Nici una

2. Radiografie lombar (anteroposterioar +
laterolateral)

3. Alte investigaii: RMN
Ce investigaii vei solicita ?

1. Nici una

2. Radiografie lombar (anteroposterioar +
laterolateral)

3. Alte investigaii: RMN
Radiografia n lombalgia comun
Rol imagistic diagnostic in durerea lombar ncurajarea
pacientului c patologia serioas este absent !!!
Etiologia durerii nu poate fi determinat prin radiografie lombar
la majoritatea pacienilor
Expunerea nenecesar la radiaii ionizante radiografie lombar
(AP+LL) face ct un Rx toracic zilnic timp de 4 ani
Radiografia lombar asociat cu satisfacia pacientului
Studiu RCT 421 pacieni cu durere lombar cu o durat medie
de 10 sptamani 80% ar fi preferat s faca o radiografie
lombar dac li s-ar fi dat ocazia sa aleag
Fr diferen semnificativ n evoluia i tratamentul
pacienilor care au fcut radiografia i cei care nu a fcut
Nu
Rezonana Magnetic Nuclear n lombalgia
comun
Pacieni asimptomatici - RMN cu hernii de disc, protruzii, prolabri i
degenerri discale
Studiu RMN - 98 indivizi asimptomatici
38% anomalii a mai mult de un disc intervertebral
52% prolabri discale, 27% protruzii discale, hernii discale 1%

Alt studiu 67 indivizi nu au avut niciodat durere
57 % au o anomalie RMN, inclusiv hernii de disc 36 % si stenoza spinal 21% .
Anomaliile detectate coincidene, nelegate de durerea actual
Teste imagistice precoce concluzii greite, intervenii nenecesare,
prognostic prost !!
Nu
Date of download:
8/8/2012
Copyright The American College of Physicians.
All rights reserved.
From: Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of
Physicians
Ann Intern Med. 2011;154(3):181-189. doi:10.1059/0003-4819-154-3-201102010-00008
Results From Meta-analysis of Randomized, Controlled Trials of Routine Imaging Versus Usual Care Without Routine Imaging
Figure Legend:
Medical societies list 45 dubious tests, therapies (compendium of 45
clinical donts)
April 4, 2012 Robert Lowes
Do not obtain imaging studies in patients with nonspecific low back pain !!
Do not obtain a preoperative chest X ray when lacking any clinical suspicion of intrathoracic
pathology
Do not order a stress test for asymptomatic patients who are at low risk for coronary heart
disease
Do not order RF and AAN in asymptomatic patients
Factori de alarm (red flags) care indic
necesitatea unor investigaii suplimentare
Factori de alarm
(red flags)
Cauza posibil

Investigaii
Vrsta > 50 ani
Istoric de cancer
Durere nocturn progresiv
Scdere n greutate neexplicat
Cancer
RMN
Radiografie LS
TC
VSH
Vrsta > 50 ani
Istoric de osteoporoz
Corticoterapie
Tasare vertebral
Radiografie LS
TC
Febra
Infecie recent
Consumator droguri iv
Spondilodiscita
RMN
VSH/CRP

Deficite neurologice la multiple sedii
Anestezie n a
Retenie urinar/incontinen fecal
Sindrom de coad de cal
RMN
Durere iradiat n membru, cu distribuie
dermatomeric L4, L5, S1, cu durata > 1 lun
Deficit motor semnificativ/progresiv
Hernie de disc

RMN
EMG/VCN
Durere lombar joas inflamatoare
Vrsta < 45 ani
Spondilita anchilozanta
RMN art. SI
Radiografie bazin
VSH/CRP/HLA B27
Care sunt principalii factorii de risc
pentru cronicizarea lombalgiei ?

1. Factori psihologici

2. Factori sociali

3. Factori anatomici
Factori de risc pentru cronicizare
(yellow flags)
Categorii factori de risc
cronicizare
Factori risc cronicizare
(yellow flags)
Sistem de credine
Comportament de evitare a activitilor de teama durerii
Expectana intensificrii durerii n momentul reintoarcerii la
munc
Gndire de tip catastrofic centrarea excesiv pe durere ,
sentimentul lipsei de control asupra durerii
Atitudine pasiv n cadrul terapiei de recuperare
Factori afectivi
Istoric profesional negativ - mediu de lucru nesuportiv
Noncomplian la kinetoterapie
Evitarea activitilor zilnice
Istoric de dependen medicamentoas
Anxietate
Depresie
Iritabilitate
Comorbiditi
Istoric de boli cu disabilitate
Somn perturbat de dureri
Semne lombalgie nonorganic
(semnele lui Waddell)
Dureri la teste de ncrcare axial
Sensibilitate nonanatomic/superficial
Exagerarea durerii n cursul examenului fizic
Test Lasegue ameliorat daca pacientului i se distrage atentia
Slbiciune muscular sau tulburari de sensibilitate cu
distribuie regional
Criterii psihosociale care indic
risc de cronicizare (yellow flags)

ntrebri Indicatori de prognostic negativ
(yellow flags)
Ai mai avut concediu medical
pentru durere de spate ?
Da
Care credei c este cauza durerii de
spate ?
Focus pe leziunea structural
Atitudine pesimist sau catastrofic
Ce credei c v-ar putea ajuta?
Nimic
Alii, doctorii, nu pacientul
Cum reacioneaz ceilali la durerea
de spate ?
Ostili
Superprotectivi
Ce facei ca s ameliorai durerea ?
Atitudini pasive: repaus, evitare activiti
fizice
Credei c vei mai putea lucra ?
Peste ct timp ?
Nu sau nu tiu
Durere lombara joas Acut Subacut sau cronic
Durata < 4 sptmni > 4 sptmni
Menine activitate
Educaie
Aplicaii calde
Acetaminofen
AINS
Relaxant muscular
Antidepresive triciclice
Benzodiazepine
Antiepileptice
Tramadol/Opioide
Manipularea coloanei
Kinetoterapie
Masaj
Acupunctur
Yoga
Terapie cognitiv comportamental
Relaxare
Reabilitare intens. interdisciplinar
Durerea lombar nespecific - tratament
Educaia pacientului
Durerea lombar nespecific
Algoritm de tratament

Meninerea
activitii
fizice
n limita
toleranei
la durere

Educaia
pacientului
Repausul la pat
doar n cazuri
individuale
DLN acut DLN cronic
Analgezie
Paracetamol +/- Codein
AINS
- Tradiionale +/- IPP
- Inhibitori selectivi COX2
Miorelaxante
Antidepresive
Opioide
Proceduri fizicale, masaj, manipulri,
acupunctura
Se pot asocia
Ghid de practic pentru medicii de familie
Factori care influeneaz alegerea medicaiei
Durata simptomelor
Severitatea simptomelor
Beneficiile ateptate
Rspunsul anterior la terapie
Reaciile adverse anterioare
Comorbiditile


Prezentare caz 2
Marius, brbat de 48 ani care lucreaz ca i grdinar la un
centru de gradinrit, prezint de 3 sptmni durere
lombara cu iradiere n membrul inferior stng (pn la
degetul mare) cu amoreli i parestezii pe faa posterioar a
membrului i imposibilitatea mersului pe vrfuri (semnul
poantei).

A luat Diclofenac 150mg/zi i Mydocalm 150mg/zi, fr
ameliorare, ba chiar chioptarea i amoreala s-au
accentuat.

Ce interpretare clinic avei n aceast
etap ?

1. Hernie de disc

2. Lumbago acut nespecific /lombalgie
comun

3. Spondilit anchilozant
Ce interpretare clinic avei n aceast
etap ?

1. Hernie de disc

2. Lumbago acut nespecific /lombalgie
comun

3. Spondilit anchilozant
Lombosciatica
Lombosciatica = durere lombar
cu iradiere n membrul inferior (cu
distribuie dermatomeric) nsoit
de simptome neurologice (ex.
parestezii, deficit motor).

Cauze
n 90% din cazuri este cauzat de
o hernie de disc.
Alte cauze posibile: stenoza de
canal lombar, chisturi i tumori.

Diagnostic
n prinicipal se bazeaz pe
anamnez i examen clinic !



Caracteristicile lombosciaticii
Durerea unilateral n membrul
inferior > durerea lombar

Durerea iradiaz mai jos de
genunchi n picior i degete

Parestezii, amoreali cu acceai
distribuie ca i durerea

Testul Lasgue pozitiv (durere mai
intens n membrul inferior)

Teste neurologice pozitive deficit
motor, modificri de reflexe

Monitorizarea pacientului cu lombosciatic

! Reevaluare clinic dup 4-6 sptmni de tratament conservator
Educaia pacientului
Eec la terapia conservatoare:
RMN ?
DA - la pacienii cu simptome severe care nu rspund la tratament conservator
n 6-8 sptmni

Intervenia chirurgical?
La pacienii cu simptome severe la care exist o concordan ntre manifestrile
clinice i imagistic.
!! Aspect imagistic de HD poate aprea la 20-36% din subiecii fr
simptome
Determin o ameliorare mai rapid a simptomelor, dect tratamentul
conservator la unii pacieni cu lombosciatic
Tratamentul conservator i terapia chirurgical au rezultate similare la 1 an


Ce investigaii vei solicita ?

1. Nici una

2. Radiografie lombar (anteroposterioar +
laterolateral)

3. RMN coloan lombar
Ce investigaii vei solicita ?

1. Nici una

2. Radiografie lombar (anteroposterioar +
laterolateral)

3. RMN coloan lombar
Rezonana Magnetic Nuclear n lombosciatic
RMN lombosacrat se
recomand la pacienii cu:
Lombalgie acut la prezentare,
dac exist semne de deficit
neurologic sever

Lombalgie persistent cu semne
de compresie radicular care sunt
candidai pentru intervenie
chirurgical

Da
Modaliti terapeutice Observaii
Menine activitatea S rmn activi
Educaia pacientului
S neleag cauzele sciaticii, c nu sunt necesare investigaii n
absena semnalelor de alarm, prognosticul

Fiziokinetoterapie +/-
Acetaminofen +/- Opiode slabe La nevoie
AINS La pacienii cu rspuns insuficient la paracetamol
Relaxant muscular La unii pacieni, de regul n asociere cu antialgice i/sau AINS
Antidepresive triciclice La unii pacieni cu lombosciatic cronic
Efect de scurt durat la unii pacieni La unii pacieni cu lombosciatic cronic
Tramadol/Opioide puternice

La pacienii cu dureri mari, durat scurt

Infiltraii epidurale cu corticosteroizi Efect de scurt durat la unii pacieni
Tratament chirurgical
La pacienii cu simptome severe care persist peste 6-8
sptmni i la cei cu complicaii neurologice
Lombosciatica- tratament
Consulturi de specialitate
- Cine ? Unde ? Cnd? -
+
Durerea lombar nespecific
- Cine ? Unde ? Cnd? -
Medicul de familie
+/- Kinetoterapeut i/sau Balneofizioterapeut
Durerea lombar cu red flags
- Cine ? Unde ? Cnd? -
Trimitere la specialist
Lombosciatica
- Cine ? Unde ? Cnd? -
Lombosciatic cu
Durere sever non-responsiv la opioizi
Deficit motor progresiv
Sindrom de coad de cal



Lombosciatic acut (4-8 sptmni)




Lombosciatic subacut/cronic (> 8 sptmni)





Neurochirurg
Medic de familie
Balneofizioterapeut
Balneofizioterapeut
Reumatolog
Neurochirurg
Prezentare caz 3
Andrei, brbat de 35 ani, prezint durere lombar joas de
aproximativ 6 luni. Durerea este predominant dimineaa la
trezire, l ine cam 1 or i cedeaz cnd ncepe s mearg.
Este electrician la Electrica SA (poate urca pe stlpi).
Uneori dimineaa abia se poate ridica din pat sau mbrca.
n unele nopi, l trezete durerea, n altele nu are nimic.

Dac ia Ketonal nu mai are nici un fel de probleme.
Debut la adultul tnr
Se instaleaz treptat (n zile, sptmni)
Are evoluie cronic (durata > 3 luni)
Se amelioreaz dup exerciii
Nu se amelioreaz la repaus
Trezirea n a doua parte a nopii din cauza durerii de spate
Poate determina redoare matinal cu durata de >30 minute
Durere fesier alternant stnga-dreapta (datorat sacroiliitei)
Iradierea caracteristic a durerii lombare din sacroiliit este n
fes sau coapsa posterioar, adesea alternativ, de o parte i alta
pseudo-sciatica nalt, basculant


Lombalgia inflamatoare - caracteristici
Lombalgia inflamatoare este simptomul cheie
n spondilita anchilozant (SA)
4 din 5
Debut insidios
Vrsta de debut <40 ani
Durata lombalgiei 3 luni
Redoare matinal
Ameliorarea dup exerciii
2 din 4
Redoare matinal cu durata
de >30 minute
Ameliorarea lombalgiei dup
exerciii
Trezirea n a doua parte a
nopii din cauza durerii de
spate
Durere fesier alternant
1
Rudwaleit M, et al. Arthritis Rheum. 2006;54:569-578;
2
Calin A, et al. JAMA. 1977;237:2613-2614.
Setul iniial de
criterii
2

Criteriile recente
1

Specificitate/sensibilitate: 70%80%
Se aplic pacienilor < 50 ani cu durere > 3 luni
Manifestri musculo-scheletale axiale
Durere inflamatorie la
nivelul scheletului axial
Debuteaz la articulaiile
sacroiliace

Coloana vertebral poate fi
afectat la orice nivel

Artrite la nivelul
oldurilor (coxita) i
umerilor

Dureri ale peretelui
toracic anterior prin
afectarea articulaiilor
sternoclaviculare i entezelor
costosternale



Examen obiectiv
Teste de sensibilitate a articulaiilor sacroiliace
1. Testul compresiei antero-posterioare a pelvisului
2. Manevra Gaensslen
3. Manevra Patrick sau FABERE (hip flexion, abduction, external rotation, and extension)
4. Testul compresiei laterale a pelvisului



Examen obiectiv
SA limiteaz mobilitatea coloanei vertebrale
Manifestri clinice n spondilartrite
Manifestri musculo-scheletale




Manifestri extra-articulare

Ce investigaii vei solicita ?

1. Nici una

2. Radiografie standard

3. RMN
Rezonana Magnetic Nuclear n SA
RMN art. sacroiliace cea mai
sensibil metod pentru
evidenierea leziunilor
inflamatorii precoce

Leziuni inflamatorii active
(STIR/T1 post-gadolinium)
Edem osos (osteita)
specificitate inalta pentru SA
Capsulita
Entezita
Sinovita


Sieper J, et al. Ann Rheum Dis. 2005;64:659-663; Rudwaleit M, et al. Arthritis Rheum. 2005;52:1000-1008;
Sieper J et al. Ann Rheum Dis. 2009; 68(Suppl II):ii1-ii44.
Sacroiliit incipient, STIR
RMN coloan vertebral
Se poate efectua un bilan al
leziunilor inflamatorii spinale

Contribuie la diagnosticul
precoce al SA

Are rol n evaluarea activitii
bolii la pacienii cu SA definit

Examenul radiologic - sacroiliita
Sacroiliita radiologic este trstura
caracteristic a SA

Caracteristici
Bilateral i simetric, predomin
pe versantul iliac SA
Unilateral sau asimetric
artrita psoriazic, artrita reactiv

Radiografia art. sacroiliace poate fi
negativ n stadiile precoce de boal !
Progresia radiologic a sacroiliitei
Examenul radiologic spondilita
Modificri caracteristice n
SA:
Osteita
eroziuni anterioare -
vertebra ptrat (leziunile
lui Romanus)
scleroz osoas reactiv -
vertebra cu colurile
luminoase (shiny corner)

Sindesmofitoza
proces de neoformare
osoas - trstura distinctiv
a SA
coloana de bambus n
stadiile avansate
Radiografia standard este cea mai important metod pentru detectarea i
monitorizarea leziunilor structurale (ex.procesele de neoformare osoas).

ntrziere n diagnosticul SA
Feldtkeller E et al. Rheumatol Int 2003;23:6166
Sengupta R & Stone MA. Nat Clin Pract Rheumatol 2007;3:496-503

Primele simptome
Dianosticul iniial
Vrsta n ani
Brbai (N=920)
Femei (N=476)
0
0 10 20 30 40 50 60 70
20
40
80
60
100
P
r
o
p
o
r

i
a

d
e

p
a
c
i
e
n

i

(
%
)

ntrzierea diagnosticului 9 ani
Spondilartrita axial
Lombalgie inflamatoare
Stadiul 1 Stadiul 2 Stadiul 3
Sacroiliit - RMN
Sacroiliit - radiologic Sindesmofite - radiologic
SpA nedifereniat
SpA nedifereniat
axial
SA non-radiologic
Spondilit -
RMN
Spondilit anchilozant
Sieper J, et al. Ann Rheum Dis. 2009;68(suppl II):ii1-ii44.
Criteriile ASAS de clasificare a SpA axiale
(Ankylosing Spondylitis Assessment Study Group)
La pacieni cu durere lombar >3 luni i vrsta de debut < 45 ani
Sacroiliita pozitiv
imagistic
inflamaie activ la examenul
RMN, nalt sugestiv pentru
sacroiliita asociat SpA

sacroiliit definit radiologic
conform criteriilor New York
modificate

Manifestri de SpA
lombalgie inflamatoare
artrit
entezit (calcanean)
dactilit
psoriazis
Crohn/colit
rspuns bun la AINS
istoric familial de SpA
proteina C-reactiv


sau
Rudwailet M et al. Ann Rheum Dis 2009;68:777-783

Sacroiliit dg. imagistic
plus
> 1 manifestare de SpA


HLA B27
plus
> 2 manifestri de SpA



Educaie
pacient,
kinetoterapie,
terapie fizical,
recuperare,
asociaii de
pacieni,
grupuri de
suport
Antiinflamatoare Nesteroidine
(AINS)
Boala
Periferic
Boala
Axial
SSZ, MTX, LEF
TNF blocani
A
n
T
I
B
I
O
T
I
C
E

Corticosteroizi local
C
H
I
R
U
R
G
I
E
Zochling J, et al. Ann Rheum Dis. 2006;65:442-452
Recomendarile ASAS/EULAR
pentru tratamentul SA
ASAS = Asessment of AS International Society
EULAR = European League Against Rheumatism
Educaia pacientului
Lombalgia inflamatoare
- Cine ? Unde ? Cnd?
Prezentare caz 4
Doamna Ileana, n vrst de 76 ani, prezint durere
lombar inalt, brusc instalat n urm cu o zi, dup ce a
ridicat o oal plin cu sup. Durerea este violent, nu o las
s se mite, se accentueaz la micare i ortostatism.
A mai avut neplceri la spate, dar niciodat aa ceva.
Are menopauz de la 40 de ani (histerectomie total cu
anexectomie), a avut o urticarie cronic pentru care a
primit de repetate ori cortizon i are = 148 cm i G = 45
kg. Este fumatoare.
A luat antialgice (paracetamol), durerea nu s-a ameliorat.

Ce investigaii vei solicita ?

1. Nici una

2. Radiografie dorso-lombar
(anteroposterioar + laterolateral)

3. Tomografie computerizat
Imagistica n tasrile vertebrale
Radiografia de coloan
vertebral se recomanda
dac exist suspiciune de tasare
vertebral pe fond osteoporotic

Tomografia computerizat
se recomand dac exist
traumatism n antecedente sau
suspiciune de tasare patologic

Rezonana Magnetic Nuclear n tasrile
vertebrale

Fracturi patologice maligne
Tasare benign
Prezentare caz 5
M.P., 38 ani, prezint din iulie-august 2013 durere lombar permanent, mai
accentuat nocturn, cu agravare progresiv. i-a administrat diverse AINS, iniial
cu rspuns parial, cu minim efect n ultimele sptmni. Asociat acuz
inapeten i scdere n greutate.

Istoric de neoplasm uterin operat n urm cu 1 an.
Consultul periodic oncologic (august 2013) examen ginecologic fr modificri;
recomandare de consult ortopedic i neurologic.
Consult balneologic (august 2013) radiografie lombosacrat, care a fost fr
modificri patologice semnificative; diagnosticat cu discopatie lombar, se
recomand continuarea tratamentului cu AINS.

n ultimele 2 sptmni a prezentat durere lombar de intensitate foarte mare,
cu iradiere n membrul inferior stng, parestezii, tulburri de sensibilitate pe faa
antero-lateral a gambei stngi i deficit motor progresiv.

Examen obiectiv: mers stepat, sensibilitate la palparea apofizei spinoase a
vertebrei L5


A fost corect interpretarea lombalgiei ca fiind
de cauz discal la aceast pacient?

1. Da

2. Nu

3. Nu tiu
Red flags- facei investigaii suplimentare !!
Red flags Cauza posibil Investigaii
Vrsta > 50 ani
Istoric de cancer
Durere nocturn progresiv
Scdere n greutate neexplicat
Cancer
RMN
Radiografie LS
Tomografie computerizat
VSH
Vrsta > 50 ani
Istoric de osteoporoz
Corticoterapie
Tasare vertebral
Radiografie LS
Tomografie computerizat
Febra
Infecie recent
Consumator droguri iv
Spondilodiscita
RMN
VSH/CRP

Deficite neurologice la multiple sedii
Anestezie n a
Retenie urinar/incontinen fecal
Sindrom de coad de cal
RMN
Durere iradiat n membru, (distribuie L4, L5,
S1), cu durata > 1 lun
Deficit motor semnificativ/progresiv
Hernie de disc

RMN
Electromiografie (EMG/VCN)
Durere lombar joas inflamatoare
Vrsta < 45 ani
Spondilita anchilozanta
RMN art. SI
Radiografie bazin
VSH/CRP/HLA B27
Care este investigaia imagistic cea
mai util ?

1. Tomografia computerizat

2. RMN

3. Scintigrafia osoas
Metastazele vertebrale
Metastazele vertebrale sunt
frecvente la pacienii cu cancer

Manifestri clinice
Lombalgie mecanic
Sindrom radicular
Sindrom de compresie medular (!!
URGEN)

Durerea este persistent i
progresiv
Durerea nocturn este simptomul
cu prognosticul cel mai nefavorabil

!! Recunoatei semnalele de alarm
red flags i evitai ntrzierile de
diagnostic
Investigaii n metastazele vertebrale


Examenul radiologic
Distrucia corpului vertebral este
vizibil radiologic doar cnd 30-
50% din trabeculele vertebrale
sunt afectate
Radiografia normal NU
EXCLUDE diagnostiul de
metastaze !
Scintigrafia osoas (screening)
Tomografia computerizat
RMN cu substan de contrast
(gadolinium) = standardul de
aur
RMN lombosacrat, secven T2
Radiografie lombosacrat

The winking owl sign
Suspiciunea de tasri vertebrale
- Cine ? Unde ? Cnd?

Tasare vertebral osteoporotic




Tasare vertebral malign
Reumatolog
Neurochirurg

Reumatolog
Oncolog
Neurochirurg
Concluzii
Diagnosticul diferenial al durerii lombare se bazeaz n principal pe o
anamnez comprehensiv, care sa includ evaluarea factorilor clinci
care sugereaz existena unei patologii serioase (red flags) i a
factorilor de risc pentru cronicitate (yellow flags), coroborat cu un
examen obiectiv intit.

La majoritatea pacienilor cu durere lombar comun (nespecific) nu
se poate stabili o cauz precis i nu sunt necesare investigaii
suplimentare.

n prezena factorilor clinici care sugereaz existena unei patologii
serioase (red flags), se recomand efectuarea de investigaii
suplimentare, n principal imagistice.



The first rule of beach safety is: Always swim between the flags