Bed side teaching (Low back pain) - Mr Yusuf 39 years old/M/ C/O: Low back pain x 1 year duration

HOPI: Alleged fall from stairs - Pain can be divided into 2: - Acute: 2-3/12 - Chronic: >3/12 - Nature of back pain: - Continuous - Worsening at night - Aggravated by movement - What are the causes of low back pain? 1.Trauma 2.Infections 3.Degenerative diseases 4.Tumor 5.Inammatory diseases 6.Referred 7.Psychological 1. Trauma Muscle: Ms sprain/strain Ligaments Bone #: Compression #, Burst #, Chance #, Translation Dura 2.Infections Acute: Abscess (eg Gullen-Barre, mylocitis), Pyogenic (localized +/- constitutional Sx - LOA) Chronic: TB 3.Degenerative diseases Stenosis Osteophytes Micro # Herniation 4.Tumor Benign: Lipoma, bone cyst Malignant: 1 (eg Multiple Myeloma, Leukemia, Lymphoma), 2 (eg Thyroid, Lung, Gut) Nature of the low back pain in tumor condition: Continuous & not relieve Worsening at night + Constitutional Sx 5.Inammatory diseases SLE, Rheumatoid Arthritis, Gouty Arthritis, Psoritic Arthritis 6.Referred
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Gastritis 7.Psychological - What is red ag and yellow ag for low back pain? - Red ag: is an Emergency & required to attend immediately (Acute) - Yellow ag: Chronic, intermittent a/w psychological changes & usually stress condition - Low back pain also can be divided into 2: - Structural: No constitutional symptoms, Aggravated by movement & relieved by resting - From bone, disc, ligament - Pathological: Continuous pain, Not relieved by resting - Infection, inammatory, tumor Pain history was given: - Site: Lumbar - Continuous - Pricking in nature - Aggravated by movement - Relieved by leaning fwd & lying down - Radiate from lumbar to left foot (radiation to the L>R) - No constitutional symptoms Neurological assessment: - Mr Yusuf said you should ask 2 things: - Ask about Rukuk: If OK --> SLR (Straight Leg Raising test) is OK - Ask about duduk antara dua sujud: If OK --> All joints are OK Ask about walking pain? = Intermittent claudication & walking distant - Ischemic causes: Pain from distal --> proximal - eg DM, Vascular, Neuropathy - Neurogenic causes: Pain from proximal --> distal - patient usually need to sit down for awhile Ask about weakness? - C5, C6, C7, C8 - L2,3 (Knee), L4,5 (Ankle) From history, what are your differential diagnoses? - Disc prolapse - Spondylolisthesis: Traumatic, Degenerative - Herniated disc Gen Exam - Look for constitutional Sx (LOW,LOA); cachexic - LNs enlargement - Sn of infections - Ask patient to walk/standing - Look for skin changes: redness, swelling - Neurobromatosis --> Cafe au le spot
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- Look for any deformity: Kyphosis, Step deformity On Supine position: LL exam - Pelvic tilt - Check for Motor(usually check for extensor hallucis longes EHL & exor hallucis longes FHL --> L4,5 roots + S1), Power, Sensation - Remember: L1,2,3 --> Femoral n; L3,4,5,S1 --> Sciatic n On prone position/Side: - Femoral Stress Test --> Lift up the leg Provisional Dx: - Trauma: Ms sprain, #, listhesis, Disc prolapse - Degenerative Investigations: - To conrm Dx: - X-rays: AP, Lateral, Special (oblique) - CT scan, MRI - For Mx: - Hb, TWBC, BUSE, RBS, CXR, ECG, ESR *Terminology - Lumbarization = Sacral --> Lumbar - Sacralization = Lumbar --> Sacral Treatment - For Acute pain Mx (RICE): - R :Rest - I :Ice - C :Compress - E :Elevation - Back pain Mx: - Medications - Analgesic - At least give PCM - NSAIDs: Selective or COX-2 inhibitor (eg Colecoxib) - Opiods - If pain due to Inammation or Neurogenic can give Tramadol (act centrally) - Side effects: GIT problem, N&V - If purely neurogenic give Opiod like in DFU. Give Tramadol - Physiotherapy - Cold: Ice compression - Hot/Warm : pack, short waves, diarthemy, infrared - Electrical: TENS, Ultrasound - Physical: eg Traction - Exercise - Lifestyle modications - Reduce activity - Proper back care - Supportive
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- Lumbosacral support - Corset - Belt - Operation: - to reduce compression - for stabilization: put pedicle screw - laminoplasty How to read spine X-ray? On AP view: - Alignment - pedicles - transverse process - body - spinous process - Bone abnormality - pedicles (owl sign) --> infection/tumor - Vertebra/lytic lesion --> infection/tumor (prostate) - Ribs - Iliac/sacrum --> multiple myeloma (MM) - Osteoporotic changes - Cartilage/Disc - look for space (increase in size on lowering down) - Soft tissues - Psoas shadow - Ureter injury - Ossications On Lateral view: - Alignment: - Ant. longitudinal line - *Retrolisthesis [posterior displacement of one vertebral body with respect to the adjacent vertebrae to a degree less than a luxation (dislocation)]. - It can be due to: - Traumatic spondylolisthesis L4, L5 + Disc prolapse L5, S1 - Some degrees of disc herniation (prolapse) - Spinolaminar line - Tip of spinous process - Remember about the grades of spondylolisthesis - Grade I: < 25% - Grade II: 25-50% - Grade III: >50% On oblique view (special): - Look for Scorty dog appearance --> TB spine p/s: Case was presented by Nur Syana.
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