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
 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
 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
 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
 GB syndrome

 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
 BACK PAIN
Jaya Ravindran
Rheumatologist
 Causes
 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

- 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
- 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
 Myotomes
 L2 Hip flexion
 L3 Knee extension (knee jerk)
 L4 Knee extension, ankle dorsiflexion
(knee jerk)
 L5 toe dorsiflexion
 S1 foot plantar flexion, eversion
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
 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
 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
 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
 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
Degenerative disease and sciatica
 Malignancy
 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.
 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
 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
 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.
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
 Causes of low bone density
Secondary Causes of Osteoporosis
Endocrine Neoplasm Congenital Miscellaneous

Hyperparathyroidism Multiple myeloma Osteogenesis Rheumatoid arthritis

Hyperthyroidism Lymphoma Homocystinuria Gastrectomy
Cushing’s syndrome Mastocytosis 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
 7-dehydrocholesterol sunlight cholecalciferol
 (diet)
 liver


 25-hydroxycholecalciferol
 kidney 1-hydroxylase
 1,25-dihydroxycholecalciferol (-)


 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
 Spinal stenosis
 Symptoms
– Age - >50
– Dull aching pain in the lower back and legs
– Exertional leg pain/weakness/numbness
– Symptoms relieved leaning forward, sitting or lying

 Examination
– 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)
 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
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
 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
AS
AS
AS
THE END

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