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Elderly male with Flaccid paraparesis diagnosed as Cauda Equina Syndrome due to Multiple Myeloma
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Low Back Pain

  1. 1. Low Back Pain Dr Liau Kai Ming Dept. of Orthopaedic
  2. 2. Incidence  Very common among working group  90% in pt >45years old  80% resolves with conservative treatment (in <3 months)  Only 5-10% may require operation
  3. 3. Implication  Work & productivity loss
  4. 4. Anatomical consideration  Commonly at lumbosacral junction (L4/L5, L5/S1)  Why?
  5. 5.  Most mobile region of the spine  Therefore prone to degeneration (wear & tear)
  6. 6. Causes of pain  Degenerative (most common)  Instability(fracture, spondylolisthesis)  Organic (Tumour,infection)  Nerve compression/irritation(PID, root compression)  Rule out psychogenic cause (insurance claim, problem with employer etc)
  7. 7. Referred pain 1. Abdominal cavity gastritis/peptic ulcer pancreatitis cholecystitis 2. Urinary system renal calculi UTI 3. Pelvic cavity ovarian cyst dysmenorrhea 4. Aorta Aortic aneurysm
  8. 8. Nature of pain  MECHANICAL VS NON-MECHANICAL  REFERRED VS RADICULAR  CLAUDICATION – VASCULAR VS SPINAL
  9. 9. MECHANICAL PAIN 1. Muscle strain 2. Ligament sprain 3. Facet joint arthritis 4. Disc-Discogenic 5. Instability - Spondylolysis/spondylolisthesis
  10. 10. NON-MECHANICAL PAIN  Infection – PYOGENIC VS TB  Tumour – PRIMARY VS SECONDARY  Primary - BENIGN VS MALIGNANT
  11. 11. Common causes of low back pain Pathology Age Pain nature Assoc pain Assoc sx DEGENERA >40y mechanical Distance Active pt TIVE claudication Spondylosis Spondylolisth <20y mechanical extension Hyperextensi esis >40y on activity Trauma Any age mechanical - Trauma Infection Any age non- Rest pain Fever mechanical Mets >50y Non- Rest pain Primary + mechanical LOW LOA Osteoporosis >60y mechanical - Trivial trauma
  12. 12. RED FLAGS  Constitutional symptoms  LOW, LOA, fever  AGE(>50)  IMMUNOCOMPROMISED,  TB CONTACT  KNOWN CANCER  NEUROLOGICAL DEFICIT (CAUDA EQUINA SYN)
  13. 13. Physical findings  General examination  Age  Ill looking  Local examination – DO NOT MISS A GIBBUS
  14. 14.  Deformity  Scoliosis/kyphosis  Step deformity  Local tenderness/paraspinal spasm  Limited ROM
  15. 15.  Full neurological examination  ANAL TONE / PERIANAL SENSATION  DERMATOME & MYOTOME
  16. 16. Investigations
  17. 17. Plain radiograph  AP -loss of lumbar lordosis -reduced disc space -osteophytes -deformity -fracture (increase interpedicular distance) -osteoporosis -pedicle disruption
  18. 18.  Lateral -fracture/wedging -kyphosis -spondylolisthesis  Oblique -spondylolysis (SCOTTIE DOG)
  19. 19. Plain x-rays
  20. 20. Blood investigations  FBC  Anemia, TWC  ESR  Liver function test  ALP  Renal function test  Calcium level
  21. 21. CT Scan  better visualization of bone pathology (eg. cortical destruction)  fracture  tumor
  22. 22. MRI  -better soft tissue visualization  -disc  -ligaments (ALL,PLL)  -nerves (spinal cord, roots)  -bone marrow  -pus collection
  23. 23. MRI
  24. 24. CT myelogram  role replaced by MRI  for delineation of neural structures where MRI is not available/contraindicated
  25. 25. CT Myelogram
  26. 26. Bone scan  Suspicious of multiple bone mets  Eg. with history of untreated/treated CA  Negative in Multiple myeloma
  27. 27. Treatment  Mainly conservative -Bed rest/pelvic traction -physiotherapy -back exercise -modification of daily activities -SWD/ultrasound -NSAIDs/COX-2 inhibitor -local injection (epidural steroids, facet joint)
  28. 28. Pelvic traction
  29. 29. Surgery
  30. 30. Indications for surgery -PAIN - failed conservative treatment (>6 months) -Evidence of neurological deficit (motor) -Cauda equina syndrome -Spinal instability (excessive spinal motion) -Unacceptable deformity (eg degenerative scoliosis)
  31. 31. Surgery 1. DECOMPRESSION of spinal nerves (BURST FRACTURE, Spinal stenosis, PID) 2. Fusion & Stabilization (Instrumentation) 3. Correction of deformity
  32. 32. DECOMPRESSION Surgery
  33. 33. FUSION Surgery
  34. 34. THANK YOU
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Low Back Pain

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