Back pain Rozkydal, Z. Chaloupka, R. Liskay, J. Back pain •I. Pain from spinal structures • •II. Pain from visceral organs into the spine • •I. spine • •Lumbosacral spine • •Thoracic spine • •Cervical spine •Low back pain • •Lumbago • •Lumbalgia • •Sciatica • •SI joint • •Coccygodynia OO- páteř fysio2 OO- fysio páteř1 •Anatomy •Spinal segment -two vertebral bodies and • intervertebral disc •Lumbago – acute back pain • •Causes - meniscoids of intervertebral joints • - subluxation in IV joint - slight protrusion of disc • •Acute onset, mucle spasm • •Therapy: rest, warm • analgetics • myorelaxans • •Lumbalgia • •Chronic pain • •Osteochondrosis disci •Spondylosis deformans •Spondylarthrosis deformans Bolesti zad- LS páteř •Osteochondrosis disci • • •Degeneration of the disc •Narrowing, sclerosis •Irregulary contours BZ Velcev 2 •Th.- rest, NSAID • fysical therapy • fysiotherapy •Spondylosis deformans • •Degeneration between vertebral bodies • •X- ray •Osteophytes, sclerosis •narrowing, instability • •Therapy. rest • NSAID, fysical therapy Bolesti zad- spondylóza 1 •Obr. 2 •Spondylosis deformans Bolesti zad- spondyloza 2 •Obr. 3 •Spondylarthrosis deformans • •Osteoarthritis of intervertebral joints • •Back ache, limited movements • •Th: rest, NSAID, analgetics • fysiotherapy, chondroprotectives • Bolesti zad- spondylartróza Sciatica •Pan in lumbosacral region with limited function and irradiating into lower extremities • • roots L5-S2 • roots L2-L4 •Intervertebral dics •Upper layer •Nucleus pulposus •Anulus fibrosus •Lower layer •Obratlové tělo • Bolesti zad- mobilní segment Pathophysiology •Less turgor in nucleus pulposus •Degeneration of the disc with •protrusion or extrusion of nucleus pulposus •Microruptures in anulus fibrosus •Tear in anulus fibrosus •Tear of posterior longitudinal ligament • Tears hernia-01.jpg herniated-disc-types_sm uprava.jpg •Types typy lokalizaci herinace.jpg Bolesti zad- hernia disci 1 •Localisation Incidence •30-50 years •Hereditary succesibility in younger age •Mostly segment L5-S1 • 2-3% of population have radicular symptoms •70 -85 % of population suffer from bach ache at least once on their lives Symptoms S1 •Pain on dorsal aspect of the extremity •Changes in sensation on dorsal aspect •Achillis tendon reflex •Not able to stand tip toe •Lasegue maneuver Symptoms L5 •Pain on lateral aspect of the xtremity •Changes in sensation •Not able to stand on heels •Lasegue maneuver positive •Limited dorsiflexion of the ankle and toes Symptoms L4 •Pain on anterior aspect •Changes in sensation •Patelar tendon reflex •Weak active extension of the knee Imaging methods •X-ray •MRI •CT scann •CT myelography L4-l5-disc-herniation.png BZ Filová 1 BZ Filova 2 •Hernia disci BZ malásková 6 •Hernia disci Therapy- conservative •NSAID, myorelaxans, analgetics, rest • •Periradicular therapy (corticoids, morfin, marcain) • •Drips with NSAID • •Fysiotherapy • •Effect 80-90 % • Therapy- surgery •Indication •- cauda equina syndrom -motor dysfunction – conservative treatment not succesful -timing- soon, at least up to 6 weeks • • •Protrusion up to 5 mm is not indication to surgery •Cauda equina syndrom •The spina cord terminates at L1 •Nerve roots are L2-S4 •Supply bladder and rectal sphincter •Supply muscles of the lower limb and sensation of the perineum •Symptoms: •Back pain, lower limb flaccid paralysis, loss of reflexes •Paresthesia of the perineum, loss of anal tonus, faecal incontinence •Retention of urine •Cauda equina = emergency Therapy - surgery •Hemilaminectomy, decompression of the nerve root • •Microdiscectomy • •Percutaneous discectomy • Complications •Nerve root lesion •Some part of the sequestrum left •Infection •Reccurence •Instability •Failed back surgery syndrom • • • •Failed back surgery syndrom • •Failure of surgery • •causes: epidural fibrosis, infection • arachnoiditis • instability of the spinal segment • spinal stenosis • psychological problems • •Therapy: decompression , stabilisation, instrumentation • conservative treatment •Spondylolysis • •Fibrous tissue in pars interarticularis •Th- conservative • surgery • Bolesti zad - spondylolýza 1 Páteř- lýza •Obr.13 •Obr. 14 Bolesti zad- spondylolistéza 1 •Spondylolisthesis •Slip of vertebral body in isthmic region anteriorly • Páteř- listéza •Obr. 15 •Obr. 16 Bolesti zad- spondylolisthéza2 • 1. dysplastic 2. isthmic 3.degenerative • •Spondylolisthesis •Stages of spondylolisthesis • •I. 25 % •II. 50% •III. 75 % •IV. 100 % •V. spondyloptosis •Obr. 18 Spondyloptosis Bolesti zad- spondyloptosis •Spondylolisthesis • •Low back pain •Sciatica •Muscle spams • •Th: fysioth, analgetics •Op: decompression, reduction, • anterior or posterior fusion • PLIF - TLIF, ALIF • Páteř- listéza •Obr. 19 Spondylolisthesis • • • D:\archiv\2003\0203\1702\01.jpg D:\archiv\2003\0203\1702\02.jpg D:\archiv\2003\0203\1702\03.jpg •Spinal stenosis • •Narrow spinal canal •Advanced spondylosis and • spondylarthritis •Compression of dural sack • Bolesti zad- stenóza •Normal width of spinal canal 17 mm •Narrowing bellow 10 mm - myelopathy • Symptoms • mild pain • nerve root compression • cauda equina syndrom • neurogenic claudications • • C:\obrazky_\chaloupka\05.jpg C:\obrazky_\chaloupka\06b.jpg • •Flexion- extension D:\CHAL\FIALOVA\18.jpg D:\CHAL\FIALOVA\20.jpg • •6/2008 •Therapy • •Conservative: •Orthesis, epidural aplications of steroids •Pain department, exercise • •Operative: decompression, instrumentation •10/2011 •S.Z. 68 yrs. • •Decompression, fusion, transpedicular screws D:\CHAL\novotn\06.jpg • D:\CHAL\leson\-01.jpg • • • D:\obrazky_\sal\prodisk\2709\847.jpg D:\obrazky_\sal\prodisk\0410\PA041903.JPG •Intervertebral disc replacement • • • D:\archiv\prodisk\009.jpg D:\archiv\prodisk\010.jpg •Pain from SI joint • •Sacroileitis •Blockage •Osteoarthritis •Posttraumatic conditions Kyčel- rtg pánve páteř 4 •Coccygodynia • •Iritation of nerves around the bone •Ventral angulation •Hypermobility •Posttraumatic conditions •Iradiation from lumbosacral spine • OO- fysio páteř1 •M. Bechtěrev - spondylitis ancylopoetica • ancylosing spondylitis Bolesti zad- Bechtěrev 1 •Obr. 20 •M. Bechtěrev • •Obr. 21 Páteř- Bechtěrev •M. Bechtěrev Bolesti zad- Bechtěrev 2 •Obr. 22, obraz bambusové tyče •M. Bechtěrev Bolesti zad- Bechtěrev3 •Obr. 2 •Therapy • •Reumatology, physioterapy • •Total hip replacement •Thoracic spine • •Ostechondrosis disci •Spondylosis deformans •Spondylarthrosis deformans •Arthrosis costovertebralis •Hyperkyphosis •Scoliosis Páteř 3 BZ malásková 3 •Cervical spine • •Osteochondrosis disci •Hernia disci •Spondylosis deformans •Spondylarthrosis intervertebralis •Spondylarthrosis uncovertebralis • Bolesti zad- C páteř •Neck pain •Torticollis •Chronic neck pain •Cervicocranial syndrom •Cervicobrachial syndrom •Nerve roots syndroms •Spondylogenic myelopathy Bolesti zad- spondyloza krčního obratle •Spondylosis in cervical spine •Obr. 26. Foramen costotransversarium with vertebral artery BOlesti zad- C páteř1 •Cervicocranial syndrom •Obr. 27 •Neck pain •Iradiation in to head and forhead •Muscle hypertonus •Nausea, vomiting, sweating •Dizziness • •Cause: •Iritation of posterior sympatic cord •along vertebral artery BOlesti zad- C páteř1 •Obr. 28 •Cervicobrachial syndrom •Neck pain iradiating into •upper extremity up to fingers • •Diffuse localisation • •No nerve root localisation • Bolesti zad- C kořeny •Nerve roots cervical syndroms •Compression of nerve roots •Often C6 and C7 •Motor and sensor deficit • •The cause: •Herniation of disc •Spondylogenic cervical myelopathy •Narrow spinal canal • •Direct compression of •the spinal cord • •Ischemia of spinal cord • • •Mixed palsy of upper and lower •extremity •Impaired gait Bolesti zad- spondyloza krčního obratle •Therapy of spondylogenic myelopathy •Anterior approach • •Posterior approach • •Combined appproaches 15 16 •S.Z. • • • • • • 27 01 20 21 22 23 •Open door •laminoplasty •and fusion 09 08 •Differencial diagnosis • •R.A. •Ancylosis spondylitis •Tumors •Myeloma •Entesopathy •Osteoporosis •Fractures •Herpes zoster •Peripheral neuropathy •Deformities of the spine •Spondylodiscitis BZ malásková 1 •II. Pain from visceral organs • •Larynx, pharynx, lymphonodes •Pleura, lungs, diaphragma •Gall bladder, liver, pancreas, duodenum •Retroperitoneum, kidney, ureter •Gynecological region •Urinary bladder, prostate