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 OO- fysio páteř1 Anatomy Spinal segment -two vertebral bodies and intervertebral disc Low back pain Lumbago Lumbalgia Sciatica SI joints Coccygodynia OO- páteř fysio2 OO- fysio páteř1 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 • • 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 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 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 Rheumatology, 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