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Back pain
• Back pain is a common problem that affects most people at some point in their life.
• It usually feels like an ache, tension or stiffness in the back.
• The pain can be triggered by: • bad posture while sitting or standing• bending awkwardly• lifting incorrectly
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Back pain
• is not generally caused by a serious condition and, in most cases, it gets better within few days or weeks
• is most common in the lower back, although it can be felt anywhere along your spine, from your neck down to your hips
• It can usually be successfully treated by taking keeping mobile, painkillers, physioterapy
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Back pain
• Dividing by its cause:
• nonspecific back pain
• back pain with radiculopathy or spinal stenosis (disk herniation, spondylartritis)
• back pain associated with another specific cause (such as infection or cancer)
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Back pain
• Non specific pain indicates that the cause is not known precisely, but is believed to be due from the soft tissues such as muscles, fascia, and ligaments
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Back pain
• Other causes of back pain:
• Postural abnormalities (scoliosis, kyphosis)
• Congenital malformations (spondylolistesis)
• Trauma
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Back pain
• The pain may radiate into the arms and hands as well as the legs or feet
• may include symptoms other than pain
• tingling, weakness or numbness.
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Back pain
• Back pain can be divided anatomically: neck pain, middle back pain, lower back pain
• By its duration: acute (up to 12 weeks), chronic (more than 12 weeks) and subacute (the second half of the acute period, 6 to12 weeks)
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LigamentsSpinal Anatomy
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Spinal Anatomy
Spinal pathology
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Disc Degeneration: chemical changes associated with aging causes discs to weaken, but without a herniation.
Prolapse: the form or position of the disc changes with some slight impingement into the spinal canal. Also called a bulge or protrusion.
Extrusion: the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.
Sequestration or Sequestered Disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP).
The four stages to a herniated disc include:
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Ligaments Facet joints
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Cervical osteophytes
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Upper extremities dermatomes
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Normally, the cervical spine has a slight anterior curvature (lordosis). The cervical spine is straightened, which may be due to paravertebral
muscle spasm
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Cervical myelopathy
• Spastic paraparesis
• Quadriparesis
• Difficulties with balance
• Spasticity – lower extremities
• Radicular symptoms – upper extremities
• Incontinence – uncommon, urinary frequency - common
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Diagnostics
• Plane X-ray
• MRI
• CT
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Fyziological diameters of spinal canal - L4
1. Interpedicular distance 20–30 mm2. výška pedikla 3–5 mm3. výška facety 5–8 mm4. AP sagital distance 15–25 mm5. interfacetarna vzdialenosť 15–20 mm
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Spinal canal stenosis
• Borderline anterio-posterior diameter for spinal canal
• Cervical – 11 mm
• Lumbar – 11-13 mm
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Cervical myelopathy
• Cervical myelopathy refers to compression on the cervical spinal cord from either a disc herniation or cervical spinal stenosis.
• Generally, it is more common in the elderly population and is a slow process.
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Cervical myelopathyk
• Symptoms include
• incoordination in the hands
• a heavy feeling in the legs
• or numbness and tingling in the legs
• It is generally a slowly progressive condition. It is usually not painful as compression of the spinal cord does not cause pain.
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Cervical myelopathy
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Cervical myelopathy
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Lower extremities dermatomes
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Lumbar nerve root compression
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Lassegueroot L5, S1
Opposite Lassegueroot L4
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Lassegue maneuver
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Nerve root pain pattern
Radiculopathy C6 Radiculopathy S1
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Location of Pain and Motor Deficits in Association with Nerve Root Involvement at Each Lumbar Disc Level
Disc level Location of pain Motor deficit
T12-L1 Pain in inguinal region and medial None
thigh
L1-2 Pain in anterior and medial aspect Slight weakness in quadriceps;
of upper thigh slightly diminished suprapatellar
reflex
L2-3 Pain in anterolateral thigh Weakened quadriceps; diminished patellar or suprapatellar reflex
L3-4 Pain in posterolateral thigh and Weakened quadriceps;
anterior tibial area diminished patellar reflex
L4-5 Pain in dorsum of foot Extensor weakness of big toe
and foot
L5-S1 Pain in lateral aspect of foot Diminished or absent Achilles reflex
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Cauda equina syndrome
• L1-5 a S1-5.
• Areflexic and flaccid paraparesis• Back pain that radiates down posterior
aspect of both legs• Sensory loss in distribution of involved
roots (saddle distribution)• Urinary and fecal incontinence (loss of
bladder and bowel function)
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Cauda equina syndrom
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Fyziological diameters of spinal canal - L4
1. Interpedicular distance 20–30 mm2. výška pedikla 3–5 mm3. výška facety 5–8 mm4. AP sagital distance 15–25 mm5. interfacetarna vzdialenosť 15–20 mm
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Spinal canal stenosis
• Borderline anterio-posterior diameter for spinal canal
• Cervical – 11 mm
• Lumbar – 11-13 mm
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Lumbar stenosis
• medical condition in which the spinal canal narrows and compresses the spinal cord nerves at the level of the lumbar vertebra
• Leg pain (proximal to distal pain)
• Numbness
• Weakness exacerbated by standing or walking and relieved with lumbar flexion
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Lumbar stenosis
• Narrowing of the spinal canal or neural foramina that produces root compression
• Most common – L4-L5, L3-L4
• Congenitally or degenerative disease
• Usually after 60
• Single segment or multiple segments
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L4/5 Spondylolisthesis
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Prolapse of the disc - CT
Diffuse prolapse of the disc and osteophyte
Central prolapse of L4-L5 disc
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Dif. dg. radiculopathy
• Vertebrate MTS
• Boreliosis
• Pelvic tumors (LS), lungs (Th, C) and others
• Intraspinal tumors
• Inflammatory diseases
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Dif. dg. radiculopathy
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Therapy – acute stage
• Rest
• Analgetics
• Non-steroid antiinflammatory drugs
• Myorelaxants
• Local anesthetics
• Epidural corticosteroides
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Therapy - later
• Analgetics
• Non-steroid antiinflammatory drugs
• Myorelxants
• Local anesthetics
• Physiotherapy, exercising
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Therapy
• Neuropathic pain – anticonvulsants (pregabalin)
• Surgery
• Cauda equina syndrome
• Pain
• Peripheral paresis
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Therapy - surgery
• Cauda equina syndrome with urinary symptoms
• Marked muscular weakness pertaining to a nerve roots
• Progressive neurologic deficit
• Pain that exists more than 4 months