Adobe Systems Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Differential diagnosis of back pain Adobe Systems Ortopedická klinika LF MU a FN Brno - MUDr. Michael Lujc, MUDr. Jan Kocanda Čtvrtek SIMU Ortopedie a rehabilitace CZ+ENG VLOR7X1c aVLOR7X1 - dvě skupiny po 10 (+- 4) studenti -dva lektoři: Ortopedie FN Brno a FNUSA HARMONOGRAM 07:30 - 08:45 teorie - artroskopie obecně/entezopatie/bursitity+ klinické vyšetření 08:45 - 09:00 pauza 09:00 - 10:00 praxe na simulátoru + case reports 10:00 - 10:15 pauza 10:15 - 11:30 teorie - páteř + klinické vyšetření 11:30 - 11:45 pauza 11:45 - 12:30 praxe na simulátoru + case reports FNUSA lektor FN Brno lektor Adobe Systems Summary ̶Definition ̶Etiology and Epidemiology ̶Risk factors ̶Differential diagnosis ̶Examination ̶Red flags/Yellow flags ̶Literature Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Definition Back pain is defined by a triad of symptoms: ̶pain ̶muscle tension ̶stiffness tied to a topographically defined area of the body. ̶the pain may radiate to the extremities Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems According to time ̶Acute pain (0 - 6 weeks) It can be a transient pain (hours - 2 days) that subsides spontaneously, usually without medical intervention. More often it lasts for days to weeks, it can progress together with neurological symptomatology. It can appear repeatedly. ̶Subacute pain (6-12 weeks) ̶Chronic pain (continuous or recurrent pain for more than 12 w.) Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems •Neck and arm pain •trauma •cervical spondylosis •metastatic disease / infection •cervical radiculopathy •cervical myelopathy •ankylosing spondylitis •Thoracic back and rib pain •trauma •metastatic disease / infection •thoracic disc herniation •osteoporotic comression fracture •trauma Acording to location •Low back pain •muscles strain •disc herniation / discogenic pain •degenerative spondylolithesis •spinal stenosis •lumbar radiculopathy •abdominal aortic aneurism •Sacroiliac pain •SI infection •ankylosing spondylitis •Sacral pain •coccydynia •sacral insufficiency fracture ̶ Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems CONSTRUCTING A DIFFERENTIAL DIAGNOSIS ̶Most low back pain is caused by conditions that are troublesome but not progressive or life-threatening. ̶Serious back pain (pain due to a systemic or visceral disease or pain with significant neurologic symptoms or signs) ̶Nonspecific back pain related to the musculoskeletal structures of the back, called mechanical back pain. Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems According to etiology 1/3 1. Back pain due to disorders of the musculoskeletal structures A.Nonspecific (mechanical) back pain: no definite relationship between anatomic abnormalities seen on imaging and symptoms B.Specific musculoskeletal back pain: clear relationship between anatomic abnormalities and symptoms A.Lumbar radiculopathy due to herniated disk, osteophyte, facet hypertrophy, or neuroforaminal narrowing B.Degeneration…..Spinal stenosis, spondylolisthesis….. C.Cauda equina syndrome ̶ Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems According to etiology 2/3 2. Back pain due to visceral disease (serious, requires specific and rapid diagnosis and treatment) A.Retroperitoneal A.Aortic aneurysm B.Retroperitoneal adenopathy or mass B.Pelvic A.Prostatitis B.Endometriosis C.Pelvic inflammatory disease C.Renal A.Nephrolithiasis B.Pyelonephritis C.Perinephric abscess D.GI A.Pancreatitis B.Cholecystitis C.Penetrating ulcer ̶ ̶ Adobe Systems According to etiology 3/3 3. Back pain due to systemic disease affecting the spine A.Serious and emergent (requires specific and often rapid treatment) A.Neoplasia A.(1) Multiple myeloma, metastatic carcinoma, lymphoma, leukemia B.(2) Spinal cord tumors, primary vertebral tumors B.Infection A.(1) Osteomyelitis B.(2) Septic diskitis C.(3) Paraspinal abscess D.(4) Epidural abscess B.Serious but nonemergent (requires specific treatment but not urgently) A.Osteoporotic compression fracture B.Inflammatory arthritis A.(1) Ankylosing spondylitis B.(2) Psoriatic arthritis C.(3) Reactive arthritis D.(4) Inflammatory bowel disease–associated arthritis Adobe Systems Epidemiology ̶Prevalence 60 – 85% ̶Aging population, obesity, sedentary lifestyle Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Epidemiology https://upload.wikimedia.org/wikipedia/commons/0/02/Stickman.gif https://upload.wikimedia.org/wikipedia/commons/0/02/Stickman.gif https://upload.wikimedia.org/wikipedia/commons/0/02/Stickman.gif https://upload.wikimedia.org/wikipedia/commons/0/02/Stickman.gif https://upload.wikimedia.org/wikipedia/commons/0/02/Stickman.gif 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock https://upload.wikimedia.org/wikipedia/commons/0/02/Stickman.gif 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock 1,362 Woman Stick Figure Icon Flat Graphic Design Illustrations & Clip Art - iStock Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský 90% lidí za život, ½ z nich opakovaně během jednoho roku , někde 8/10 a 65% třeba Austrálie, ale čísla jsou pro industrilizovaný svět +- stejný Adobe Systems Classification of low back pain (Waddell 1987) ̶Specific low back pain ̶the cause is an identifiable progressive pathology with possible involvement of nervous structures (15%): ̶intervertebral disc herniation ̶spondylolisthes ̶spinal stenosis ̶segmental instability ̶fractures, tumors, inflammations ̶Non-specific low back pain ̶pain without an identifiable specific anatomical or neurophysiological disorder (85%) Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Diagnostic triad (Waddell 1998,Barsa,Häckel 2004,Vrba 2008) ̶I. Simple back pain ̶Obvykle muskuloskeletální původ, postižení LS oblasti ̶nejčastěji mezi 20- 55 lety, dobrá prognoza konzervativní léčby ̶90% se uzdraví do 6 týdnů ̶II. Root (neurogenic) pain ̶typical lateralization with projection to DK with paresthesias ̶loss of sensitivity and nerves (motor skills, reflex changes) due to neurological symptomatology. Prognosis of conservative treatment worse (50% recover within 6 weeks) ̶III. Pain caused by a serious disease of the spine - “red flags“ ̶Tumors, inflammations, fractures-deformities, serious neurological diseases. ̶Risk factors: age under 20 and over 55, spinal injury, pain in the thoracic spine and abdomen without obvious causes, pain at rest, permanent and independent of movement Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Mechanical causes ̶Spinal stenosis ̶Spondylosis ̶Spondylolysis, spondylolisthesis ̶Herniated disc ̶Scoliosis ̶Trauma Výřez obrazovky Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Mechanical causes ̶Spinal stenosis ̶Spondylosis ̶Spondylolysis, spondylolisthesis ̶Herniated disc ̶Scoliosis ̶Trauma Cervical Spondylosis - Spine - Orthobullets Degenerative Disc Disease & You VA Claim | VA Disability Attorneys Blog Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Adobe Systems Mechanical causes ̶Spinal stenosis ̶Spondylosis ̶Spondylolysis, spondylolisthesis ̶Herniated disc ̶Scoliosis ̶Trauma ̶ Výřez obrazovky Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Mechanical causes ̶Spinal stenosis ̶Spondylosis ̶Spondylolysis, spondylolisthesis ̶Herniated disc ̶Scoliosis ̶Trauma Výřez obrazovky Adobe Systems Mechanical causes ̶Spinal stenosis ̶Spondylosis ̶Spondylolysis, spondylolisthesis ̶Herniated disc ̶Scoliosis ̶Trauma Adult degenerative scoliosis – A literature review - ScienceDirect Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Mechanical causes ̶Spinal stenosis ̶Spondylosis ̶Spondylolysis, spondylolisthesis ̶Herniated disc ̶Scoliosis ̶Trauma Thoracolumbar classification. Reprinted with permission from AOSpine... | Download Scientific Diagram Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Mechanical causes ̶Other degenerative changes: ̶Facet joints, lateral recess, foramina ̶Osteophytes ̶Synovial cysts ̶Lipomatosis ̶Discogenic pain and endplate changes ̶oPLL Adobe Systems ̶ Adobe Systems ̶ Zdroj.: 1.Ciftdemir M, Kaya M, Selcuk E, Yalniz E. Tumors of the spine. World J Orthop. 2016;7(2):109-116. Published 2016 Feb 18. doi:10.5312/wjo.v7.i2.109, 2.DREGHORN, C. R., NEWMAN, R. J., HARDY, G. J., & DICKSON, R. A. (1990). Primary Tumors of the Axial Skeleton. Spine, 15(2), 137–140. doi:10.1097/00007632-199002000-00018 27 /33 Adobe Systems •Chondrosarcoma •Osteogenic sarcoma •Ewing's sarcoma •Chordoma •Multiple myeloma •Lymphoma •Metastases - breast, lung, prostate, thyroid, kidney Plain X-ray Spine Malignant tumors Vertebral Augmentation and Ablation in Cancer Patients With Spine Metastases - Endovascular Today Vertebral Augmentation and Ablation in Cancer Patients With Spine Metastases - Endovascular Today Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Benign tumors ̶Osteochondroma ̶Osteoid osteoma and osteoblastoma ̶Giant cell tumor ̶Aneurysmal bone cyst ̶Hemangioma ̶Eosinophilic granuloma Vertebral hemangioma | Radiology Reference Article | Radiopaedia.org Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Infection ̶Osteomyelitis ̶Epidural abscess ̶Discitis ̶Granulomatous infection ̶TBC Discitis osteomyelitis - Candida albicans | Radiology Case | Radiopaedia.org Osteomyelitis | Radiology Reference Article | Radiopaedia.org Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Infection ̶Osteomyelitis ̶Epidural abscess ̶Discitis ̶Granulomatous infection ̶TBC Epidural Abscess | Radiology Key Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Osteoporosis ̶senilní ̶postmenopauzální ̶farmakologicky induk. Osteoporosis - The Lancet Compston JE, McClung MR, Leslie WD. Osteoporosis. Lancet. 2019 Jan 26;393(10169):364-376. doi: 10.1016/S0140-6736(18)32112-3. PMID: 30696576. Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Congenital and other degenerative changes ̶Sacralization, lumbarization ̶Bertolotti's syndroma ̶Lumbar hyperlordosis with vertical sacrum ̶Baastrup phenomenon 6th lumbar vertebra: lumbarization of S1 | Radiology Case | Radiopaedia.org 1 2 3 4 5 6 File:Sacralization of the fifth lumbar vertebra.jpg - Wikimedia Commons Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Congenital and other degenerative changes ̶Sacralization, lumbarization ̶Lumbar hyperlordosis with horizontal sacrum ̶Baastrup phenomenon File:Hyperlordosis XRay lat.jpg - Wikimedia Commons Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Congenital and other degenerative changes ̶Sacralization, lumbarization ̶Lumbar hyperlordosis with vertical sacrum ̶Baastrup phenomen Kissing spines: an underdiagnosed cause of low back pain | SpringerLink Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Spondyloarthropathy ̶Ankylosing spondylitis – HLA - B27+ ̶Rheumatoid arthritis Ankylosing Spondylitis | SpringerLink Hip joint involvement in ankylosing spondylitis | Radiology Case | Radiopaedia.org Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Spondyloarthropathy ̶Ankylosing spondylitis – HLA - B27 ̶Rheumatoid arthritis Rheumatoid arthritis (musculoskeletal manifestations) | Radiology Reference Article | Radiopaedia.org Cervical spine in rheumatoid arthritis | Radiology Case | Radiopaedia.org Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems EXAMINATION ̶Anamnestic data– RA, OA, FA, AA, PSA ̶Perfect clinical examination and documentation ̶XR – standardized images ̶CT – acute trauma ̶MRI - the gold standard for soft tissue ̶Other imaging modalities after MDT ̶Consultation of expertise in the case of therapeutic doubts Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Red flags ̶infection x tumor x trauma x cauda equina syndrome ̶New onset back pain age <20, 50+ ̶Night pain ̶Saddle anaestesia, bladder bowel distrubance ̶Fever, loosening weight ̶Anamnesis of cancer, steroid use Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Ortopedická klinika LF MU a FN Brno - MUDr. Michael Lujc, MUDr. Jan Kocanda Back Pain Red Flags - By Age IMMUNOCOMPROMISED INTRAVENOUS ... Adobe Systems Adobe Systems Red flags – TUNA FISH ̶Trauma ̶Unexplained Weight Loss ̶Neurologic Symptoms ̶Age over 50 ̶Fever ̶IVDU (IntraVenous Drug User) ̶Steroid Use ̶History of Cancer ̶ Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Yellow flags ̶"yellow/warning/flags" ̶psychosocial risk factors ̶e.g. wrong attitudes and superstitions of the patient about back pain ̶unsuccessful diagnostic and treatment results ̶behavioral, emotional, family and work problems ̶catastrophizing and depression ̶passive coping with pain (passive expectation of pain, limitation or exclusion of physical and social activity) ̶increase in muscle tension (muscle imbalance) ̶signs of protective behavior (taking comfortable positions, limping, overuse of support aids, etc.) Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský Adobe Systems Literatura ̶Benzel, E. C., & Steinmetz, M. P. (2017). Benzel's spine surgery: Techniques, complication avoidance, and management (Fourth edition.). Philadelphia, PA: Elsevier. ̶COST B13: European guidelines for the management of low back pain. Eur Spine J 15, s125– s127 (2006). https://doi.org/10.1007/s00586-006-1066-z ̶DUNGL, Pavel. Ortopedie. Praha: Grada, 2005. ISBN 80-247-0550-8. ̶ Department of Orthopaedic surgery MU ＆ UH Brno - MUDr. Jan Kocanda, MUDr. Jan Sklenský