Download - case based learning
CBL 4 Done by:
Najla Al-Ghabban
Mashael Al-Towairqi
Sumaya Al-Amri
HISTORY
Mr. Ahmed is a 67 years old retired male engineer
presented to primary care clinic complaining of chronic
low back pain radiating to both lower limbs for the last
one year.
KEY FACTORS
• 67 years old retired male engineer
• Chronic low back pain
• Radiating to both lower limbs
• For one year
LOWER BACK PAIN(CHRONIC)
Spinal infection
Spinal tumors
Vertebral fracture
Muscular sprain
Lumbar disc herniation
Degenerative spine
disease, Spinal
stenosis
Dissecting aneurysm
Pyelonephritis
Pancreatitis
Spinal causes : Extra Spinal causes :
HISTORY
•HPI:
-Pain
-Hx of trauma
-Functional level
HISTORY
•Risk factors:
-Genetic predisposition
-Age
-Smoking
-Obesity
-Previous injury, fracture or subluxation (trauma)
-Deformity
-Occupation
-Infections
-PHx of cancer
HISTORY
•Red Flags:
-Loss of weight / appetite
-Fevers, sweats
-Night pain, rest pain
-Immunosuppresion
-Loss of sensation
-Loss of motor function
-Sudden difficulties with urination or defecation
HISTORY
•MSK systemic review:
-Stiffness
-Swelling
-Instability
-Deformity
-Limp
-Altered Sensation
-Loss of function
-Weakness
HISTORY
•PMH: He reported that he is known diabetic but
otherwise has no other health problems
•PSH
•Drug Hx
•Allergy
•Family Hx
•Social Hx
FURTHER HISTORY
• There is no history of trauma
• Pain has been progressing during last year but
there has been milder pain over many years
•Pain is aggravated by walking for long distance
and radiates to legs with numbness
•Patient gets relief on bending or lying down
•Patient has no night pain or urinary symptoms
TO DIFFERENTIATE BETWEEN NEUROGENIC
AND VASCULAR CLAUDICATION
Neurogenic Vascular
palliative
factors
provocative
factors
PHYSICAL EXAMINATION Back examination
VITAL SIGNS
Pulse =90/min normal (60-100/min)
BP=145/95 normal(90-140/60-90) what could
be the cause?
RR=18/min normal (12-18)
Temperature=37
BACK EXAMINATION
o Position: Standing , supine position
o Exposure: Trunk and lower limbs covering the
unneeded area
o Look: Front, side, behind
o Feel
o Move
o Do
STANDING POSITION
1-LOOK:
o Skin changes (café au latte spots in
neurofibromatosis)
o Hairy patch
o Deformity: Scoliosis, kyphosis
o Level of: shoulder ,waist and pelvis
o Swelling
o Gait
GAIT
What are the abnormal gaits you know?
GAIT
1-Standing on heels:
o To test L4-L5
o To test 3 muscles:
tibialis anterior, extensor halluces longus,
extensor dgitorum
2-Standing on tiptoes:
o To test S1
o To test gastrocnemius muscle and soleus
2-FEEL
o Spinous processes (tenderness, stips, gaps)
o Paravertebral muscles (tenderness , spasm)
o Temperature
3-MOVE
Active movement :
Flexion: see the level of fingers tip, normally the
patient can bend reach 10cm from the floor 90
degree reaching the medial malleoli without pain
Extension: up to 30 degree
Lateral bending: 30 degree
Rotation: up to 45degree (stabilize the hip)
During the movement note any limitation and if
there is any pain
If the patient cannot move actively then do
passive range of motion
4-DO SPECIAL TEST
Adam`s forward bending test:
o To see if there is rib hump
o If positive: Sign for scoliosis
SUPINE POSITION
o Look: any muscle wasting in the lower limbs
o Feel : tenderness, hotness
o Do special test : SLR (Straight Leg Raising)
HOW IT`S DONE
o With the leg fully extend , put your hand under
the heel and start to raise it passively and slowly.
o Normally the raising degree should be 80 or more
without pain.
o If there is shooting pain radiates to the lower
part between 30-70 degrees the test is positive
and indicate?
o To confirm the diagnosis we dorseflex the ankle
joint (pain increse) and with knee flexion(pain
relieved).
AT THE END
We finish our examination by neurovascular
examination and rectal examination
NEUROLOGICAL EXAMINATION
1-Dermatoms (sensation)
L1= inguinal ligament
L2= front of the thigh
L3= at knee
L4= medial side of shin
L5= dorsum of the foot
S1= small toe
S2= lateral back of the thigh
S3-S5= saddle area
2-Myotoms(power)
L2= hip flexion
L3=knee extension
L4=dorsal flexion of the
ankle
L5=big toe extension
S1=plantar flexion
VASCULAR EXAMINATION
o Pulse:
Dorsalis pedis
Posterior tibial
Pupliteal
o Capillary refilling
TO DIFFERENTIATE BETWEEN NEUROGENIC
AND VASCULAR CLAUDICATION
Neurogenic Vascular
Pulses
Bicycle test
EXAMINATION FINDINGS
Patient walk with slightly flixed back
Moderate spasm of paravertebral muscles
Tenderness of lumbar spine from L4-S1
Moderate restriction of back movement
Reduced sensation at L5andS1 dermatomes.
No muscle weakness
Reduced ankle jerk reflexes? (diabetic and old age not
important)
Lower limbs pulses are palpable
SLR is negative there is no nerve root compression.
OTHER EXAMINATIONS TO RULE OUT EXTRA
SPINAL CAUSES
Abdomen was soft with no tenderness, masses or
pulsation. No renal tenderness
INVESTIGATIONS
CBC :
Hb=13.4g/dl normal (14-18 gm/dl)
WBC=9800 normal( 4,500-10,000 )
ESR=22 normal (0-20)
Bone profile :
Ca=2.8mmol/l normal 2.2-2.6
Phosphorus=1.3mmol/l normal
Alkaline phosphates= 110units/l
IMAGE STUDY
X-ray
MRI
X-RAY
FINDINGS
In the AP view:
The alignment = normal no scoliosis
Density=normal
There are osteophytes formed at the lateral sides
of the vertebra L3-L4
In the lateral view:
Anterior osteophytes
Decreased lordosis because of the degeneration
MRI
FINDINGS
Normally the disc color in T2 is dark on the
peripheral part and white in the central part
In the previous image the disc appears to be dark
lost hydration and died
Bulging of the disc
Ligamentum flavum and facet joint hypertrophy
spinal cord stenosis
SUMMARY
Slightly flexion when standing
Tenderness at L4-S1
Moderate spasm of paravertebral muscles
Moderate restriction of back movement
Reduced sensation at L5andS1
Reduced ankle jerk reflexes
Normal CBC and bone profile
LOWER BACK PAIN(CHRONIC)
Spinal infection
Spinal tumors
Vertebral fracture
Muscular sprain
Lumbar disc herniation
Degenerative spine
disease, Spinal
stenosis
Dissecting aneurysm
Pyelonephritis
Pancreatitis
Spinal causes : Extra Spinal causes :
DEGENERATIVE SPINE DISEASE,
SPINAL STENOSIS
WHAT IS THE
DIFFERENCE
BETWEEN
BULGING DISC
AND HERNIATED
DISC?
ANATOMY
-Anterior elements:
Vertebral body
vertebral disc-Inter
Degeneration occurs at the the disc
-Posterior elements:
Pedicles, laminae, spinous process, transverse process,
)in each level2 (facet joints
Osteoarthrosis occurs at the facet joints
PATHOPHYSIOLOGY
-Bulging of the disc into the spinal canal
-Increase the load on the facet joint
-Facet and ligaments hypertrophy
-Contributing to spinal stenosis
-Pressure on nerve roots >pain
-Patient will bend forward
MANAGEMENT: LOW BACK PAIN
-It is the first line of
treatment
-Physiotherapy:
core muscle
strengthening,
posture training
-NSAID
-Surgical treatment
indicated for:
• Instability or
deformity
e.g. high-grade
spondylolisthesis
• Failure of
conservative
treatment
Decompression of spinal
stenosis
Conservative Operative
MANAGEMENT: SPINAL STENOSIS
-It is the first line of
treatment
-Activity modification
-Analgesics
-Epidural cortico-steroid
injections
- Surgical treatment
indicated for:
• Motor weakness e.g.
drop foot
• failure of –minimum-
6 months of
conservative
treatment
- Spinal
decompression
(laminectomy) is the
commonest
procedure
conservative operative
PROGRESS
• Patient diagnosis was explained to him
• He was given advise about weight reduction and
back care
• He was prescribed physiotherapy and NSAIDs
• He was told extra-dural steroid injections may be
tried to help in symptoms relief
• Patient was told surgery may be offered if
symptoms continues or worsens
CONCLUSION
•Patient reported some improvement with
NSAIDs, Physiotherapy, weight loss and
modification of DLA ( Daily Life Activities )
•Patient wished to have further treatment and was
given Extra -Dural steroid injection
•Patient's symptoms were reasonably controlled
for a long period
•Surgery in the form of Decompression of spinal
stenosis was still a possibility for future