Pain in the back

Pain in the back

1. Anatomy of the back

   • General Characteristic of a typical vertebrae
     • Sacrum
       • Lateral mass
       • Median crest
       • Lateral sacral crest
       • Sacral hiatus
       • Anterior & Posterior Sacral foramina
     • Coccyx
       • 3-5 Fused vertebrae
     • Cervical
       • Foramen Transverarium
       • Spinous Process-bifid
     • Thoracic
       • Costal Facets for (i) Side od body , (ii) Transverse Process
     • Lumbar
       • No costal facet
       • No Froamen transverarium
   • Joints
     • Intervertebral discs
       • Present between the whole vertebrae except the atlas & the axis
       • Constitutes 25% of the whole lenght of the vertebral clumn
       • Made up of secondary fibro-cartilage
       • Consist of :
         • Annulus Fibrosis
           • Parallel collagen bundles arranged in concentric lamellae.
         • Nucleus Pulposus
           • Nearer to the posterior
           • Gelatinious material
           • Elasticity is gradually diminished by age
     • Zygapophyseal Joints (facet joints)
       • Synovial joints
       • Between the inferior articular process of superior vertebrae and the superior articular process of inferior vertebrae.
       • Action
         • Control flexion, extension, and rotation of adjacent cervical and lumbar vertebrae
     • Atlanto Occipital Joint
       • Between C1 (atlas) & the occipital condyles (skull).
       • Actions
         • The flexion and extension of the neck
       • Synovial joint - Condylar
     • Atlanto Axial joints
       • Synovial Joint - Pivot
       • Two lateral joints
       • Between C1 (Atlas) & C2 (Axis)
   • Ligaments of the Vertebral Column
     • Anterior longitudinal ligament
       • Strong, broad fibrous band
       • Importance
         • Helps to maintain the stability of the joints between the vertebral bodies
         • Helps prevent hyperextension of the vertebral column
       • Extends from the pelvic surface of the sacrum to the anterior tubercle of C1 (atlas) and the occipital bone of the skull
     • Posterior Longitudinal ligament
       • Narrower, weaker band than the anterior longitudinal ligament
       • Runs along the posterior aspect of the vertebral bodies, within the vertebral canal
       • Importance
         • Helps to prevent hyperflexion of the vertebral column and posterior protrusion of the nucleus pulposus of the disc
     • Ligamentum Flavum
       • Connects the lamina of each vertebrae with eachother
       • Importance
         • Helps to preserve the normal curvature of the vertebral column
         • To straighten the column after it has been flexed
     • Supraspinous and Interspinous ligaments
       • Weak interspinous ligaments
       • Strong cord-like supraspinous ligs.
       • Join adjacent spinous processes
       • Represented superiorly by the ligamentum nuchae
     • Intertransverse ligaments
       • Connecting adjacent transverse processes
   • Muscles of the back
     • Superficial Layer = Control upper extremity
     • Intermediate Layer = Moves the ribs
     • Deep Layer = Move trunk and back

2. Anatomy for Spinal Puncture

   • Structures pierced
     • 1. Skin
     • 2. Subcutaneous fat
     • 3. Supraspinous ligaments
     • 4. Ligamentum flavum
     • 5. Epidural space
     • 6. Dura
     • 7. Subarachnoid space

3. Dermatomes

4. Causes of back pain

   • Muscle or ligament strain
   • Bulging or ruptured disks
   • Arthritis
   • Skeletal irregularities
   • Osteoporosis

5. Referred pain from visceral disease

   • Low Thoracic or Lumbar Pain with Abdominal Disease
   • Sacral Pain with Gynecologic and Urologic Disease

6. Risk factor

   • Age
   • Lack of exercise
   • Excess weight
   • Carrying too much weight puts extra stress on your back
   • Improper lifting
   • Psychological conditions
   • Smoking

7. Investigation of back pain

   • History
     • Onset of pain
     • Location of pain
     • Type and character of pain
     • Aggravating and relieving factors
   • Physical examination
     • Superficial, nonanatomic tenderness
     • Pain with simulated testing
     • Inconsistent responses with distraction
     • Nonorganic regional disturbances
     • Overreaction
   • Laboratory tests
     • Complete blood count
     • Erythrocyte sedimentation rate
   • Radiographic evaluation
     • MRI
     • CT Scan
     • Bone scintigraphy = Bone Scanning
   • Visual Analogue Scale
     • Measurement instrument that tries to measure a characteristic or attitude that is believed to range across a continuum of values and cannot easily be directly measured

8. Psycho-social impact on complience

   • Drug adherence
     • Person’s ability and willingness to follow recommended health practices
     • Patients must:
       • 1- Fill the prescription given to them by the physician
       • 2- Routinely take the medication as directed by the physician
       • 3- Refill the medication as needed in order to take the medication as long as recommended by the physician.

9. Sciatica

   • Pain caused by irritation of the sciatic nerve
   • Causes
     • Lumbar Bulging Disc or Herniated Disc
     • Lumbar Spinal Stenosis
     • Spondylolisthesis
     • Trauma
     • Piriformis Syndrome
     • Spinal Tumors
   • Sings and symptoms
     • Shooting pain from the lower back, through the buttock, and down the back of either leg
     • Numbness in the leg along the nerve
     • Tingling sensation in the feet and toes
   • Complications
     • Loss of feeling
     • Weakness
     • Loss of bowel or bladder function
   • Physiotherapy
     • Herniated Disc Sciatica Management
     • Spinal Stenosis Sciatica Management
     • Piriformis Syndrome Sciatica Management

10. Alternative therapy

    • Dietary supplements
    • Megadose vitamins
    • Herbal preparations
    • Massage therapy
    • Spiritual healing

11. Surgical Intervention

    • Sciatic Nerve Decompression
    • Microdiscectomy & Discectomy
    • Laminectomy or Laminotomy

12. Abnormalities of the spine

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