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Pain in the back

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Pain in the back

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
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
Dermatomes
Causes of back pain
- Muscle or ligament strain
- Bulging or ruptured disks
- Arthritis
- Skeletal irregularities
- Osteoporosis
Referred pain from visceral disease
- Low Thoracic or Lumbar Pain with Abdominal Disease
- Sacral Pain with Gynecologic and Urologic Disease
Risk factor
- Age
- Lack of exercise
- Excess weight
- Carrying too much weight puts extra stress on your back
- Improper lifting
- Psychological conditions
- Smoking
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
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.
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
Alternative therapy
- Dietary supplements
- Megadose vitamins
- Herbal preparations
- Massage therapy
- Spiritual healing
Surgical Intervention
- Sciatic Nerve Decompression
- Microdiscectomy & Discectomy
- Laminectomy or Laminotomy
Abnormalities of the spine