Inflammatory V Mechanical Low Back Pain. Diane Moss / Jenny Love AFLAR Oct 2009

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1 Inflammatory V Mechanical Low Back Pain Diane Moss / Jenny Love AFLAR Oct 2009

2 Areas affected are lumbar spine and SIJ. Caused by reactive arthritis, A.S., PsA

3 Pathology affecting SIJ Sacroilitis

4 Grades of Sacroilitis

5 WHAT PATHOLOGICAL PROCESSES OCCUR IN THE SPONDYLOARTHROPATHIES ENTHESITIS Inflammatory reaction at the enthesis Common enthesitis sites are : ischial tuberosities, greater & lesser tuberosities; iliac crests, pelvic brim, costochondral junction, plantar fascia; achilles tendon, medial & lateral epicondyles. Enthesitis can be seen on diagnostic u/s. In axial joints, SIJs, facets, discovertebral;costovertebral & costotransverse jts, synovitis & fibrosis can lead to ankylosis At the IV disc vertebral margin there can be enthesitis of the annulus & formation of syndesmophytes. In early stages squaring of sup & inf margins of vert body. This is called a romanus lesion Eventually the longitudinal ligs can ossify resulting in the classic bamboo spine. SYNOVITIS can occur in peripheral jts.

6 Syndesmophytes

7 Syndesmophytes

8 Syndesmophytes

9 Bamboo spine

10 Subjective findings Sacroilits. Age Worse with walking, particularly on inclines. Easier with flexion Pain can be local or referred distally or into groin. Can respond to NSAIDS. Sleep disturbed. Associated conditions e.g IBS & iritis. Other joint / skin / nail involvement. Systemic malaise. EMS. Fatigue.

11 SUBJECTIVE FINDINGS Lumbar spine. Age. Eases with exercise. EMS duration. Pain can be local or referred distally. Pain lessens with fusion. Associated conditions e.g IBS & iritis. Other joint / skin /nail involvement. Fatigue. Systemic malaise.

12 BASDAI

13 BASG

14 BASFI

15 Objective findings Sacroilitis. Positive fabers and shear tests. Positve on palpation and accessory movements of SIJ. Clear hip and lumbar spine. Xrays of SIJS. MRI. Haematological tests positive for inflammation + or infection.

16 Objective Findings Lumbar spine. Altered posture. Reduced movement and pain increase on lumbar spine movements. EMS duration. Xrays. Inflammatory markers. Genotype. MRI

17 Basmi

18 BASMI

19 BASMI

20 Physiotherapy input Pain relieving modalities e.g. acupuncture,tens. Exercise programme to increase ROM & strength on dry land and in water. Disease Education to patients and carers.

21 Medical Input NSAIDs. DMARD therapy. Biologic therapy. Joint injections to peripheral joints.

22 Mechanical LBP Self limiting problem: 44% better 1/52 86% better 1/12 92% better 2/12 However: 90% become recurrent 35% develop sciatica 10% chronic Despite this only 2-3% require surgical intervention ( Croft et al. 1998)

23 Why does LBP occur Predisposing factors: posture (static / dynamic) Loss of ROM Frequency flexion Sedentary lifestyle De-conditioning Occupational stresses Poor abdominal control These lead to adaptive change of soft tissue, dysfunction, altered joint mechanics and discal pressures

24 Why. Precipitating factors : New Use Overuse Misuse Trauma No one cause of LBP, potential lies with predisposing/ precipitating. If pain & dysfunction linked, pain resolves & dysfuncton remains, likelihood of recurrence leading to increased freq/severity causing chronic pain. (McKenzie 1981; Hodges et al 1996)

25 How does LBP occur Flexion Extension post disc pressure central canal space foraminal space neural tension post disc pressure central canal foraminal space neural tension

26 Spinal Stenosis : Pathophysiology Narrowing of central canal or lateral foramina Causes irritation/compression on cord/nerve roots Congenital /developmental Degenerative (more common) Deg : involves 1 or more following : Facet jt degenerative change IV disc degen change / protrusion Ligamentum flavum thickening / buckling Spondylolithesis Degenerative scoliosis

27 Degenerative spondylolisthesis

28 Spinal stenosis : Presentation 50yrs + Males > female LBP, unilateral /bilat leg pain Radicular or non dermatomal Pain intermittent or constant Initially episodic but becomes consistant with time Onset gradual, insidious

29 Spinal Stenosis : Presentation c/o numbness, weakness, cramping (neurogenic claudication) Aggravating activities : standing,walking (ext) Easing activities : sitting, stooping, bending (flex)

30 Spinal Stenosis : Examinaton Unremarkable at times Poor posture Reduced lordosis, inc. kyphosis ROM general reduced all mvts - flexion normal - ext limited + /- pain SLR - normal ( most commonly) Neurological normal Circulation pedialis dorsalis & venous return normal

31 Spinal stenosis : Investigations XRAY normal Age related changes - Spondylolisthesis Grade1-4 MRI

32 Degenerative spondylolisthesis with stenosis T2 sagittal MRI

33 Spinal stenosis T2 axial MRI

34 Spinal Stenosis : Management Conservative Surgical Physio core stability Decompression - flexion Interspinous distraction NSAID s (XStop) Epidural Nerve Root Block

35 Nerve Root / Disc : Presentation Age : yrs LBP + radicular leg pain Constant / intermittent + / - Parasthesia & numbness (dermatomal) Onset Sudden or gradual Previous episodes inc severity,duration & radiation

36 Nerve Root / Disc Agg factors flexion, bending, sitting, static posture Ease factors walking, prone lying, on the move Cough / sneeze - +ve leg pain Bladder / bowel - +ve if large central disc Saddle anaesthesia - +ve if large central disc

37 Nerve Root / Disc : Examination Poor posture Red /inc lordosis + /- lateral shift Loss movement & function Movement loss assymetrical SLR poss +ve for leg pain XSLR poss +ve leg pain Neurological altered in relevant dermatome / myotome Reflexes reduced or absent

38 Nerve Root / Disc : Investigation XRAY normal MRI

39 Management: D/C physiotherapy Review ortho following physiotherapy MRI +ve - Lumbar discectomy MRI? nerve root block } therapeutic - epidural } diagnostic

40 To Conclude : Subjective findings Inflammatory Age yrs Gender- M>F Pain- local/referred Pain-constant/Int. Agg/Ease Sleep disturbance Systemic malaise Add joint/skin/nail Assoc conditions (IBS) 24hr pattern- EMS Mechanical 20+ disc; 50+ stenosis Variable Local/referred/radicular Constant/Int. Agg/ease Variable None None None 24hr pattern- variable

41 To Conclude: Objective findings Inflammatory Posture ROM: SIJ / Lx SLR/XSLR- normal Neuro- normal Hip- normal (except Ank.Spon) Fabers/Shear- +ve Palp n/acc.mob- +ve Mechanical Posture SIJ-normal; Lx limited SLR/XSLR- +ve Neuro- poss +ve Hip- normal Fabers/Shear- normal Palp n/acc mob- local pn

42 Investigations. Inflammatory Haematological : ESR; CRP; WCC; Genotype. XRAY MRI Mechanical Haematology- normal XRAY MRI

43 Management. Inflammatory NSAID s Physiotherapy; pain relief & exercise. Education Mechanical Physiotherapy Education Surgery Nerve root block/ Epidural

44 Thankyou Questions?

LUMBAR SPINAL STENOSIS

LUMBAR SPINAL STENOSIS Always occurs in the mobile segment. Factors play role in Stenosis Pre existing congenital or developmental narrowing of the lumbar spinal canal Translation of one anatomic segment