STUDY - Technical - New Dacian's Medicine
Cervical
and Back Pain (1)
Translation Draft
Everything I will present here has been grouped (in the blog menu) under the name "column pains" (referring to the spine).
The importance of cervical and back pain is underlined by the following: 1. very high annual social costs (there is enormous economic pressure to ensure effective and rational care), 2. dorsolumbar pain is the most common cause of incapacity in patients under 45 years of age, 3. in one study it was found that 50% of working adults admit to having suffered an annual back injury and 4. a significant percentage of the population is permanently incapacitated due to back pain.
For a start I should have introduced you to the anatomy of the spine but, being full of descriptive stuff that does not interest anyone (those with medical training with full knowledge of this anatomy), I chose to move on without these "details". So, I'm going to proceed directly to the description of the pains that occur at this "level".
There are five types of lumbar pain (lumbalgia): local, irradiated to the spine, pain of irradiated spine origin in the legs or buttocks, radicular pain and muscle spasm. The characteristics of dorsolumbar pain vary considerably, but there are a few traits that help differentiate.
Local pain is caused by processes that compress or irritate the sensory nerve endings, usually due to fractures that break or stretch pain-sensitive structures, the site of pain being placed near the affected vertebral portion.
Irradiated pain in the spine can arise from abdominal or pelvic viscera and is usually described as abdominal or pelvic pain, as well as spinal pain and is often not influenced by the position of the spine. This type of pain can sometimes only be described as low back pain.
Pain of spinal origin can irradiate in the buttocks or in the thighs. The upper lumbar spine disorders can trigger pain that radiates to the lumbar region, the groin or the anterior thighs.
Diseases affecting the lower lumbar spine can trigger pain that radiates into the buttocks, in the posterior thighs or, rarely, in the shins or legs. Note that the exact pathology of these pains (sclerotoma) is quite unclear.
Classical root lumbar pain is usually sharp and radiates from the spine into the lower limb, on the territory of a nerve root. Coughing, sneezing or voluntary contraction of the abdominal muscles (lifting weights or defecation effort) frequently cause irradiated pain.
The patient notices the increase of pain in positions that stretch the nerves and nerve roots: the sitting position stretches the sciatic nerve (roots L5 and S1), because the nerve passes posteriorly of the hip, the femoral nerve (roots L2, L3 and L4) passes the hip before and is not stretched in the sitting position. Only the isolated description of pain cannot clearly differentiate a pain of spinal origin from a radiculopathy.
Pain associated with muscle spasm, although of unclear origin, is commonly associated with many disorders of the spine. Spasms are accompanied by abnormal postures, contraction of the paravertebral muscles and deaf pain. Sleepy or non-posture-related low back pain may raise suspicion of underlying spinal tumour, fracture, infection or irradiated pain from visceral structures.
Pain in the lower limb caused by walking or orthostatism and improved in the sitting position or clinostatism is suggestive for spinal stenosis. Knowing the circumstances in which back pain occurs is important when a serious underlying cause of pain is suspected. The diagnostic usefulness of symptoms and signs suggestive of a serious underlying cause of back pain is important for treatment.
When examining the lumbar region it is advisable to perform a general physical examination including the rectum and abdomen. The lumbar pain that radiates from the viscera can be reproduced by palpation of the abdomen (pancreatitis, abdominal aortic aneurysm) or by the percussion of the costovertebral angles (pyelonephritis, adrenal disease, fracture of transverse apophysis L1-L2).
Normal spine inspection shows toracal kyfosis, lumbar lordosis and cervical lordosis. Extraction of these curves can lead to hyperkycosis (coke) or hyperlordosis (back) curved. Spasm of the paravertebral lumbar muscle leads to flattening of normal lumbar lordosis.
The inspection may show lateral deviation of the spine (scoliosis) or asymmetrical appearance of the paravertebral muscle, suggesting muscle spasm. Contraction of the paravertebral muscles limits the movements of the spine in the sagittal and frontal plane. Local back pain is often reproduced by palpation or percussion of the spiny apophyses of the damaged vertebrae.
Forward bending is often limited by the contraction of the paravertebral muscles accompanying the damage to the pain-sensitive structures of the spine. Hip flexion is normal in patients with lumbar spine disorders (spondylose), while lumbar spine flexion is limited and sometimes painful.
Side bending on the opposite side of the damaged vertebral structure can stretch the affected tissues, aggravating pain and causing movement to be limited. Hyperextension of the spine (with the patient in ventral decubit or in orthostatism) is limited when there is compression on the nerve root or damage to the spine.
Pain in hip disorders can mimic pain from lumbar spine diseases. The first limited movement is the internal rotation of the hip. The internal and external manual rotation of the hip with the flexed calf and thigh can cause pain, as can the percussion with the palm of the patient's heel.
Passive flexion of the thigh on the abdomen when the calf is in extension produces the stretching of the nerve roots L5 and S1 and the sciatic nerve (the sciatic nerve passes posteriorly on the hip). Passive dorsiflexia of the foot during the manoeuvre accentuates the stretching.
Normally it is possible at least 80 degrees without the appearance of pain, but the tendons of the muscles that fit into the thigh can limit movement. This sign of "stretched leg lift" (RPI) is positive if the maneuver causes pain.
The RPI sign can also be performed in the sitting position to determine whether the result is reproducible. The patient may describe pain in the lower back, buttocks, the back of the thigh or the lower lower limb.
The cross-RPI sign is positive when performing this manoeuvre on one leg causes pain in the contralateral leg or buttock. The damaged nerve or the affected nerve root are always in the painful part.
The inverted RPI sign is obtained by putting the patient in the ventral decubit and producing the passive extension of the thigh. This maneuver stretches the roots of L2 - L4 and the femoral nerve, which passes previously the hip. The inverted RPI test is positive if the maneuver causes pain to the patient.
The neurological examination also includes the search for muscle atony, atrophy, asymmetrical or age-inappropriate reflexes, decreased sensitivity to the lower limbs and signs of spinal cord damage. laboratory tests, X-rays and other methods of exploration have their usefulness in locating and identifying the causes of the diseases.
Let us now proceed to the presentation of the causes of disabling low back pain, starting with congenital abnormalities of the lumbar spine.
Spondylosis consists of a bone defect probably caused by a fracture in the interarticular portion of the vertebra of an abnormally congenital segment (a segment near the junction of the pedicle with the lamina). The defect (usually bilateral) is best visualized in oblique radiological projections or by computed tomography (CT) and occurs after a single injury, repeated minor trauma or increase.
The vertebral body, pedicles and upper articular facets may slide forward and leave behind the posterior elements, this last anomaly (spondylolistesis) being the most commonly symptomatic. The patient may experience irradiated lumbar pain in the lower limbs and sensitivity may occur near the segment that has "slipped" previously (most commonly L5 on S1 or, more rarely, L4 on L5). Deep palpation of the posterior elements of the segments above the spondylolistesis joint may reveal a "step" displacement. The torso may be shortened, and the abdomen may become prominent as a result of the extreme displacement of L5 on S1, in severe cases (cases where ponytail syndrome may occur).
It follows lumbar and cervical trauma, which is an important cause of acute pain (lumbar or cervical). These patients require careful initial evaluation. Thus, a patient who complains of back or neck pain and cannot move his legs may have a fractured spine.
In acute injuries which may involve fractures or dislocations of vertebral segments, consideration should be given to avoid causing other lesions of the spinal cord or nerve roots when examined. The neck or back, depending on the location of the trauma, should be immobilized until the X-ray is performed to rule out the presence of a fracture or dislocation.
Lombosacrate stretches and sprains do not clearly describe a specific anatomical lesion. The terms mechanically induced stretching, spraining or lumbar muscle spasm are used for minor, self-limiting injuries associated with heavy lifting, a fall or sudden fall occurring in car accidents. Patients with low back pain often take unusual positions due to paravertebral muscle spasm. Pain is usually localized in the lower back and there is no irradiation to the buttocks or lower limbs.
I will end today's fast with the vertebral fractures of the lumbar vertebral bodies that are the result of compression or flexion and consist of splitting or anterior compression. In more severe traumas, the patient may have a dislocation or cominutive fracture, involving not only the vertebral body, but also the posterior elements.
Vertebral fractures are caused by fall from height (where fracture of the interarticular portion of the L5 vertebra is frequent), sudden detection in car accidents or direct trauma. Neurological alterations are commonly associated with these traumas, and early treatment ensures better development.
When fractures are caused by minor trauma or in the absence of trauma, it is assumed that the bone is affected by a pathological process (usually osteoporosis of climacterium, type 1, or senescence, type 2), but the vertebral bodies may also be affected by systemic diseases such as osteomalacia, hyperparathyroidism, hyperthyroidism, multiple myeloma, carcinoma metastases or treatment with glucocorticoids.
Clinical context (trauma, patient age, steroid use), elements of physical examination (neurological deficiency, paravertebral muscle spasm) and radiological appearance will establish the diagnosis. Fractures of transverse apophyses are associated with severe lesions of the paravertebral muscle, mainly with reference to psoas, associated retroperitoneal hemorrhage may lead to decreased hematocrit and hypovolemic shock. Such lesions can cause profound sensitivity at the site of injury and limitation of all lumbar movements (CT and MRI establishing the diagnosis).
Everything I will present here has been grouped (in the blog menu) under the name "column pains" (referring to the spine).
The importance of cervical and back pain is underlined by the following: 1. very high annual social costs (there is enormous economic pressure to ensure effective and rational care), 2. dorsolumbar pain is the most common cause of incapacity in patients under 45 years of age, 3. in one study it was found that 50% of working adults admit to having suffered an annual back injury and 4. a significant percentage of the population is permanently incapacitated due to back pain.
For a start I should have introduced you to the anatomy of the spine but, being full of descriptive stuff that does not interest anyone (those with medical training with full knowledge of this anatomy), I chose to move on without these "details". So, I'm going to proceed directly to the description of the pains that occur at this "level".
There are five types of lumbar pain (lumbalgia): local, irradiated to the spine, pain of irradiated spine origin in the legs or buttocks, radicular pain and muscle spasm. The characteristics of dorsolumbar pain vary considerably, but there are a few traits that help differentiate.
Local pain is caused by processes that compress or irritate the sensory nerve endings, usually due to fractures that break or stretch pain-sensitive structures, the site of pain being placed near the affected vertebral portion.
Irradiated pain in the spine can arise from abdominal or pelvic viscera and is usually described as abdominal or pelvic pain, as well as spinal pain and is often not influenced by the position of the spine. This type of pain can sometimes only be described as low back pain.
Pain of spinal origin can irradiate in the buttocks or in the thighs. The upper lumbar spine disorders can trigger pain that radiates to the lumbar region, the groin or the anterior thighs.
Diseases affecting the lower lumbar spine can trigger pain that radiates into the buttocks, in the posterior thighs or, rarely, in the shins or legs. Note that the exact pathology of these pains (sclerotoma) is quite unclear.
Classical root lumbar pain is usually sharp and radiates from the spine into the lower limb, on the territory of a nerve root. Coughing, sneezing or voluntary contraction of the abdominal muscles (lifting weights or defecation effort) frequently cause irradiated pain.
The patient notices the increase of pain in positions that stretch the nerves and nerve roots: the sitting position stretches the sciatic nerve (roots L5 and S1), because the nerve passes posteriorly of the hip, the femoral nerve (roots L2, L3 and L4) passes the hip before and is not stretched in the sitting position. Only the isolated description of pain cannot clearly differentiate a pain of spinal origin from a radiculopathy.
Pain associated with muscle spasm, although of unclear origin, is commonly associated with many disorders of the spine. Spasms are accompanied by abnormal postures, contraction of the paravertebral muscles and deaf pain. Sleepy or non-posture-related low back pain may raise suspicion of underlying spinal tumour, fracture, infection or irradiated pain from visceral structures.
Pain in the lower limb caused by walking or orthostatism and improved in the sitting position or clinostatism is suggestive for spinal stenosis. Knowing the circumstances in which back pain occurs is important when a serious underlying cause of pain is suspected. The diagnostic usefulness of symptoms and signs suggestive of a serious underlying cause of back pain is important for treatment.
When examining the lumbar region it is advisable to perform a general physical examination including the rectum and abdomen. The lumbar pain that radiates from the viscera can be reproduced by palpation of the abdomen (pancreatitis, abdominal aortic aneurysm) or by the percussion of the costovertebral angles (pyelonephritis, adrenal disease, fracture of transverse apophysis L1-L2).
Normal spine inspection shows toracal kyfosis, lumbar lordosis and cervical lordosis. Extraction of these curves can lead to hyperkycosis (coke) or hyperlordosis (back) curved. Spasm of the paravertebral lumbar muscle leads to flattening of normal lumbar lordosis.
The inspection may show lateral deviation of the spine (scoliosis) or asymmetrical appearance of the paravertebral muscle, suggesting muscle spasm. Contraction of the paravertebral muscles limits the movements of the spine in the sagittal and frontal plane. Local back pain is often reproduced by palpation or percussion of the spiny apophyses of the damaged vertebrae.
Forward bending is often limited by the contraction of the paravertebral muscles accompanying the damage to the pain-sensitive structures of the spine. Hip flexion is normal in patients with lumbar spine disorders (spondylose), while lumbar spine flexion is limited and sometimes painful.
Side bending on the opposite side of the damaged vertebral structure can stretch the affected tissues, aggravating pain and causing movement to be limited. Hyperextension of the spine (with the patient in ventral decubit or in orthostatism) is limited when there is compression on the nerve root or damage to the spine.
Pain in hip disorders can mimic pain from lumbar spine diseases. The first limited movement is the internal rotation of the hip. The internal and external manual rotation of the hip with the flexed calf and thigh can cause pain, as can the percussion with the palm of the patient's heel.
Passive flexion of the thigh on the abdomen when the calf is in extension produces the stretching of the nerve roots L5 and S1 and the sciatic nerve (the sciatic nerve passes posteriorly on the hip). Passive dorsiflexia of the foot during the manoeuvre accentuates the stretching.
Normally it is possible at least 80 degrees without the appearance of pain, but the tendons of the muscles that fit into the thigh can limit movement. This sign of "stretched leg lift" (RPI) is positive if the maneuver causes pain.
The RPI sign can also be performed in the sitting position to determine whether the result is reproducible. The patient may describe pain in the lower back, buttocks, the back of the thigh or the lower lower limb.
The cross-RPI sign is positive when performing this manoeuvre on one leg causes pain in the contralateral leg or buttock. The damaged nerve or the affected nerve root are always in the painful part.
The inverted RPI sign is obtained by putting the patient in the ventral decubit and producing the passive extension of the thigh. This maneuver stretches the roots of L2 - L4 and the femoral nerve, which passes previously the hip. The inverted RPI test is positive if the maneuver causes pain to the patient.
The neurological examination also includes the search for muscle atony, atrophy, asymmetrical or age-inappropriate reflexes, decreased sensitivity to the lower limbs and signs of spinal cord damage. laboratory tests, X-rays and other methods of exploration have their usefulness in locating and identifying the causes of the diseases.
Let us now proceed to the presentation of the causes of disabling low back pain, starting with congenital abnormalities of the lumbar spine.
Spondylosis consists of a bone defect probably caused by a fracture in the interarticular portion of the vertebra of an abnormally congenital segment (a segment near the junction of the pedicle with the lamina). The defect (usually bilateral) is best visualized in oblique radiological projections or by computed tomography (CT) and occurs after a single injury, repeated minor trauma or increase.
The vertebral body, pedicles and upper articular facets may slide forward and leave behind the posterior elements, this last anomaly (spondylolistesis) being the most commonly symptomatic. The patient may experience irradiated lumbar pain in the lower limbs and sensitivity may occur near the segment that has "slipped" previously (most commonly L5 on S1 or, more rarely, L4 on L5). Deep palpation of the posterior elements of the segments above the spondylolistesis joint may reveal a "step" displacement. The torso may be shortened, and the abdomen may become prominent as a result of the extreme displacement of L5 on S1, in severe cases (cases where ponytail syndrome may occur).
It follows lumbar and cervical trauma, which is an important cause of acute pain (lumbar or cervical). These patients require careful initial evaluation. Thus, a patient who complains of back or neck pain and cannot move his legs may have a fractured spine.
In acute injuries which may involve fractures or dislocations of vertebral segments, consideration should be given to avoid causing other lesions of the spinal cord or nerve roots when examined. The neck or back, depending on the location of the trauma, should be immobilized until the X-ray is performed to rule out the presence of a fracture or dislocation.
Lombosacrate stretches and sprains do not clearly describe a specific anatomical lesion. The terms mechanically induced stretching, spraining or lumbar muscle spasm are used for minor, self-limiting injuries associated with heavy lifting, a fall or sudden fall occurring in car accidents. Patients with low back pain often take unusual positions due to paravertebral muscle spasm. Pain is usually localized in the lower back and there is no irradiation to the buttocks or lower limbs.
I will end today's fast with the vertebral fractures of the lumbar vertebral bodies that are the result of compression or flexion and consist of splitting or anterior compression. In more severe traumas, the patient may have a dislocation or cominutive fracture, involving not only the vertebral body, but also the posterior elements.
Vertebral fractures are caused by fall from height (where fracture of the interarticular portion of the L5 vertebra is frequent), sudden detection in car accidents or direct trauma. Neurological alterations are commonly associated with these traumas, and early treatment ensures better development.
When fractures are caused by minor trauma or in the absence of trauma, it is assumed that the bone is affected by a pathological process (usually osteoporosis of climacterium, type 1, or senescence, type 2), but the vertebral bodies may also be affected by systemic diseases such as osteomalacia, hyperparathyroidism, hyperthyroidism, multiple myeloma, carcinoma metastases or treatment with glucocorticoids.
Clinical context (trauma, patient age, steroid use), elements of physical examination (neurological deficiency, paravertebral muscle spasm) and radiological appearance will establish the diagnosis. Fractures of transverse apophyses are associated with severe lesions of the paravertebral muscle, mainly with reference to psoas, associated retroperitoneal hemorrhage may lead to decreased hematocrit and hypovolemic shock. Such lesions can cause profound sensitivity at the site of injury and limitation of all lumbar movements (CT and MRI establishing the diagnosis).
With
a smile we open the gates of heaven. And it doesn't cost
anything.
Dorin, Merticaru