SYMPTOMS Pain Sciatica Stiffness Deformity Numbness or paraesthesia Urinary symptoms Other

Signs with the patient standingLook

› Skin› Shape and posture

Feel› Tenderness

Move› Flexion / Extension› Rotation / Lateral flexion

Signs with patient lying face downwards› Bony outlines› Tenderness› Sensations and Power› Femoral stretch test

Signs with patient lying on his back› Straight leg raising test (sciatic stretch)› Neurological examination of lower limbs› Circulation in the limbs› Rectal examination

0 Total paralysis1 Barely detectable contracture2 Not enough to act against gravity3 Strong enough to act against

gravity4 Still stronger but less than

normal5 Full power

Plain x-rays› AP and lateral views› Oblique views › PA view of S.I. Joint

Computed tomography (with mylography)

MR imaging Radioisotope scanning Discography and facet joint

arthrography

Lifetime incidence ranges from 60 -80%Most cases resolve spontaneouslyD/Dx:

› Simple back pain (non specific low back pain)

› Nerve root pain› Possible serious spinal pathology

Presentation 20 - 50 years Lumbosacral, buttocks and thigh “Mechanical” pain Patient well Specialist referral not required

Vast majority improve within 2 months Symptomatic Rx with Aspirin/NSAIDs Bed rest should be limited to 1-2 days ? Corsets, TENS, Traction Exercise - Stretching & range of motion

active

Pain that persists after 3 months < 5% of patients with L.B.P develop

Ch.L.B.P Multiple factors

› Disc, facet joints, annulus fibrosis, ligaments Psychosocial factors Surgery is rarely helpful Functional restoration programme

Uncommon in very young and the very old

Nerve root pain follows the dermatome of the involved nerve

Pain is generally worse in the leg than in the back

Exacerbation of leg pain by straining, sneezing or coughing

Localised neurological signs

Large midline disc prolapse Compresses several nerve roots Sphincter disturbance Saddle anaesthesia Prompt surgical intervention

Conservative› Bed rest for 48-72 hours› NSAIDs› Epidural steroids› 85% relief rate

Surgical treatment› 10-15% of patients ultimately require surgery› More rapid relief but the ultimate end point is

the same regardless of treatment

Commonest cause of neurologic leg pain in older patients

Symptoms Neurogenic claudication - Vascular

claudication Treatment

Presentation under age 20 or onset over 55

Thoracic pain Past hx of carcinoma, steroids Unwell, weight loss Widespread neurology Structural deformity Abnormal blood parameters

Forward slippage of one vertebral body on another

Causes› Congenital› Isthmic› Traumatic› Pathologic› Degenerative

Treatment

Forward slippage of one vertebral body on another

Deformity may occur in either coronal or sagittal plane

Scoliosis - Lateral curvature of the spine› Structural› Nonstructural

Kyphosis - Sagittal plane deformity in the thoracic or thoracolumbar spine

Idiopathic Scoliosis80% of all scoliosis

Adolescent - age 10 or overJuvenile - age 4 to 9Infantile - age 3 or under

Structural scoliosis presenting at or about the onset of puberty and before maturity80 % of cases of idiopathic scoliosisMostly (90%) in girlsPredictors of progression

very young agemarked curvatureRisser sign

Treatment Prevent a mild deformity from becoming severeCorrect an existing deformity

Nonsurgical treatmentCurves between 20-40 when spinal growth is incompleteCurves >30 (Risser 2 or less) even if no progression

Surgical treatmentCurves >40 in skeletally immatureUnbalanced curves between 20 - 40 in skeletally immatureCurves >50

Due to congenital anomalous vertebral development

HemivertebraeWedged vertebraeFused vertebraeAbsent or fused ribs

TreatmentEarly fusion in progressive curves

CausesPoliomyelitisCerebral palsySyringomyeliaFriedrich’s ataxiaMuscular dystrophies

Typical paralytic curve is long, convex towards the side with weaker muscles

TreatmentMild curves No treatmentModerate curves with spinal stability

As for idiopathic scoliosisSevere curves Fitting a suitable sitting support

Surgical stabilization of the entire spinal segment

Postural (Round back) Compensatory Structural

CausesPostural kyphosis Postradiation

kyphosisScheuermann’s disease Metabolic

disordersMyelomeningocele Skeletal dysplasiasTraumatic kyphosis Tumourous

conditionsPostsurgical Infections

Excessive thoracic kyphosis (Cobb angle >45° with wedging of 5° or more) of at least 3 adjacent apical vertebrae and vertebral end plate irregularities

Aetiology unknownIncidence 1% of general

population with slight female dominance

TreatmentOrthotic treatment

Skeletally immature - Milwaukee brace (poor compliance)

Surgical (rare)Severe deformity in skeletally matureSevere deformity and neurologic

signs