Headache, Back and Neck Pain Flashcards
HEADACHE
• Most common reasons to seek medical attention
• Globally responsible for more disability than other
neurologic problem
• Can be primary or secondary
PRIMARY - headache
o Caused by overactivity of or problems with
pain-sensitive structures in your head
(Mayo Clinic)
o Isn’t a symptom of any underlying disease
o often results in considerable disability and
a decrease in patient’s quality of life
SECONDARY - headaches
o a symptom of a disease that can activate the pain-sensitive nerves of the head o mild secondary headaches are seen in association with upper respiratory tract infections
Stimulus (peripheral nociceptors)
Tissue injury, visceral distention, etc.
o Damaged or inappropriate activation of
PNS or CNS
Cranial structures that are pain-producing:
o Scalp o Middle meningeal artery o Dural sinuses o Falx cerebri o Proximal segments of large pial arteries
KEY STRUCTURES INVOLVED IN PRIMARY HEADACHE
• Large intracranial vessels and dura mater
• Peripheral terminals of the trigeminal nerve that
innervate these structures
• Caudal portion of the trigeminal nucleus, which
extends into the dorsal horns of the upper cervical
spinal cord and receives input from the 1st and
2nd cervical nerve roots (trigeminocervical
complex)
• Rostral pain processing region
• Pain modulatory system in the brain that receives
input from trigeminal nociceptor
ACUTE NEW ONSET HEADACHE
• Potentially serious cause is considerably greater
than recurrent headache
• Signs and symptoms pertain to potentially serious
etiology, wherein there is presence of worrisome
symptoms (being sudden & severe)
• Need prompt evaluation and management
• Complete neurologic examination (1st step)
• Dx/Labs: CT, MRI, lumbar puncture (LP)
• Serious causes include:
o Meningitis
o Subarachnoid hemorrhage
o Epidural or subdural hematoma
o Glaucoma
o Tumor
o Purulent sinusitis
FINDINGS OF POTENTIALLY SERIOUS OR WORRISOME
HEADACHES
• Worst headache ever • First severe headache • Subacute worsening over days or weeks • Abnormal neurologic examination • Fever or unexplained systemic signs • Vomiting preceding headache • Pain induced by bending, lifting, coughing • Pain that awakens patients or is present upon awakening • Known systemic illness • Onset after age 55 • Pain associated with local tenderness
GENERAL EVALUATION OF ACUTE HEADACHE
• Investigation of cardiovascular and renal status
o Blood pressure monitoring and urine
examination
• Fundoscopy (presence of papilledema suggests
increased intracranial pressure), intraocular
pressure measurement, and refraction
• Cranial arteries by palpation
• Cervical spine by the effect of passive movement of
the head and by imaging
• Psychological state (comorbidity rather than cause)
o There is a relationship between head pain
and depression.
SECONDARY HEADACHE
63% - systemic infection (most common) o 4% - head injury o 1% - vascular disorders o <1% - subarachnoid hemorrhage o 0.1% - brain tumor
MENINGITIS
• Acute (<5 min.), severe (>5 min.) headache
• Fever and stiff neck (suggestive symptoms)
• Accentuation of pain with eye movement
• Pounding headache, photophobia, nausea and
vomiting (easily mistaken for migrain)
• Dx test: LP is mandatory
• Treatment: antibiotics
INTRACRANIAL HEMORRHAGE
• Acute and severe
• Stiff neck WITHOUT fever
• Secondary to ruptured aneurysm, AV
malformations, or intraparenchymal hemorrhage
• Dx: CT scan and LP may be used for diagnosis
o head CT is normal, if hemorrhage is small
or below the foramen magnum, you can
do a lumbar tap
LUMBAR PUNCTURE CONTRAINDICATIONS
Increased intracranial pressure is a relative LP
contraindication
• Absolute contraindications
o The presence of infected skin over the needle
entry site and the presence of unequal pressures
between the supratentorial and infratentorial
compartments
Characteristic findings on CT of
the brain of LP
• Midline shift • Loss of suprachiasmatic and basilar cisterns • Posterior fossa mass • Loss of superior cerebellar cistern • Loss of quadrigeminal plate cistern
BRAIN TUMOR
• Chief complaint in 30% of patients: HEADACHE
• Intermittent, deep, dull aching pain of moderate
intensity
• Aggravated by exertion or change in position maybe
associated with nausea/vomiting (more in migraine)
• In 10% of cases, headache disturbs sleep
• Vomiting precedes headache by weeks (posterior
fossa brain tumors)
• History of amenorrhea or galactorrhea (prolactinsecreting pituitary adenoma or the polycystic ovary
syndrome)
• Headache arising from a known malignancy (cerebral
metastases or carcinomatous meningitis, or both)
• HA appearing abruptly after bending, lifting or
coughing may indicate presence of posterior fossa
mass, a Chiari malformation, or low CSF volume
TEMPORAL ARTERITIS (Giant Cell)
• aka Horton’s or giant cell arteritis; Inflammatory
disorder of arteries; Extracranial carotid circulation
• Commonly seen in females age 50 and older
o average age of onset is 70 years, and
women account for 65% of cases
• If left untreated, may lead to blindness due to the
development of ischemic optic neuropathy
• Presents with headache, PMR (polymyalgia
rheumatica), jaw claudication, fever, weight loss
and tenderness with scalp
TEMPORAL ARTERITIS (Giant Cell) headache
Head pain may be unilateral or bilateral, temporally
located in 50% of cases. Associated with malaise
and muscle aches
• Pain usually appears gradually over few hours
before peak, occasionally explosive and seldom
throbbing
• Almost invariably described as dull and boring and
usually worse at night and often aggravated by
exposure to cold
• Head pain is superficial, external to the skull, rather
than originating deep within the cranium
• Marked degree of scalp tenderness
o brushing of hair or resting the head on a
pillow may be impossible
• Reddened, tender nodules or red streaking of the
skin overlying the temporal arteries, less common
tenderness on occipital arteries
TEMPORAL ARTERITIS (Giant Cell) headache Diagnosis
Dx: Elevated ESR
• Gold standard Tx: temporal artery biopsy
• Mx: steroids (Prednisone 80mg daily fir the first 4-6
weeks); initiated when clinical suspicion is high
GLAUCOMA
Usually secondary to acute angular closure glaucoma (a medical emergency) • Prostating headache • Nausea and vomiting • Severe eye pain • Red, fixed, moderately dilated pupil • Tx: medication and surgery
PRIMARY HEADACHE SYNDROME
• Headaches and associated symptoms occur in the
absence of an exogenous cause
PHS common causes
o 69% - Tension type o 16% - Migraine o 2% - Idiopathic stabbing o 1% - Cluster (trigeminal autonomic cephalgias) o 1% - Exertional
MIGRAINE
• 2nd most common cause of headache
• Benign and recurring syndrome of headache
associated with other symptoms of neurologic
dysfunction
Episodic headache
associated with sensitivity to
light, sound, or movement
• Usually accompanied with nausea and vomiting
• Most common headache-related disability in the
world, afflicts 15% of women and 6% of men over a
year
• Have triggers prior to the onset of an attack
• Stimulus could be environmental or sensory
• Sensitivity is amplified in female during menses
Triggers for Migrane
o Glare, bright lights, sounds, or other afferent stimulation o Hunger o Excess stress o Physical exertion o Stormy weather or barometric pressure changes o Hormonal fluctuations during menses o Lack of or excess sleep o Alcohol or other chemical stimulation
PATHOGENESIS of Migrane
o Activation of vasoactive neuropeptides § Calcitonin gene related peptide o 5-hydroxytryptamine (5-HT) or serotonin § Methysergide can stimulate 5- HT1B/1D o Dopamine o Dopamine receptor hypersensitivity § as demonstrated by the induction of yawning, nausea, vomiting, hypotension, and other symptoms of a migraine attack by dopaminergic agonists at doses that do not affect non-migraineurs
Familial Hemiplegic Migraine (FHM)
Mutation of voltage-gated calcium channel CACNA1A gene (FHM1) o Na+K+ATPase ATP1A2 gene (FHM2) - 20% of FHM cases o Neuronal voltage-gated sodium channel SCN1A
Associated symptoms of migraine
o Nausea o Photophobia o Lightheadedness o Scalp tenderness o Vomiting o Visual disturbance § Photophobia § Fortification spectra o Paresthesia o Vertigo o Alteration of consciousness § Syncope § Seizure § Confusional state o Diarrhea
Diagnostic Criteria for Migraine
o Repeated attack of headache lasting 4-72h in patient with normal PE, no other reasonable cause for the headache and o At least 2 of the following § Unilateral pain § Throbbing pain § Aggravation by movement § Moderate or severe intensity o Plus at least 1 of the following features § Nausea/vomiting § Photophobia/phonophobia o A high index of suspicion is required to diagnose migraine § The migraine aura, consisting of visual disturbances with flashing lights or zigzag lines moving across the visual field or of other neurologic symptoms (20-25% of patients) § Headache diary • Helpful in making the diagnosis • Helpful in assessing disability and the frequency of treatment for acute attacks
Migraine must be differentiated from
tension-type headache
§ Migraine headache is headache
with associated features
§ Whereas tension-type headache
that is featureless
One third of patient referred for vertigo or
dizziness have a
primary diagnosis of
migraine known as acephalgic migraine
wherein there is typical aura but without
headache.
non-pharma Management/ Treatment of migrane
§ Avoidance of triggers § Regulated lifestyle • Healthy diet • Exercise • Regular sleep patterns • Avoid excess caffeine and alcohol • Avoid acute changes in stress levels
PHARMACOLOGICAL migrane
§ NSAID’s § 5-HT1 agonist § Ergotamine and dihydroxyergotamine • These are non-selective receptor agonist • Comes in oral, nasal, and IV preparation • Can induce nausea • Dosage is 2 mg § Triptans (e.g. sumatriptan, zolmitriptan, almotriptan etc) • Selective 5-HT1B/1D agonist • Not effective in migraine with aura • Contraindicate in patient with cardiovascular and cerebrovascular disease § Dopamine antagonist • Oral metoclopramide 10mg • Parenteral (e.g. chlorpromazine, prchlorperazine, and metoclopramide) • It enhances gastric absorption • It decreases nausea vomiting • Restores normal gastric motility § Others • Narcotics • B-blockers (propranolol and timolol) • Topiramate • Sodium valproate or gabapentin • Methysergide o Migraine can be modified and controlled but cannot be eradicated o Migraine is commonly not associated with serious or life-threatening illness
Preventive Treatments in Migraine
The probability of success with any one of the
antimigraine drugs is only 50-75%
§ Many patients are managed adequately with
low-dose amitriptyline, propranolol, topiramate,
gabapentin, or valproate but if it fails or lead to
unacceptable side effects, second-line agents
such as methysergide or phenelzine can be
used.
§ Once effective stabilization is achieved, the
drug is continued for 5-6 months and then
slowly tapered to assess the continued need
TENSION TYPE HEADACHE
• Chronic head type pain syndrome
• Bilateral tight band-like discomfort
• Episodic or chronic (>15 days per month)
• No accompanying symptoms
• Management is usually by acetaminophen,
analgesics, or NSAIDs
• Amitriptyline for chronic TTH
TRIGEMINAL AUTONOMIC CEPHALAGIAS
• Include cluster headache, paroxysmal
hemicrania, and SUNCT (short lasting unicranial
neuralgiform headache attacks with conjunctival
injection & tearing)
• Relatively, this has short attacks of head pain
• Associated with cranial autonomic symptoms
such as lacrimation, conjunctival injection, or
nasal congestion
• Usually the pain is severe and may recur more
than once a day
• It may be a manifestation of a pituitary tumor related headache
CLUSTER HEADACHE
• It is a rare form 0.1% of cases
• Deep pain, usually retro-orbital, excruciating in
intensity, non-fluctuating and explosive in quality
• Periodicity: 1-2 bouts for a period of 8-10 weeks
in a year (core feature) recurring at about the
same hour each day
• Patients are generally well between episodes of
attacks
• Male affected 3x more than women
• Nocturnal in onset 50% of the time
Associated symptoms of Cluster headache
o Conjunctival injection or lacrimation
o Rhinorrhea
o Ptosis
o Unilateral photophobia phonophobia
Acute attacks
§ O2 inhalation (100% at 10- 12L/min for 15-20 mins.) § Sumatriptan SQ (subcutaneously) or nasal spray (oral not effective for acute attacks) § Zolmitriptan nasal spray
Preventive
§ Corticosteroids § Ergotamine § Lithium § Verapamil (up to 960mg with caution) o Neurostimulation in the region of the posterior hypothalamic gray matter (when medical therapy fails) § The risk of benefit ratio make it inappropriate
PAROXYSMAL HEMICRANIA
• Unilateral, severe short-lasting episodes (2 to 45 mins)
• Frequent attacks (>5x a day)
• Rapid course (<72 h)
• May be retro-orbital, with marked autonomic
features ipsilateral to the pain
• Equal distribution between male and female
• Excellent responds to indomethacin (25-75mg tid)
Secondary PH
Lesions in the sella turcica § Av malformations § Cavernous sinus meningioma § Epirermoid tumors o Require high doses of indomethacin (indomethacin reduce CSF) o Bilateral PH should suspect a raised CSF pressure o MRI is indicated to exclude a pituitary lesion
SUNCT/SUNA
• Rare primary headache syndromes
• Severe unilateral orbital or temporal pain,
described as stabbing or throbbing in quality
Diagnostics of SUNA
At least 20 attacks per day o Duration of 5 to 240 seconds per episode o Ipsilateral conjunctival injection or lacrimation should be present § If absent, it is known as SUNA (short acting unilateral neuralgiform headache attacks with cranial autonomic symptoms)
Pain
o Single stab
o Group of stabs
o Prolonged attack with no refractory or
pain free period (saw-tooth phenomenon)
o Characteristics that leads to a suspected
diagnosis of are the cutaneous triggers of
attacks, a lack of refractory period to
triggering between attacks and nonresponsive to indomethacin
Secondary (symptomatic) SUNCT
o Seen with posterior fossa or pituitary
lesions
Treatmen of SUNCT
Acute pain § Intravenous lidocaine • This can arrest symptoms but not useful because of short duration § Preventive therapy • Lamotrigine 200-400 mg/d • Topiramate and gabapentin • Greater occipital nerve injection • Occipital nerve stimulation
CHRONIC DAILY HEADACHE
Medication Overuse Headache
o Overuse of analgesic medications
o Increased frequency of refractory daily or
near daily headache
o Improvement of cessation of analgesic
§ Specially those who take
codeine and barbiturates
o Primary problem still present (residual
symptoms)
• Headache lasting for >15days/month
• Encompasses a number of different headache
syndromes (chronic TTH, headache secondary to
trauma, inflammation, infection, medication
overuse, and other causes)
• May be primary or secondary
Management of CDH
o Tapering doses of analgesics o Use of NSAIDs o Use of preventive medications (Preventives generally do not work in the presence of analgesic overuse) § most common cause of unresponsiveness to treatments is the use of a preventive when analgesics continue to be used regularly
Management for in-patients
Rapid removal of analgesics o Anti-emetics, fluids o Clonidine (withdrawal from opiates) o IV aspirin, dihydroergotamine o 5HT3 antagonist can be used to prevent
Management of CDH
o Tricyclics o Anticonvulsants (topiramate, gabapentin, valproate) o Flunarizine, methysergide, phenelzine o Occipital nerve stimulation
Medication Overuse Headache
o Overuse of analgesic medications o Increased frequency of refractory headache o Improvement noted with cessation of analgesic Specially those who take codeine and barbiturates o Primary problem still present (residual symptoms)
NEW DAILY PERSISTENT HEADACHE
- New clinical syndrome
- Daily headache
- Recent onset
- Maybe abrupt or gradual up to 3 days
- Can be primary or secondary
PRIMARY
- Migrainous Type
- Featureless (tension type)
- Unilateral headache
- Nausea, photophobia, phonophobia
- Treatment similar to migraine
- 86% free of headaches in 24 months
- Refractory to treatment
SECONDARY
- Subarachnoid hemorrhage
- Low CSF volume headache
- Raised CSF pressure headache
- Post traumatic headache
- Chronic meningitis
LOW CSF VOLUME HEADACHE
• Headache is positional • Starts when patient is on an upright position, improves when patient reclines • Usually occipito-frontal • Can be dull or throbbing • Can be due to a previous LP, valsalva maneuver, epidural injection, lifting, popping the eustachian tube, or multiple orgasms • Symptoms are due to low CSF volume o MRI with gadolinium is the imaging of choice • Identifying the source of leak o CT myelogram o Spiral MRI o 111In-DTPA CSF studies
Management of low CSF
o Bed rest o Intravenous caffeine o Abdominal binder o Autologous blood patch o Oral theophylline (alternative for intractable pain, however, its effect is less rapid)
RAISED CSF VOLUME HEADACHE
• Daily headache that presents on waking up and
improves gradually
• Worsens with recumbency
• Visual obscuration is present
DDX for Raised CSF
Obstructive Sleep Apnea
o Hypertension
Diagnosis
o MRI
o Lumbar Puncture
Management of High CSF
o Acetazolamide o Topiramate o Weight loss o Neuronal membrane stabilization o Shunting
HEMICRANIA CONTINUA
• Cause: unknown
• Age 11-58 years
• More common in female
• Moderate and continuous unilateral pain with
fluctuations of severe pain
• Ipsilateral lacrimation, conjunctival injection and
photophobia
• Indomethacin is both diagnostic and therapeutic
• Occipital nerve stimulation
PRIMARY STABBING HEADACHE
- Headache confined to the head or face
- Irregular occurrence lasting hours to days
- No associated cranial autonomic features
- No cutaneous triggers
- Associated with other primary headaches
- Responds to indomethacin
PRIMARY COUGH HEADACHE
• Precipitated by coughing • May be benign • Other etiologies o Chiari malformation o Cerebral aneurysms o Carotid stenosis o Vertebrobasilar disease • Tx: indomethacin
PRIMARY EXERTIONAL HEADACHE
• Features similar to cough and migraine headache
• Pulsatile or throbbing lasting for 5 mins to 24 hrs
• Referred pain
• Angina
• Pheochromocytoma, Intracranial lesions and
stenosis of the carotid arteries are other possible
etiologies
• Management:
o Indomethacin
o Ergotamine
o DHE; Methysergide
PRIMARY SEX HEADACHE
• Precipitated by sexual excitement • Three (3) types: o Dull ache in head and neck o Explosive headache at orgasm o Postural headache after coitus • Common in males • Not always benign because at least 5 – 12% of cases are usually secondary to sexual intercourse • Management: o Propranolol o Diltiazem o Ergotamine o Assurance
PRIMARY THUNDERCLAP HEADACHE
Sudden onset of severe headache without complication • Etiologies: o Intracranial aneurysms, cerviccocephalic arterial dissection, cerebral venous thrombosis o Secondary to ingestion of sympathomimetic drugs, tyramine containing foods or pheochromocytoma • Management: o LP, MRI o Nimodipine may be helpful § although by definition the vasoconstriction of primary thunderclap headache resolves spontaneously
HYPNIC HEADACHE
Onset – few hours after sleep • Generalized, severe or unilateral throbbing o Lasting from 15 to 30 mins. • More common in Females • More common in age > 60 • Probably secondary to poorly controlled hypertension • Management o Coffee o Lithium carbonate o Verapamil o Methysergide
BACK AND NECK PAIN
• The importance of back and neck pain in our
society is understood by the following:
o The cost of back pain in the US Exceed 1
billion annually.
o Back symptoms are the most common
cause of disability in those less than 45
years old.
o Low back pain is the most common
reason for visiting a physician In the
United States.
o 70% of people will have back pain at some
point in their life.
• Back pain and neck pain are usually secondary to
radiculopathy or nerve root injury
Pain-sensitive structures:
o Periosteum of the vertebra o Dura o Facet joint o Annulus fibrosus o Epidural veins o Posterior longitudinal ligament
LOCAL PAIN
caused by stretching of pain-sensitive structures that compress or irritate sensory nerve endings
Each site of the pain is near the affected
part of the back.
PAIN REFERED TO THE BACK
Arises from abdominal or pelvic viscera.
o Usually described as primarily abdominal
or pelvic, but is accompanied by back pain
and usually unaffected by posture.
o Back pain only.
PAIN OF SPINE ORIGIN
In the back or referred to the buttocks or legs. o Diseases affecting the upper lumbar spine tend to refer pain to the lumbar region, groin or anterior thighs. o Diseases affecting the lower lumbar spine tend to produce pain referred to the buttocks, posterior thighs, or rarely the calves or the feet. It can explain pain syndromes that cross multiple dermatomes without evidence of nerve or nerve root injury.
RADICULAR PAIN-
sharp and radiate from the
low back to a leg within the territory of a nerve
root. Coughing,sneezing, or voluntary contraction
of abdominal muscles may elicit radiating pain.
Pain may increase in postures that stretch the
nerve root.
PAIN ASSOCIATED WITH MUSCLE SPASM
Pain associated with vasospasm, are obscured In
origin, commonly associated with many spine
disorders, may be accompanied by an abnormal
posture, tense paraspinal muscle, and dull or achy
pain in the paraspinal region
SPODYLOLYSIS
• Congenital cause
• Bony defect in the pars interarticularis of the
vertebral arch, usually occur at L5 vertebrae
• Stress microfracture In congenital abnormal
segment
• Dx: Oblique projection in the x-rays, CT scan,
orSPECT (Single photon emission computerized
tomography)
• Single most common cause of back pain in
adolescents
• Usually activity related (Sports)
SPONDYLOLISTHESIS
• Anterior slippage of the vertebral body, peduncles,
and superior articular facets
• May be due to congenital defects, infection,
tumor,trauma, osteoporosis, prior surgery, and or
degenerative spine disease
• Asymptomatic or cause low back pain and
hamstring tightness, nerve root injury (L5) or spinal
stenosis,deformities, cauda equina syndrome
• Atherolisthesis – spine condition wherein upper
vertebral body slips forward unto vertebra below
• Retrolisthesis – posterior displacement of one
vertebral body with respect to the subjacent
vertebra;backward slippage
• Diagnostic method would be lumbar x-ray of
the neck and lumbar - in flexion and extension
will reveal the movement at the abnormal spinal
segment
• Management: Surgery indicated if:
o Symptoms > 1 year w/ no improvement
o Progressive neurologic deficit
o Abnormal gait
o Postural deformities
o Slippage >50%
o Scoliosis
• Symptoms:
o Back pain
o limitation of motion
o abnormal posture
o radicular pain
o sensory loss or absent DTR
o unilateral but maybe bilateral for large
herniations
SPINA BIFIDA OCCULTA
• Failure to close of one or more vertebral arches
posteriorly
• Meninges and spinal cord are normal
• Worst cases are asymptomatic
• Incidental finding for an evaluation of back pain
• Neuroimaging studies reveal a low-lying conus
and a short and thickened filum terminale
TETHERED CORD SYNDROME
• Progressive cauda equina disorder
• Young adult complaining of perianal or perineal
pain
• Neuroimaging present with a low lying conus and
a short and thickened filum terminale
TRAUMA
Can cause spinal fracture, compression fracture,
dislocation
• Traumatic Vertebral Fracture
o Fracture-dislocation (burst fracture)
o Caused by falls, vehicular accidents or
direct injury
o Neurologic impairment is common
o Early surgical intervention is indicated
SPRAIN AND STRAIN
• Minor, self-limited injuries
• Associated with lifting heavy objects, fall or sudden
deceleration
• Pain is confined to the lower back and no radiation
to the legs and buttocks
LUMBAR DISK DISEASE
• Common cause of chronic or recurrent low back and neck pain • Most likely to involve L4-L5 or L5-S1 levels but upper lumbar levels can also be involved • Cause is unknown, more common in overweight individuals • Pain is at the low back with referral pain to the leg, buttock or hip • Symptoms o Back pain o Limitation of motion o Abnormal posture o Radicular pain o Sensory loss or absent DTR o Unilateral but may be bilateral for large herniations • Differential diagnosis o Epidural abscess o Hematoma; Tumor • Diagnostics o CT myelogram, MRI • Indication for surgery o Progressive motor weakness o Bowel or bladder disturbance o Incapacitating nerve root pain o Recurrent incapacitating pain • Indicated Procedure: Partial hemilaminectomy with excision of the prolapsed disk
CAUDA EQUINA SYNDROME
• Injury of multiple spinal nerve roots within the
spinal cord
• Low back pain, weakness, areflexia,
saddleanesthesia (loss of sensation in the area of
the buttocks & perineum), and loss of bladder
function
• Due to ruptured lumbosacral intervertebral
disk,lumbosacral spine fracture, hematoma
compression tumor or other spinal lesion
• Surgical decompression
LUMBAR SPINAL STENOSIS
• Degenerative condition
• Narrowed lumbar spinal canal
• Frequently asymptomatic
• Neurogenic claudication consisting of back,
buttock & leg pain, induced by walking or standing,
and relieved by sitting
• Congenital forms: characterized by short thick
pedicles that produce a spinal canal and lateral
recess stenosis.
• Acquired forms include: degenerative disk
disease,trauma, surgery, metabolic diseases and
Paget’s Disease
• Dx: MRI is the best imaging modality
• Management:
o NSAIDs
o Exercise program
o Surgery
FACET JOINT HYPERTROPHY
Usually accompanied with unilateral radicular
symptoms and signs due to bony compression
• Hypertrophic superior or inferior facets can be
seen by x-ray, CT scan or MRI
• Surgical foraminotomy produces relie
SPONDYLOSIS / CERVICAL OSTEOARTHRITIS
• Osteoarthritic spine disease involves the cervical
and lumbosacral spine
• Back pain increased with movement and
associated with stiffness
• Radiculopathy occurs when hypertrophied facets
and osteophytes compress nerve roots in the
lateral recess or in the intervertebral foramen
NEOPLASMS
• Back pain (most common neurologic symptom in
patient with systemic CA -> presenting symptom in
20%)
• Usually secondary to vertebral metastasis
o Cancers that may cause vertebral
metastasis:
§ Breast, lung, prostate, thyroid,
kidney, GIT, multiple myeloma,
NHL, and HL
• Pain is usually constant, dull, unrelieved by rest,
worse at night
• DX: MRI, CT myelogram
INFECTIONS/ INFLAMMATION
Usually secondary to vertebral osteomyelitis
• Cause can be bacterial or mycobacterial
• Back pain
o Unrelieved by rest and exacerbated by
motion and tenderness on the involved
spine segments with elevated ESR
• Radiographs: narrowed disc spaces with erosion
of the adjacent vertebra
• Dx: CT or MRI
OSTEOPOROSIS
• It can cause compression fracture and pain
• Most commonly seen in post-menopausal or senile
• Most common manifestation is localized back pain
or radicular pain exacerbated by movement
• Tx: Antiresorptive drugs
o Biphosphonates, estrogen, tamoxifen
• Surgery: percutaneous vertebroplasty and
kyphoplasty
REFERRED PAIN FOM VISCERAL DISEASE
• Abdominal diseases o Peptic ulcers o Biliary diseases o Pancreatitis o Iliopsoas mass o Abdominal aortic aneurysm o Inflammatory bowel disease • Gynecologic disease o Endometritis and uterine cancers o Pelvic tumors o Prostate CA or prostatitis
PAIN IN THE NECK AND SHOULDERS
TRAUMA
• It can cause cervical spine fracture, subluxation
• It is secondary to accidents, falls and violent crimes
• Tx: Immediate immobilization
• Diagnostics:
o CT scan (detection of acute fracture)
o MRI, angiography (vertebral arteries)
WHIPLASH INJURY
- Due to rapid flexion and extension of the neck
- Caused by motor vehicle accidents
- Caused by cervical musculoligamental injury
ANKYLOSING SPONDYLITIS
• Insidious onset of low back and buttock pain
• Common in male predilection less than 40 years
• Features include:
o Warning back stiffness, nocturnal pain,
pain unrelieved by rest
• Diagnostics: associated with elevated ESR, HLAB27
• Radiologic findings: bamboo spine, sacroiliitis, and
periarticular destructive changes
• Management:
o Exercise
o NSAIDs
o Anti-TNF
CERVICAL DISC DISEASE
• Herniation of a lower cervical disk is a common
cause of neck, shoulder, arm, or hand pain or
tingling
• Commonly associated with neck pain, stiffness,
pain limited range of motion
• Commonly affected are C7 and C6
• Positive Spurling sign
o If you do extension and lateral rotation of
the neck it will reproduce radicular
symptoms
CERVICAL SPONDYLOSIS
• Osteoarthritis of the cervical spine • Neck pain radiating to the back of the head,
shoulder or arms
• Source of headache in the posterior occipital
region
Positive Lhermitte syndrome
Sudden sensation resembling an electric shock that passes down the back of the neck and into the spine, and may then radiate out into your arms and legs when bending the head forward.
Other causes
Rheumatoid arthritis • Ankylosing spondylitis o C1-C2 subluxation • Thoracic outlet obstruction o Comprises the first rib, subclavian artery
and vein, brachial plexus, clavicle, and the
lung apex
True neurogenic TOS (Thoracic Outlet
Syndrome)
o Compression of the lower trunk of the ventral rami or brachial plexus of the C8 OR T1 o Uncommon disorder o Pain is mild or absent o Signs include: § Weakness and wasting of the intrinsic hand muscles and diminished sensation at the palmar aspect of the fifth digit o Treatment: surgical resection
Arterial TOS
o Compression of the subclavian artery by a
cervical rib
o Poststenotic dilatation and thrombus
formation
o BP is reduced in the affected limb o Signs of emboli may be present o No neurologic signs o Ultrasound confirms diagnosis o Tx: Thrombolysis or anticoagulant or
surgical resection
Venous TOS
o Subclavian vein thrombosis o Swelling of the arm and pain o Dx: Venography
Disputed TOS
o Unclear cause o Lack sensitive and specific findings o Multidisciplinary pain management
(usually unsuccessful)
