This document discusses age-related health problems like low back pain and osteoarthritis that are on the rise due to an aging global population living longer lives. It focuses on low back pain, providing details on epidemiology, risk factors, anatomy, clinical evaluation through history, physical exam, imaging tests and diagnostic considerations. Case examples are presented to illustrate lumbar spondylosis, sciatica due to disc herniation, and degenerative spondylolisthesis diagnoses. The summary highlights the rising prevalence of age-related health issues, evaluation of low back pain, and examples of lumbar spine diagnoses.
7. Epidemiology
â˘âŻ 65-80%: during entire lifetime
â˘âŻ Most prevalent chronic pain
syndrome
â˘âŻ Leading cause of limitation: <45 y/
o
â˘âŻ 2nd most frequent reason for MD
visit
â˘âŻ 3rd most common surgical
indication
8. Epidemiology
â˘âŻ Pain and function improve
substantially within 1 month
â˘âŻ >90% are better at 8 weeks (but
are susceptible to future brief
relapses)
â˘âŻ 7-10% chronic LBP
13. HISTORY
â˘âŻ Identify those with neural compression or
underlying systemic disease (<5%)
â˘âŻ Look for âRed Flagsâ
â˘âŻ Look for social or psychologic distress
ââŻJob dissatisfaction
ââŻPursuit of disability compensation
ââŻDepression
15. HISTORY
MECHANICAL
 LBP
 INFLAMMATORY
 LBP
Â
>95%
 Less
 common
Â
Usually
 seen
 in
 elderly
 people,
Â
postmenopausal
 women
Â
Seen
 in
 men
 <40y/o
 (sPA)
Â
Typically
 increases
 with
 physical
 ac6vity
Â
and
 upright
 posture
Â
Marked
 morning
 s6ďŹness
 >30mins
Â
Worse
 during
 2nd
 half
 of
 the
 night
Â
Alterna6ng
 bu"ock
 pain
Â
Relieved
 by
 rest
 and
 recumbency
 Improves
 with
 exercise
 but
 not
 rest
Â
Most
 common
 cause
 is
 degenera6ve
Â
change
 in
 the
 LS
Â
Spondyloarthri6des
Â
16. PHYSICAL
EXAMINATION
INSPECTION
 Scoliosis;
 Spina
 biďŹda
 occulta;
 muscle
 atrophy
Â
PALPATION
 Paravertebral
 muscle
 spasm
 (loss
 of
 normal
 lumbar
 lordosis);
Â
Fibromyalgia
 (widespread
 tender
 points)
Â
Spondylolisthesis
 (palpable
 step-ÂâoďŹ
 b/n
 adjacent
 spinous
 processes)
Â
ROM:
Â
-ÂâLimited
 spinal
 mo6on
 (ďŹexion,
 extension,
 lateral
 bending,
 rota6on):
Â
more
 useful
 for
 Tx
 monitoring
Â
-ÂâChest
 expansion
 <2.5cm
 (AS)
Â
-ÂâTenderness
 over
 greater
 trochanter
 of
 femur
 (trochanteric
 bursi6s)
Â
âDecreased
 ROM
 hip
 (hip
 OA)
Â
PERRCUSSION
 Point
 tenderness
 over
 spine
 (Sensi6ve
 but
 not
 speciďŹc
 for
 Vertebral
Â
OM
Â
AUSCULTATION
 Bruits
 (AAA)
Â
18. PHYSICAL
EXAMINATION
â˘âŻ Litigation or with psychologic distress
â˘âŻ Exaggerated symptoms
â˘âŻ Nonorganic signs
â˘âŻ Most reproducible tests*:
ââŻSuperficial tenderness
ââŻOverreaction during examination
ââŻDiscrepancy in the SLR test done in seated and supine
positions
*Waddell
 G,
 McCullogh
 JA,
 Kummel
 E,
 Venner
 RM:
 Non-Ââorganic
Â
Â
physical
 signs
 in
 low
 back
 pain,
 Spine
 5:117â125,
 1980.
Â
Â
20. IMAGING
Imaging is NOT required UNLESS significant symptoms
PERSIST BEYOND 6-8 weeks
Dixit RK: Approach to the patient with low back pain. In Imboden J, Hellmann D, Stone J, editors. Current diagnosis and
treatment in rheumatology, ed 2, New York, 2007, McGraw-Hill
NEITHER MRI NOR PLAIN RADIOGRAPHS taken EARLY
in the course of LBP evaluation improves clinical
outcome, predicts recovery course, or reduces overall
cost of care
Chou R, Fu R, Carrino JA, Deyo RA: Imaging strategies for low back pain: systematic review and meta-analysis, Lancet
373:463â472, 2009.
21. IMAGING
â˘âŻ Weak association between imaging abnormalities
and symptoms
â˘âŻ Up to 85%: cannot make precise pathoanatomic Dx
with identification of the pain generator
â˘âŻ Reinforce suspicion of serious disease, magnify the
importance of non-specific findings, and label
patients with spurious diagnosis
Deyo
 RA,
 Weinstein
 DO:
 Low
 back
 pain,
 N
 Engl
 J
 Med
 344(5):363â
 370,
 2001.
Â
24. IMAGING: MRI
â˘âŻ Best initial test for LBP patients who require advanced
imaging
â˘âŻ Preferred for detection of spinal infection, cancers,
herniated disks, and spinal stenosis
â˘âŻ INDICATIONS:
â⯠Suspicion of systemic disease
â⯠Preop evaluation of surgical candidates on clinical grounds
â⯠Pxs with radiculopathy or spinal stenosis who are candidates
for epidural steroids
Jarvik
 JG,
 Deyo
 RA:
 Diagnos6c
 evalua6on
 of
 low
 back
 pain
 with
Â
emphasis
 on
 imaging,
 Ann
 Intern
 Med
 137:586â597,
 2002
Â
Chou
 R,
 Qaseem
 A,
 Snow
 V,
 et
 al:
 Diagnosis
 and
 treatment
 of
 low
Â
back
 pain:
 a
 joint
 clinical
 prac6ce
 guideline
 from
 the
 American
 College
Â
of
 Physicians
 and
 the
 American
 Pain
 Society,
 Ann
 Intern
 Med
 147(7):
478â491,
 2007
Â
25.
26. IMAGING: CT Scan
â˘âŻ Superior to MRI in evaluation of bone anatomy
â˘âŻ Safe in patients with ferromagnetic implants
â˘âŻ CT myelography is preferred in patients with
surgically placed spinal hardware
28. IMAGING: Bone Scan
â˘âŻ Infection, bony
metastases,
Occult fractures
â˘âŻ Differentiation
from
degenerative
changes
â˘âŻ Limited
specificity: Poor
spatial resolution
â˘âŻ Require
confirmatory
imaging by MRI
29. ELECTRODIAGNOSTIC
STUDIES
â˘âŻ LS Radiculopathy
â˘âŻ EMG-NCV
â˘âŻ Confirm nerve root compression and define the distribution
and severity of involvement
â˘âŻ INDICATIONS:
â⯠Pxs with persistent disabling symptoms of radiculopathy with
discordance b/n clinical presentation and findings on imaging
â⯠Evaluation of possible factitious weakness
â˘âŻ LIMITATIONS:
â⯠delayed detection
â⯠Persistent abnormalities
32. Chou
 R,
 Qaseem
 A,
 Snow
 V,
 et
 al.
 Diagnosis
 and
 treatment
 of
 low
 back
 pain:
 a
 joint
 clinical
 prac6ce
 guideline
Â
from
 the
 American
 College
 of
 Physicians
 and
 the
 American
 Pain
 Society.
 Ann
 Intern
 Med.
 2007;147:478-Ââ491.
Â
Â
35. CASE
â˘âŻ 55M, fisherman, with low back pain
â˘âŻ >5 years duration
â˘âŻ Pain radiates to buttock and anterior thigh
â˘âŻ Alleviated by forward flexion
â˘âŻ Exacerbated by bending to the right side of the body
37. Diagnosis
â˘âŻ LUMBAR SPONDYLOSIS (Facet Syndrome)
â˘âŻ Degenerative changes in facet joints
â˘âŻ Imaging evidence is common in the general
population, increases with age and maybe unrelated
to back symptoms
â˘âŻ Patients with severe mechanical LBP may have
minimal radiographic changes, and conversely,
patients with advanced changes may be
asymptomatic
38. CASE
â˘âŻ 35M, businessman
â˘âŻ Low back pain that radiates to the medial aspect foot
â˘âŻ Sudden onset
â˘âŻ Duration: 6 weeks
â˘âŻ Lancinating, sharp pain with numbness and tingling
â˘âŻ Worsened by coughing, sneezing or when he defecates
â˘âŻ +SLR Right
â˘âŻ Weak dorsiflexion of foot and great toe
40. Diagnosis
â˘âŻ SCIATICA secondary to INVERTERBRAL DISK
HERNIATION L4-L5
â˘âŻ Occurs when the NP in a degenerated disk prolapses
and pushes out the weakened annulus, usually
posterolaterally
â˘âŻ Seen in 27% of asymptomatic individuals
Jensen
 MC,
 Brandt-ÂâZawadski
 MN,
 Obuchowski
 N,
 et
 al:
 Magne6c
Â
resonance
 imaging
 of
 the
 lumbar
 spine
 in
 people
 without
 back
 pain,
 N
Â
Engl
 J
 Med
 331:69â73,
 1994
Â
41. Diagnosis
â˘âŻ LS spine is susceptible to herniation because of its
mobility
â˘âŻ 75% of flexion-extension occurs at the LS joint (L5-
S1)
â˘âŻ 20% occurs at L4-5
â˘âŻ Therefore, 90-95% of clinically significant
compressive radiculopathies occur at these 2 levels
42. Diagnosis
â˘âŻ Disk herniation is rare in young individuals
â˘âŻ Frequency increases with age
â˘âŻ Peak: 44-50y/o (progressive decline in frequency
thereafter)
43. Diagnosis
â˘âŻ L1 radiculopathy: rare; pain, paresthesias and sensory
loss in inguinal areas
â˘âŻ L2-4 radiculopathies: uncommon; seen in elderly with
spinal stenosis
â˘âŻ Cauda equina syndrome: midline L4-5 herniation
â⯠LBP, bilateral radicular pain, bilateral motor deficit with leg
weakness
â⯠Urinary retention with Overflow incontinence
â⯠Asymmetric PE
â⯠Saddle anesthesia
â⯠Surgical emergency!
44. Diagnosis
â˘âŻ Natural history is favorable (progressive
improvement in most patients)
â˘âŻ Regression in sequential MRI
â˘âŻ Partial or complete resolution in 2/3 of cases after 6
mos
â˘âŻ Only 10% have sufficient pain after 6 weeks of
conservative care (consider decompressive surgery))
45. CASE
â˘âŻ 70F, store owner
â˘âŻ Chronic aching low back pain
â˘âŻ Duration: 8 years
â˘âŻ Occasionally relieved by Paracetamol, Mefenamic
Acid, rest
â˘âŻ Normal PE
47. Diagnosis
â˘âŻ DEGENERATIVE SPONDYLOLISTHESIS
â˘âŻ Anterior displacement of a vertebra on the one
beneath it
â˘âŻ Two types
ISTHMIC
 DEGENERATIVE
Â
Caused
 by
 bilateral
Â
spondylolyis
Â
Caused
 by
 severe
Â
degenera6ve
 changes
 with
Â
subluxa6on
 at
 the
 facet
 joints
Â
Acquired
 early
 in
 life;
 young
Â
boys
Â
Older
 age
 group
 >60,
 women
Â
Most
 commonly
 a
 defect
 in
Â
the
 pars
 ar6cularis
 at
 L5
Â
MC
 L4-Ââ5
Â
Nerve
 root
 impingement
 Spinal
 stenosis
Â
48. CASE
â˘âŻ 73M, carpenter
â˘âŻ Chronic low back pain
â˘âŻ >5 years
â˘âŻ Pain and paresthesias in buttocks, thighs
and legs
â˘âŻ Exacerbated by erect posture and walking
but has no problems cycling
â˘âŻ Relieved by sitting or flexing forward
â˘âŻ Unsteady gait, weakness lower
extremities
â˘âŻ SLR (-)
â˘âŻ DTRs: + on both LE
50. Diagnosis
â˘âŻ SPINAL STENOSIS
â˘âŻ Neurogenic claudication
â˘âŻ Simian stance; shopping cart sign
â˘âŻ Wide based gait (90% specific)
â˘âŻ 20-30% asymptomatic adults have
abnormal imaging
â˘âŻ Factors that favor neurogenic claudication
(vs vascular)
â⯠Preservation of pedal pulses
â⯠Provocation of Sxs by standing erect as
readily as walking
â⯠Relief of symptoms by spine flexion
â⯠Location of maximal discomfort to the
thighs rather than calves
52. CASE
â˘âŻ 55M, previously diagnosed with prostate cancer, s/p
cTURP
â˘âŻ Persistent, progressive Low back pain for 2 months
â˘âŻ Not alleviated by rest
â˘âŻ Worse at night
â˘âŻ Minimal relief with Paracetamol, NSAIDs
â˘âŻ Weight-loss, anorexia
â˘âŻ Recently, acute weakness of both lower extremities
(MMT 2/5)
â˘âŻ Urinary retention with overflow incontinence
54. Diagnosis
â˘âŻ CAUDA EQUINA Syndrome 2 to Vertebral
Metastases from Prostate Ca
â˘âŻ Neoplasia accounts for <1% of patients with LBP
â˘âŻ Prior history of Ca was the most important
predictor for likelihood of underlying Ca
56. Diagnosis
â˘âŻ Plain radiographs less sensitive
â˘âŻ Metastatic lesions may be lytic (radiolucent), blastic
(radiodense) or mixed.
â˘âŻ Unlike infections, the disk space is usually spared
â˘âŻ MRI: greatest sensitivity and specificity
â˘âŻ Purely lytic lesion (MM) will not be detected by
bone scan
57. CASE
â˘âŻ 30M, kargador, IV drug user
â˘âŻ Fever, low back pain, weight loss
â˘âŻ Pain is persistent, present at rest, exacerbated by
activity
â˘âŻ +point tenderness: L4-L5
â˘âŻ Grade 3/6 systolic murmur over the 4th ICS RPSB
â˘âŻ Leukocytosis
â˘âŻ Elevated ESR, CRP
â˘âŻ Blood CS: Moderate growth of S. aureus
59. Diagnosis
â˘âŻ Vertebral OM
â˘âŻ Hematogenous, direct inoculation, contiguous
spread
â˘âŻ MC: lumbar spine
â˘âŻ MC: #1 S. aureus #2 E.coli
â˘âŻ Leukocytosis in 2/3
â˘âŻ CRP correlates with clinical response to Tx
â˘âŻ Bone Bx if Blood CS (-)
60. Diagnosis
â˘âŻ Plain Xray: initial imaging (late and non-specific)
ââŻLoss of disk height and loss of cortical definition
ââŻBony lysis of adjacent vertebral bodies
â˘âŻ MRI: most sensitive and specific
ââŻClassic finding: involvement of 2 vertebral bodies with
their intervening disk
64. ACUTE (Less than 3
mos)
â˘âŻ Excellent prognosis
â˘âŻ Only 1/3 seek medical care
â˘âŻ >90% recover within 8weeks or earlier
â˘âŻ Stay active; continue ordinary daily activities within limits
permitted by pain
â˘âŻ Discourage bedrest >1-2days
â˘âŻ Acetaminophen and NSAIDs: 1st line for symptom relief
â˘âŻ Short term opioids: for severe disabling LBP or if with CI to NSAIDS
â˘âŻ Muscle relaxants are moderately effective (but high prev of adverse
events
Coste
 J,
 Delecoeuillerie
 G,
 Cohen
 deLara
 A,
 et
 al:
 Clinical
 course
 and
 prognos6c
 factors
 in
Â
acute
 low
 back
 pain:
 an
 incep6on
 cohort
 study
 in
 primary
 care
 prac6ce,
 BMJ
 308:577,
 1994.
Â
Chou
 R:
 Pharmacological
 management
 of
 low
 back
 pain,
 Drugs
 70(4):384â402,
 2010.
Â
65. ACUTE (Less than 3
mos)
â˘âŻ Back exercises not helpful in the acute phase
â˘âŻ PT referral not usually necessary in the first month
â˘âŻ Individually tailored exercise program
â˘âŻ Educational booklets strongly recommended
â˘âŻ Heating pads or blankets
Chou
 R,
 Qaseem
 A,
 Snow
 V,
 et
 al:
 Diagnosis
 and
 treatment
 of
 low
Â
back
 pain:
 a
 joint
 clinical
 prac6ce
 guideline
 from
 the
 American
 College
 of
 Physicians
 and
 the
 American
 Pain
 Society,
 Ann
Â
Intern
 Med
 147(7):478â491,
 2007.
Â
66. ACUTE (Less than 3
mos)
â˘âŻ INSUFFICIENT EVIDENCE
â⯠Spinal manipulation
â⯠Cold packs, corsets or braces
â⯠Acupuncture, massage
â⯠Traction
â⯠TENS, PENS, interferential therapy, low-level laser therapy,
shortwave diathermy, ultrasound
â⯠Injection of trigger points, ligaments, SI joints, facet joints,
intradiskal steroid injections
Clarke
 JA,
 van
 Tulder
 MW,
 Blomberg
 SE,
 et
 al:
 Trac6on
 for
 low
 back
 pain
 with
 or
 without
 scia6ca,
Â
Cochrane
 Database
 Syst
 Rev
 (23):CD003010,
 2007.
Â
Chou
 R,
 Qaseem
 A,
 Snow
 V,
 et
 al:
 Diagnosis
 and
 treatment
 of
 low
Â
back
 pain:
 a
 joint
 clinical
 prac6ce
 guideline
 from
 the
 American
 College
 of
 Physicians
 and
 the
Â
American
 Pain
 Society,
 Ann
 Intern
 Med
 147(7):478â491,
 2007
Â
Chou
 R,
 Loeser
 JD,
 Owens
 DK,
 et
 al:
 Interven6onal
 therapies,
 surgery,
 and
 interdisciplinary
Â
rehabilita6on
 for
 low
 back
 pain.
 An
 evidence
 based
 clinical
 prac6ce
 guideline
 from
 the
 American
Â
Pain
 Society,
 Spine
 34(10):1066â1077,
 2009.
Â
67. SUBACUTE (More
than 6wks)
ââŻInjection therapy
ââŻEpidural CCS: remarkable but unjustified popularity
ââŻEvidence of moderate benefit compared to placebo for
short term relief of leg pain from HNP
ââŻNo significant functional benefit
ââŻNo reduction in need for surgery
Care"e
 S,
 Leclaire
 R,
 Marcouxs
 S,
 et
 al:
 Epidural
 cor6costeroid
 injec6ons
 for
 scia6ca
 due
 to
 herniated
Â
nucleus
 pulposus,
 N
 Engl
 J
 Med
 336(23):1634â1640,
 1997.
Â
70. CHRONIC (More than
3 mos)
ââŻOverall: results of treatment are unsatisfactory
ââŻComplete relief of pain is unrealistic for most
ââŻHigh costs
ââŻAcetaminophen and NSAIDs as first line
ââŻOpioid analgesics for severe disabling LBP
ââŻNo evidence that long-acting RTC dose is superior to
short-acting PRN dosing
ââŻContinuous exposure leads to tolerance and dose
escalation
Chou
 R:
 Pharmacological
 management
 of
 low
 back
 pain,
 Drugs
 70(4):384â402,
 2010.
Â
71. CHRONIC (More than
3 mos)
ââŻMuscle relaxants are not recommended for long-term
use
ââŻAntidepressants that inhibit NE uptake: pain modulating
properties
ââŻLow dose TCAs are an option
ââŻNo evidence for SSRIs (except for concomitant Tx of
depression)
ââŻDuloxetine (SNRI) has marginal efficacy
ââŻInsufficient evidence for Gabapentin and topiramate
72. CHRONIC (More than
3 mos)
â⯠PT modalities and injection techniques: not recommended
â⯠Lumbar supports and traction: ineffective
â⯠Medium firm mattress or back-conforming mattress (water-
bed or foam): superior to a firm mattress
â⯠Spinal manipulation is superior to sham manipulation but is
no more effective than conventional medical Tx
â⯠Less evidence for massage and acupuncture
â⯠Chemonucleolysis with chymopapain: potentially life-
threatening
â⯠Radiofrequency denervation: lacks evidence
73. CHRONIC (More than
3 mos)
ââŻLack of evidence:
â˘âŻ Radiofrequency denervation
â˘âŻ Intradiskal electrothermal therapy
â˘âŻ Percutaneous intradiskal RF thermocoagulation
â˘âŻ Prolotherapy
â˘âŻ Spinal cord stimulation
â˘âŻ Instraspinal drug infusion systems (?): morphine
74. CHRONIC (More than
3 mos)
â⯠Supportive measures
â˘âŻ Interdisciplinary rehabilitation
â˘âŻ Functional restoration (work hardening)
â⯠Surgery
â˘âŻ As a general rule, the results of back surgery are disappointing when the
goal is relief of back pain rather than relief of radicular symptoms from
resulting neurologic compression
â˘âŻ Role of surgical treatment for chronic disabling LBP w/o neurologic
improvement in patients with degenerative disease remains controversial
â˘âŻ MC: spinal fusion
â˘âŻ For non-radicular back pain with degenerative changes, fusion is no more
effective than intensive interdisciplinary rehab but is associated with small
to moderate benefits compared with standard non-surgical care
76. NERVE ROOT COMPRESSION SYNDROMES
Disk
 HerniaDon
 Spinal
 Stenosis
 Spondylolithesis
Â
Treat
 nonsurgically
 (as
 in
 Acute
Â
LBP)
 unless
 with
 serious
 or
Â
progressive
 neuro
 deďŹcit
Â
Conserva6ve
 non-Ââopera6ve
 Tx
Â
Surgery
 if
 with
 serious
 or
Â
progressive
 neuro
 deďŹcit
Â
Treat
 conserva6vely
Â
Only
 about
 10%
 have
 suďŹcient
Â
pain
 aoer
 6
 weeks
 of
 conserva6ve
Â
Tx
 to
 warrant
 Surgery
Â
Symptoms
 stable
 for
 yrs;
 may
Â
improve
 in
 some
Â
Drama6c
 improvement
 uncommon
Â
Surgery:
 moderate
 short
 term
Â
beneďŹts
 (thru
 6-Ââ12wks)
 vs
 non-ÂâSx
Â
but
 outcome
 diďŹerences
 diminish
Â
over
 6me
 and
 no
 longer
 present
 in
Â
1-Ââ2
 yrs
Â
PT:
 mainstay
 of
 mgt
Â
Core
 strengthening,
 stretching,
Â
aerobic,
 loss
 of
 wt,
 Px
 educa6on;
Â
Cycling
Â
Lumbar
 corsets
Â
Open
 diskectomy
 or
Â
microdiskectomy
Â
Laminectomy,
 par6al
Â
fascetectomy,
 excision
 of
Â
hypertrophied
 LF
Â
Epidural
 CCS
 injec6ons:
 moderate
Â
beneďŹt
 for
 short
 term
 relief
 but
 no
Â
func6onal
 beneďŹt
 and
 donât
 reduce
Â
need
 for
 Surgery
Â
Lumbar
 epidural
 CCS
 injec6ons:
Â
small
 RCT
 showed
 reduc6on
 in
Â
pain
 and
 improvement
 in
 fxn
 at
 6
Â
mos
 but
 donât
 inďŹuence
 fxnal
Â
status
 and
 need
 for
 surgeyr
 at
 1yr
Â
Decompression
 surgery
 with
 fusion
Â
be"er
 than
 non-Ââsurgical
 care
 for
Â
isthmic
 spondylolisthesis
 and
Â
disabling
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 at
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77. OUTCOME
â˘âŻ Natural history of acute LBP is favorable
â˘âŻ Improvement in pain and fxn within 1 month in the
majority of patients; >90% are better at 8weeks
â˘âŻ Only 1/3 of acute LBP patients seek medical care
â˘âŻ Rest resolves
78. OUTCOME
â˘âŻ Improvement is also the norm for Pxs with sciatica 2
to HNP
â˘âŻ 1/3 better in 2 weeks, 75% improve after 3 mos,
10% ultimately undergo surgery
â˘âŻ Spinal stenosis: stable in 70%, improved in 15%,
worsened in 15%
â˘âŻ 7-10% with chronic LBP: responsible for high costs
79. Factors that predict
chronicity
â˘âŻ Maladaptive coping behavior
â˘âŻ Presence of non-organic signs
â˘âŻ Functional impairment
â˘âŻ Poor general health status
â˘âŻ Psychiatric comorbidities
â˘âŻ Job dissatisfaction
â˘âŻ Disputed compensation claims
â˘âŻ High level of âfear avoidanceâ
80. SUMMARY
â˘âŻ History and PE are more important than Imaging
â˘âŻ Prognosis of acute LBP is excellent
â˘âŻ Prognosis of chronic LBP is unsatisfactory
â˘âŻ Surgery is reserved for neurologic deficits
84. Diagnosis
" âŻPathologically
" Radiographically
" âŻOsteophyte
" âŻJoint space narrowing (JSN) on Plain Xray (or MRI)
" âŻClinically
" âŻNodal changes in the hands
" âŻLimited and painful internal rotation of the hip
" âŻCrepitus with knee movement
SYMPTOMATIC OA = pain, aching or stiffness in a joint
with radiographic OA
85. Diagnosis
ACR Criteria
1986 (Knee), 1991 (Hip), 1990 (Hand)
SENSITIVITY
 SPECIFICITY
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Hand
 92%
 98%
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Hip
 91%
 89%
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Knee
 91%
 86%
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86. ACR
Radiologic and Clinical Criteria
" âŻHAND
1. Hand pain, aching, or stiffness on most days of prior
months
2. Hard tissue enlargement of >=2 of 10 selected joints*
3. Fewer than 3 swollen MCP joints
4. Hard tissue enlargement of >=2 DIP joints
5. Deformity of >=2 of 10 selected joints*
" âŻDIAGNOSIS REQUIRES ITEMS 1-3 AND EITHER 4 OR 5
" âŻ10 Selected Joints: DIP 2-3, PIP 2-3, and CMC 1
bilaterally
88. ACR
Radiologic and Clinical Criteria
" ⯠KNEE: Clinical
1. Knee pain for most days of prior month
2. Crepitus with active joint motion
3. Morning stiffness lasting <=30 min
4. Bony enlargement of the knee on examination
5. Age >=38 yr
" ⯠Diagnosis REQUIRES 1+2 + 4, or 1+2+3+5, or 1+4+5
89. ACR
Radiologic and Clinical Criteria
" ⯠KNEE: Clinical AND Radiographic
1. Knee pain for most days of prior month
2. Osteophytes at joint margins
3. Synovial fluid typical of OA
4. Age ⼠40 y/o
5. Morning stiffness lasting ⤠30min
6. Crepitus with active joint motion
" ⯠Diagnosis REQUIRES 1+2, or 1+3+5+6, or 1+4+5+6
90. ACR
Radiologic and Clinical Criteria
" âŻHIP: Clinical AND Radiographic
1. Hip pain for most days of the prior month
2. ESR â¤20mm/hr
3. Radiographic femoral and/or acetabular
osteophytes
4. Radiographic hip joint space narrowing
Diagnosis REQUIRES 1+2+3, or 1+2+4, or 1+3+4
91. Primary vs Secondary
â˘âŻ Primary: absence of an injury history or other
joint disease
â˘âŻ Secondary: (+) of predisposing disorder
â˘âŻ Division currently less clear
â˘âŻ Genetics, Hx of injury/jt damage, mechanical
factors, psychosocial milieu Ă ď joint Ă ď end-
stage or failed joint
92. Etiologies of Secondary OA 1637CHAPTER 99 | CLINICAL FEATURES OF OSTEOARTHRITIS
Table 99-3 Etiologies of Secondary Osteoarthritis
Metabolic
Crystal-associated arthritis
Calcium pyrophosphate or apatite deposition
Acromegaly
Ochronosis
Hemochromatosis
Wilsonâs disease
Hyperparathyroidism
Ehlers-Danlos
Gaucherâs disease
Diabetes
Mechanical/Local Factors
Slipped capital femoral epiphysis
Epiphyseal dysplasias
Legg-CalvĂŠ-Perthes disease
93. Etiologies of Secondary OA
Ochronosis
Hemochromatosis
Wilsonâs disease
Hyperparathyroidism
Ehlers-Danlos
Gaucherâs disease
Diabetes
Mechanical/Local Factors
Slipped capital femoral epiphysis
Epiphyseal dysplasias
Legg-CalvĂŠ-Perthes disease
Congenital dislocation
Femoroacetabular impingement
Congenital hip dysplasia
Limb-length inequality
Hypermobility syndromes
Avascular necrosis/osteonecrosis
Traumatic
Joint trauma (e.g., ACL tear)
Fracture through joint
94. Etiologies of Secondary OA
Legg-CalvĂŠ-Perthes disease
Congenital dislocation
Femoroacetabular impingement
Congenital hip dysplasia
Limb-length inequality
Hypermobility syndromes
Avascular necrosis/osteonecrosis
Traumatic
Joint trauma (e.g., ACL tear)
Fracture through joint
Prior joint surgery (i.e., meniscectomy, ACL)
Charcot joint (neuropathic arthropathy)
InďŹammatory
Rheumatoid arthritis or other inďŹammatory arthropathies
Crystalline arthropathy (gout)
History of septic arthritis
ACL, anterior cruciate ligament.
ModiďŹed from Altman R, Asch E, Bloch D, et al: Development of criteria
for the classiďŹcation and reporting of osteoarthritis. ClassiďŹcation of osteo-
96. General Symptoms & Signs
â⯠Knees, hands, feet, hips and spine
â⯠Symptomatic or radiographic
â⯠Pain in the joints that is:
â˘âŻ Worse with activity
â˘âŻ Limited morning stiffness (â¤30mins)
â˘âŻ Pain and stiffness with rest (gelling phenomenon)
â⯠Bony enlargements, crepitus, reduced ROM
â⯠Soft tissue swelling or effusion
98. Knee
â˘âŻ Insidious onset of pain
â˘âŻ Gelling
â˘âŻ Limitation of ROM
â⯠Walking, transferring, stair climbing
â⯠Sense of instability or âgiving outâ at the knee
â˘âŻ Locking sensation
â⯠Stiffness
â⯠Loose bodies in the joint space
â⯠Meniscal lesions
â˘âŻ Crepitus, bony enlargement
99. Knee
â˘âŻ Pain: medial or lateral joint line
â˘âŻ Effusions: cool, generally w/o redness
â⯠Association with Bakerâs cyst
â˘âŻ Pain over anserine bursa or greater trochanter: altered biomechanics
â˘âŻ Malalignment (mc: varus) â risk factor for progression
â˘âŻ Severe disease: flexion deformities or joint stability
â˘âŻ Risk factors: Quadriceps weakness (modifiable) Ă ď muscle atrophy
(late stage); loss of proprioception and vibratory sense
â˘âŻ Patellofemoral OA: pain, disability; often overlooked
100.
101. Hip
â˘âŻ Groin pain (specific)
â˘âŻ Vague: pain in the thigh, buttock, low back, or ipsilateral knee
â˘âŻ Consider differential Dx
â⯠Femoral neck Fx, Avascular Necrosis
â˘âŻ Limitations in walking, bending, transferring, stair climbing
â⯠Internal rotation: limited and painful (even in early dse)
â⯠Putting on socks, tying shoes, trimming toe nails
â˘âŻ Visible deformity, hip flexion contracture, severe limitations of ROM Ă ď
severe dse (superior migration of the femoral head)
â˘âŻ Consider: Femoroacetabular impingement â young, groin pain worsened
by sitting, pain and limitation on F-IR-AD of the hip
103. Hand
â˘âŻ Heberdenâs nodes: DIP; Bouchardâs nodes: PIP
â˘âŻ Erosive arthritis: episodic inflammation, pain and swelling (elderly women)
â˘âŻ First CMC: significant pain, limitations in fucntionality, reduced grip strength
â⯠CMC squaring: osteophyte formation and JSN
â˘âŻ Bilateral involvement of multiple joints:
â⯠Within (multiple PIPs) and across (both DIPs and PIPs)
â˘âŻ MCP involvement: increasing; consider inflammatory arthropathies or secondary OA
(hemochromatosis)
â˘âŻ DeQuervainâs tenosynovitis: mimic or aggravate symptoms
104. Spine
â˘âŻ Osteophytosis of the spine Ă ď older individuals; often asymptomatic
â˘âŻ Lumbar disk degeneration (DSN, end plate sclerosis, herniation): often seen in
association with radiographic osteophytosis (relationship controversial)
â˘âŻ Cervical spine:
â⯠pain in the neck, radiation to the arms, weakness or paresthesia (osteophytic
compression)
â⯠Dysphagia (anterior cervical spine osteophytes)
â˘âŻ Lumbar spine:
â⯠Osteophytes and DSN Ă ď sciatic nerve impingement (pain, burning, numbness
and/or weakness down one or both legs)
105. Shoulder
â˘âŻ Symptoms are more often due to
osteophytosis and narrowing of the
acromioclavicular and/or sternoclavicular jts
rather than the glenohumeral jt itself
â˘âŻ DDx: Subacromial bursitis, Rotator Cuff
pathology, Adhesive capsulitis, Cervical
spine pathology
â˘âŻ Milwaukee shoulder syndrome
â⯠Destructive arthropathy: glenohumeral
joint
â⯠Large effusions
â˘âŻ High RBC count
â˘âŻ Basic Calcium crystals
106. Other Joints
â˘âŻ 1st MTP: pain and hallux valgus (bunion)
deformity
â˘âŻ Loss of function due to ankylosis
(hallux rigidus) Ă ď altered gait
â˘âŻ Other joints:
â⯠TMJ
â⯠Ankles: talonavicular, subtalar
â⯠Elbow OA: rare
â˘âŻ Trauma, vibration damage,
pseudogout
107. Polyarticular OA
â˘âŻ Generalized OA: no universally understood or accepted
definition
â˘âŻ Kellgren and Moore (1952):
â⯠Primarily: Heberdenâs nodes and CMC
â⯠With: spine, knees, hips, feet (descending frequency)
â˘âŻ Later studies:
â⯠>3 or >5 joint sites affected
â⯠Affected joint counts
â⯠Multiple hand involvement
â⯠Nodal hand OA with other jt involvement
â⯠Summed scores of OA across multiple joints
120. Imaging: Advanced Modalities
â˘âŻ MRI:
ââŻExclude DDx
ââŻDefine early changes (before Xray changes occur)
ââŻBM lesions (knee) = correlate with pain, bone
attrition, progressive cartilage damage
â˘âŻ Arthroscopy
ââŻOften used as a response to MRI findings
ââŻOverused and generally ineffective
ââŻCost not indicated in routine practice
â˘âŻ Ultrasound
ââŻBedside procedure
ââŻDetect small effusions, early cartilage changes,
diff infx vs non-inflx arthropathies
ââŻTherapeutic adjunct
121. Mortality in OA
â˘âŻ Increased compared to gen pop
â˘âŻ CV and GI causes
â˘âŻ Inc mortality with inc jt involvement
â˘âŻ Reduced survival: hand, B knees, cervical
(NOT: hip, foot, lumbar)
â˘âŻ Contributors:
â⯠Reduced physical activity
â⯠Comorbid conditions
â⯠Adverse SE of meds
127. SUMMARY
â˘âŻ Aging has caused a lot of health-related disorders
â˘âŻ It is important to get the correct diagnosis so
appropriate treatment can be given
â˘âŻ Most cases of low-back pain are benign, do not need
imaging and respond to conservative therapy
â˘âŻ Osteoarthritis is a degenerative disease that
responds to analgesics and physical therapy
â˘âŻ Soft tissue rheumatisms are overuse diseases and
respond to rest and steroid injections
128. Thank you for your attention
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