Inflammatory, Autoimmune, Infectious Diseases (Part 1) | Mimics of Low Back Pain | CO Spine Surgeon

Inflammatory, Autoimmune, Infectious Diseases (Part 1) | Mimics of Low Back Pain | CO Spine Surgeon


hello this is doctor corenman we’re going to talk about inflammatory
autoimmune infectious diseases and chronic pain and mimics of low back pain and leg pain these are essentially neurologic diseases
or chronic pain diseases that we will discuss again my favorite comment was from the physician famous doctor osler you find what you know and you see what
you look for if you don’t understand it something
can happen and you don’t know that a condition can
occur you won’t look for it I think this quote is
very valuable we’re going to start with retroperitonal
pain referral to the lower back these are structures organs essentially and the retroperitonal area that will refer pain to the lower back embroyologically the structures are all supplied by similar nerve
endings as found in the lumbar spine it’s thought that there’s possible
feedback from the afferent autonomics that goes through the same track as the
somatic sensory system this is why you get referral pain into
the lower back the retroperitonal structure of
course are the abdominal aorta the kidneys the pancreas the gallbladder the urinary bladder the ovaries and the
uterus the quality of pain can very commonly
be identified by what structure is affected kidneys normally will cause a unilateral costovertebral pain and tenderness if you percuss the area right below
the lowest unilateral rib you can get significant reproduction of
pain endometriosis and ovarian cysts of
course are cyclical pain that are associated
with the patient’s period pelvic inflammatory diseases are not
cyclical there’s something called the hanging
chandelier sign the cervix is so tender that the patient has severe pain with any palpation of this ectopic pregnancy of course is a surgical
emergency you need a good history normally seven weeks after the last
period and the patient should have a prior pelvic inflammatory disease causing
scarring of the fallopian tubes diverticulitis commonly can cause a steady type
of abdominal pain cancer of bone or organ can cause different types of pain normally night pain and gallbladder is a right sided pain
after a fatty meal anatomy of the nerve is relatively simple you have the cell body with the nucleus
that produces many of the substances necessary to quote
run the nerve unquote you have the myelin sheath and many
higher order nerves these are schwann cells in the peripheral nervous system and oligodendrocytes in the central
nervous system the speed of conduction of the nerve is increased by something called ephaphtic conduction where the signal jumps from the node
of Ranvier to the next node and this is as you can see part of the myelin sheath where we have the schwann cell that is surrounding the nerve and the
node of Ranvier the exposed nerve in between you have actually jumping from one node to the next which
increases conduction significantly the synapse is the area where you communicate
either with the next nerve or with the muscle there are synaptic vesicles which can key the
neuro transmitter these are made in the nucleus and then dug down through the cell body and then through the actual dendrite and the axon there’s a pre synaptic membrane and
these will be released there are ligand gated ion channels which will allow
sodium and potassium to flow in and change the voltage of the nerve and possibly
reaching the action potential history and physical examination is one
of the cores to determine what the neurologic problem is upper motor neuron lesion symptoms are imbalance paresthesias in a non dermatomal
pattern L’hermittes problems with fine motor skills
possible bowel and bladder involvement upper motor neuron lesion signs or hyperreflexia release signs such as hoffman’s and
invertebral reflex and incoordination lower motor neuron lesion signs are weakness reflex deficit and sensory loss symptoms of course of motor neuron lesions in the lower aspect our
pain parasthesias and weakness sensation can be increased decreased or altered allodynia and hyperalgesia are two
of the common altered sensations of course you check motor strength
reflexes endurance fatigue and also check for depression reactive depression is not uncommon in
patients with significant pain one of my favorite quotes other than
osler’s is voltaire’s quote the lower back is at the crossroads
where the psyche meets the soma and there’s no place truer than in the
lumbar spine where low back pain can really cause significant psyche issues pain perception with depression becomes amplified and this is noted to be chemically a
depletion of serotonin neuro transmitters the treatment many times can be a
SSRI and remember the four signs of
depression insomnia anhydonia irritability and lethargy these are now specific diseases multiple sclerosis is an autoimmune disease the body will produce antibodies against
the myelin sheath it’s noted to be greater in females
than males in a two-to-one ratio an onset is typically is twenty two forty
years of age the actual problem is attack and destruction
of the myelin sheath and this creates a conduction block as
you can see in the diagram to the right common symptoms are a unilateral vision
loss double vision or diplopia paresthesias of the upper or lower
extremities fatigue dizziness and incoordination the type of multiple sclerosis could be
mild or progressive it is interestingly found more commonly in light-skinned northern europeans
physical exam will note upper motor neuron findings such as motor blocks and sensory
disturbances polio thank goodness is not seen much
anymore but it is still around it’s an infectious viral disease that attacks the anterior horn cells in
the spinal cord and brain if it attacks in the brain it’s called
bulbar polio diaphragm paralysis can be fatal and the old iron lungs back in the
thirties were quite common a vaccine confers immunity as this viral coat doesn’t change unlike
in HIV paralysis of muscles is associated with obviously the nerve
cell damage in the anterior horn tabes dorsalis is not seen
commonly this is essentially the last part of syphilis the third stage of course syphilis is a sexually transmitted
spirochete bacteria normally you see certain symptoms and the patient will receive
antiobiotics immediately and the disease is cured however if the initial stages are not noticed and
the patient advances to secondary and especially tertiary syphilis this is where we get the neurologic
damage the tertiary form is associated with damage to the posterior
columns of the spinal cord the gracile and cuneate tracts which are
responsible for proprioception so with damage of those tracks the
symptoms are instability with gait patients will say
they walk with a drunken gait and of course the causes and inflammatory
destruction of the neurons which causes a temporarily increased
output of the brain and there are stories in the middle ages
of middle aged geniuses and these gentlemen have
brilliant discoveries before they lead to insanity the disease amyotrophic lateral
sclerosis is also called lou gerhig’s disease it’s
a disease of only the peripheral motor nerve cells therefore there’s no sensory involvement
and it is a painless disease somebody who has pain associated with
weakness typically does not have lou gerhig’s
disease the symptoms are loss of strength and weakness as well as clumsiness one of the hallmarks of this particular
disease is the fasciculations or non purposeful
twitching this does differentiate from other types
of neurologic diseases the disease advances leads to loss of speaking swallowing and
breathing and the median survival for this illness
is eighteen months

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