Back Pain and the AS Exam

Background: seronegative sponduloarthropathy with articular involvement (axial skeleton, peripheral joints, enthesitis – inflammation at the muscular insertions) and extra-articular (eyes, heart – AR, lungs – cough/hemoptysis, kidneys, neuro)

History

  • OLDSCARS
  • Family history
  • Rheumatological conditions
  • Trauma
  • Cauda equina
  • Function
  • Neuro

Inspection

  • Back and peripheral joints (hips, shoulders, knees)
    • Swelling
    • Erythema/Ecchymoses
    • Atrophy
    • Deformity (loss of lordosis, kyphosis, scoliosis, step deformity – Gibbis wedge compression #)
    • Scars/Skin and nail changes
  • Extra-articular
    • Eyes: anterior uveitis (photophobia, increased lacrimation)
    • CVS
    • Respiratory
  • Stance/Standing, Gait, Posture



 

Palpation

  • C-spine: base of skull to C7, traps, SCM, paraspinal
  • T-spine: spinous process, paraspinals, hands on scapula and bend forward looking for symmetry
    • Tenderness
    • Effusion
    • Swelling
    • Temperature
    • Crepitus
    • Atrophy (muscle bulk)

ROM

  • C-spine: flex 450, extend 500, lateral flex 450, rotation 700)
  • T-spine: flex, fix pelvis/sit – extend 300, lateral flex 350, rotation 300

Special tests

  • FABERE – stress SI joint – pain
    • The patient will lie supine on the examining table. Place the foot of his involved side on the opposite knee. Pain in the inguinal area indicates hip disease. To stress the sacroiliac joint, extend the range of motion by pushing on the flexed knee as well as on the superior ileac spine of the opposite side. Pain in the sacroiliac joint line indicates abnormalities
  • Schober’s (10 – 15cm)
  • Occiput to wall
  • Chest expansion (5cm from expiration to inspiration – below breasts or 4th IC space)
  • Pelvic compression test
  • Gaenslen sign – pain on hyperextension (fix opposite hip) – SI joint

Differential Diagnosis

  • Spondylolysis – # pars (lamina to pedicle)
  • Spondylolisthesis – vertebra and column above slide narrowing the canal
  • Herniation (contained, extruded, sequestered) – posterolateral, L4-5 or L5-S1
    • Symptoms/Signs
      • Sciatica (sitting worse)
      • Dermatomal changes
      • Back pain prodrome
  • Spinal stenosis – neurogenic claudication – sitting = better (opens canal)

Reflexes

  • Biceps C5
  • Brachioradialis C6
  • Triceps C7
  • Finger flexors C8
  • Knees L2-4
  • Ankles S1

Red flags of back pain (serious spinal pathology)

  • Onset <20 or >55 years
  • Violent Trauma
  • Constant, progressive, non-mechanical pain
  • Thoracic pain
  • History of cancer
  • Systemic steroids
  • Drug abuse, HIV
  • Systemically unwell
  • Weight loss
  • Persisting severe restriction of lumbar flexion
  • Cauda equina syndrome/widespread neurological disorder
    • Urinary retention
    • Fecal incontinence (lose of anal sphincter tone)
    • Saddle anaesthesia
    • Weakness in the legs or gait disturbance
    • Sensory level
  • Inflammatory disorders (ankylosing spondylitis and related disorders)
    • Gradual onset before age 40
    • Morning stiffness
    • Limitations in spinal ROM
    • Peripheral joint involvement
    • Iritis, skin rashes (psoriasis), colitis, urethral discharge
    • Family history

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