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