Low Back Pain
Objectives Review the functional anatomy of lumbo-sacral spine List essential components of a LBP history, including RED FLAGS Describe common causes of LBP Review proper indications for imaging and referral Review Physical Examination of LS spine Correlate pathology with pertinent physical findings
Epidemiology Incidence of LBP: 60-90 % lifetime incidence 5 % annual incidence 90 % of cases of LBP resolve without treatment within 6-12 weeks 40-50 % LBP cases resolve without treatment in 1 week 75 % of cases with nerve root involvement can resolve in 6 months LBP and lumbar surgery are: 2nd and 3rd highest reasons for physician visits 5th leading cause for hospitalization 3rd leading cause for surgery
Differential Diagnoses Lumbar Strain Disc Bulge / Protrusion / Extrusion producing Radiculopathy Degenerative Disc Disease (DDD) Spinal Stenosis Spondyloarthropathy Spondylosis Spondylolisthesis Sacro-iliac Dysfunction
“Red Flags” in back pain Age < 15 or > 50 Fever, chills, UTI Significant trauma Unrelenting night pain; pain at rest Progressive sensory deficit Neurologic deficits Saddle-area anesthesia Urinary and/or fecal incontinence Major motor weakness Unexplained weight loss Hx or suspicion of Cancer Hx of Osteoporosis Hx of IV drug use, steroid use, immunosuppression Failure to improve after 6 weeks conservative tx
Frequency of Back Pain Types 97% “mechanical”
Better anatomy knowledge = Better diagnoses and treatments
Vertebra Body, anteriorly Vertebral arch, posteriorly Functions to support weight Vertebral arch, posteriorly Formed by two pedicles and two laminae Functions to protect neural structures
Biomechanics 20% Posterior 80% Anterior The 80-20 rule of Spine loading www.brain101.info
Ligaments Anterior longitudinal ligament Posterior longitudinal ligament Ligamentum flavum Interspinous ligament Supraspinous ligament
Ligamentous Anterior longitudinal ligament
L4 L5 S1
PATIENT HISTORY Onset Palliative/Provocative factors Quality Radiation Severity/Setting in which it occurs Timing of pain during day Understanding - how it affects the patient Onset Palliative/Provocative factore Quality Radiation Severity/Setting in which it occurs Timing of pain during day Understanding - how it affects the patient
“Red Flags” in back pain Age < 15 or > 50 Fever, chills, UTI Significant trauma Unrelenting night pain; pain at rest Progressive sensory deficit Neurologic deficits Saddle-area anesthesia Urinary and/or fecal incontinence Major motor weakness Unexplained weight loss Hx or suspicion of Cancer Hx of Osteoporosis Hx of IV drug use, steroid use, immunosuppression Failure to improve after 6 weeks conservative tx
Onset Acute - Lift/twist, fall, MVA Subacute - inactivity, occupational (sitting, driving, flying) Pain effect on: work/occupation sport/activity (during or after)
Other History Prior h/o back pain Prior treatments and response Exercise habits Occupation/recreational activities Cough/valsalva exacerbation
Diagnoses & Red Flags Cancer Infection Fracture Cauda Equina Syndrome Age > 50 History of Cancer Weight loss Unrelenting night pain Failure to improve Infection IVDU Steroid use Fever Fracture Age >50 Trauma Steroid use Osteoporosis Cauda Equina Syndrome Saddle anesthesia Bowel/bladder dysfunction Loss of sphincter control Major motor weakness
Physical Examination Inspection Palpation Strength testing Neurologic examination Special tests
Approach to LBP History & physical exam Classify into 1 of 4: LBP from other serious causes Cancer, infection, cauda equina, fracture LBP from radiculopathy or spinal stenosis Non-specific LBP Non-back LBP Workup or treatment
Diagnostic Tools 1. Laboratory: Performed primarily to screen for other disease etiologies Infection Cancer Spondyloarthropathies No evidence to support value in first 7 weeks unless with red flags Specifics: WBC ESR or CRP HLA-B27 Tumor markers: Kidney Breast Lung Thyroid Prostate
Radiographs: History of trauma with continued pain Pre-existing Degenerative Joint Disease (Osteoarthritis) is most common diagnosis Usually 3 views adequate with obliques only if equivocal findings Indications: History of trauma with continued pain < 20 years or > 55 years with severe or persistent pain Noted spinal deformity on exam Signs / symptoms suggestive of spondylo-arthropathy Suspicion for infection or tumor
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3. Electromylogram (EMG): Measures muscle function Would not be appropriate in clinically obvious radiculopathy 4. Bone Scan: Very sensitive but nonspecific Useful for: Malignancy screening Detection for early infection Detection for early or occult fracture
Myelogram: Procedure of injecting contrast material into the spinal canal with imaging via plain radiographs versus CT
6. CT with Myelogram: Can demonstrate much better anatomical detail than Myelogram alone Utilized for: Demonstrating anatomical detail in multi-level disease in pre-operative state Determining nerve root compression etiology of disc versus osteophyte Surgical screening tool if equivocal MRI or CT
7. CT: Best for bony changes of spinal or foraminal stenosis Also best for bony detail to determine: Fracture Degenerative Joint Disease (DJD) Malignancy
8. MRI Best diagnostic tool for: Soft tissue abnormalities: Infection Bone marrow changes Spinal canal and neural foraminal contents Emergent screening: Cauda equina syndrome Spinal cored injury Vascular occlusion Radiculopathy Benign vs. malignant compression fractures Osteomyelitis evaluation Evaluation with prior spinal surgery
Degeneration & Tears www.brain101.info
Disc Classification Normal Bulge Canal Protrusion Extrusion Disc Bony Endplate Normal Bulge Disc Classification Protrusion Extrusion
Bulging www.brain101.info
Protrusion www.brain101.info
Protrusion www.brain101.info
Extrusion www.brain101.info
Extrusion www.brain101.info
Extrusion www.brain101.info
Treatment Pharmacological NSAIDS Muscle relaxents: Re-establish sleep patterns More useful in myofascial/muscular pain Membrane stabilizers TCA / Neurontin Re-establish sleep pain Reduce radicular dysesthesias Narcotics: rarely indicated Morphine, Oxy/hydrocodone, Oxymorphone, Hydromorphone, Fentanyl, Methadone Steroids: more useful for radiculitis Non-narcotic analgesics: Ultram (Tramadol)
Injections (Neural blockade) Physical Therapy Modalities Electrical Stimulation/TENS Postural Education / Body Mechanics Massage / Mobilization / Myofascial Release Stretching / Body Work Exercise / Strengthening Traction Pre-conditioning / Work-conditioning Injections (Neural blockade) Epidural blocks Facet blocks Trigger point SI joint
Epidural Steroid Injections Indicated for radiculopathy not responding to conservative mgmt Conflicting evidence Small improvement up to 3 months Less effective in spinal stenosis
Surgery Laminectomy Hemilaminectomy Discectomy Fusion Instrumented Non-instrumented fusion Minimally Invasive Spine Surgery (MISS) Kyphoplasty Percutaneous Disc Decompression (PDD) www.brain101.info
Physical Examination
Inspection Observe for areas of erythema Unusual skin markings Infection Long-term use of heating element Unusual skin markings Café-au-lait spots Neurofibromatosis Hairy patches, lipomata Tethered cord Dimples, nevi (spina bifida)
Inspection (cont.) Posture Normal lumbar lordosis Shoulders and pelvis should be level Bony and soft-tissue structures should appear symmetrical Normal lumbar lordosis Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall
Neurologic Examinaion Includes an exam of entire lower extremity, as lumbar spine pathology is frequently manifested in extremity as altered reflexes, sensation and muscle strength Describes the clinical relationship between various muscles, reflexes, and sensory areas in the lower extremity and their particular cord levels
Neurologic Examination (T12, L1, L2, L3 level) Motor Iliopsoas - main flexor of hip With pt in sitting position, raise thigh against resistance Reflexes - none Sensory Anterior thigh
Neurologic Examination (L2, L3, L4 level) Motor Quadriceps - L2, L3, L4, Femoral Nerve Hip adductor group - L2, L3, L4, Obturator N. Reflexes Patellar - supplied by L2, L3, and L4, although essentially an L4 reflex and is tested as such
L2, L3, L4 testing
Neurologic Examination (L4 level) Motor Tibialis Anterior Resisted inversion of ankle Reflexes Patellar Reflex (L4) Sensory Medial side of leg
Neurologic Examination (L5 level) Motor Extensor Hallicus Longus Resisted dorsiflexion of great toe Reflexes - none Sensory Dorsum of foot in midline
Neurologic Examination (S1 level) Motor Peroneus Longus and Brevis Resisted eversion of foot,planterflexion Reflexes Achilles Sensory Lateral side of foot
Special Tests Tests to stretch spinal cord or sciatic nerve Tests to increase intrathecal pressure Tests to stress the sacroiliac joint
Tests to Stretch the Spinal Cord or Sciatic Nerve Straight Leg Raise Cross Leg SLR Kernig Test
Test to increase intrathecal pressure Valsalva Maneuver Reproduction of pain suggestive of lesion pressing on thecal sac
Kernig Sign
Tests to stress the Sacroiliac Joint FABER Test
FABER test: Flexion A- Bduction External Rotation
Management of an acute low back muscle strain should consist of all the following EXCEPT: X-rays to rule out a fracture Educate the patient on generally good prognosis Non-opiate analgesics Remain active
Cervical disc herniation The two most common levels in the cervical spine to herniate are the C5 - C6 level (cervical 5 and cervical 6) and the C6 -C7 level. The next most common is the C4 - C5 level, and rarely the C7 - T1 level may herniate. Rarely, the herniated disc may put pressure on the spinal cord,causing problems in the leg.
Include dull or sharp pain in the neck or between the shoulder, pain that radiates down the arm to the hand or fingers, or numbness or tingling in the shoulder or arm. Certain positions or movements of the neck can intensify the pain. Weakness in the arm muscles may accompany the dull pain in some cases
Most frequent segment C4 - C5 (C5 nerve root) - Can cause weakness in the deltoid muscle in the upper arm. Does not usually cause numbness or tingling. Can cause shoulder pain. C5 - C6 (C6 nerve root) - Can cause weakness in the biceps , and wrist extensor muscles. Numbness and tingling along with pain can radiate to the thumb side of the hand. This is one of the most common levels for a cervical disc herniation to occur. C6 - C7 (C7 nerve root) - Can cause weakness in the triceps , and the finger extensor muscles. Numbness and tingling along with pain can radiate down the triceps and into the middle finger. This is also one of the most common levels for a cervical disc herniation C7 - T1 (C8 nerve root) - Can cause weakness with handgrip. Numbness and tingling and pain can radiate down the arm to the little finger side of hand.
Rare C4 - C5 (C5 nerve root) - Can cause weakness in the deltoid muscle in the upper arm. Does not usually cause numbness or tingling. Can cause shoulder pain. C5 - C6 (C6 nerve root) - Can cause weakness in the biceps (muscles in the front of the upper arms) and wrist extensor muscles. Numbness and tingling along with pain can radiate to the thumb side of the hand. This is one of the most common levels for a cervical disc herniation to occur. C6 - C7 (C7 nerve root) - Can cause weakness in the triceps (muscles in the back of the upper arm and extending to the forearm) and the finger extensor muscles. Numbness and tingling along with pain can radiate down the triceps and into the middle finger. This is also one of the most common levels for a cervical disc herniation C7 - T1 (C8 nerve root) - Can cause weakness with handgrip. Numbness and tingling and pain can radiate down the arm to the little finger side of hand.
Investigation X-ray CT Scan MRI Electromyography (EMG) &Nerve Conduction Velocity (NCV)
X-ray Plain cervical spine radiographs evaluate chronic degenerative changes, metastatic disease,infection, spinal deformity, and stability. But can’t show herniation.
CT-Scan CT scan delineates cervical spine fracture and is used extensively in trauma cases. Occasionally a CT scan with a myelogram may also be ordered, as it is more sensitive and can diagnose even subtle cases of nerve root pinching.
MRI The single best test to diagnose a herniated disc is aMRI (Magnetic Resonance Imaging) scan. A MRI scan can image any nerve root pinching caused by a herniated cervical disk.
Surgery technique Anterior Cervical Discectomy and Fusion (ACDF) , anterior cervical corpectomy and fusion (ACCF). Artificial disc replacement. Key-hole laminoforaminotomy. Laminectomy , laminoplasty Lateral mass fusion.
Discectomy