1. Low Back Pain

2. 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

3. Epidemiology Incidence of LBP: 60-90 % lifetime incidence
5 % annual incidence
90 % of cases of LBP resolve without treatment within 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

4. Differential Diagnoses
Lumbar Strain
Disc Bulge / Protrusion / Extrusion producing Radiculopathy
Degenerative Disc Disease (DDD)
Spinal Stenosis
Spondyloarthropathy
Spondylosis
Spondylolisthesis
Sacro-iliac Dysfunction

5. “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

6. Frequency of Back Pain Types
97%
“mechanical”

7. Better anatomy knowledge = Better diagnoses and treatments

10. 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

12. Biomechanics 20% Posterior 80% Anterior
The rule of Spine loading

13. Ligaments Anterior longitudinal ligament
Posterior longitudinal ligament
Ligamentum flavum
Interspinous ligament
Supraspinous ligament

14. Ligamentous
Anterior longitudinal ligament

16. L4 L5 S1

17. 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

18. “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

19. Onset Acute - Lift/twist, fall, MVA
Subacute - inactivity, occupational (sitting, driving, flying)
Pain effect on:
work/occupation
sport/activity (during or after)

20. Other History Prior h/o back pain Prior treatments and response
Exercise habits
Occupation/recreational activities
Cough/valsalva exacerbation

21. 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

22. Physical Examination Inspection Palpation Strength testing
Neurologic examination
Special tests

23. 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

24. 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

25. 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

27. 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

29. Myelogram:
Procedure of injecting contrast material into the spinal canal with imaging via plain radiographs versus CT

30. 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

31. 7. CT: Best for bony changes of spinal or foraminal stenosis
Also best for bony detail to determine:
Fracture
Degenerative Joint Disease (DJD)
Malignancy

32. 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

33. Degeneration & Tears

34. Disc Classification Normal Bulge Canal Protrusion Extrusion Disc
Bony Endplate
Normal
Bulge
Disc Classification
Protrusion
Extrusion

35. Bulging

36. Protrusion

37. Protrusion

38. Extrusion

39. Extrusion

40. Extrusion

41. 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)

42. 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

43. Epidural Steroid Injections
Indicated for radiculopathy not responding to conservative mgmt
Conflicting evidence
Small improvement up to 3 months
Less effective in spinal stenosis

45. Surgery Laminectomy Hemilaminectomy Discectomy Fusion Instrumented
Non-instrumented fusion
Minimally Invasive Spine Surgery (MISS)
Kyphoplasty
Percutaneous Disc Decompression (PDD)

47. Physical Examination

48. 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)

49. 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

50. 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

51. 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

52. 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

53. L2, L3, L4 testing

54. Neurologic Examination (L4 level)
Motor
Tibialis Anterior
Resisted inversion of ankle
Reflexes
Patellar Reflex (L4)
Sensory
Medial side of leg

56. Neurologic Examination (L5 level)
Motor
Extensor Hallicus Longus
Resisted dorsiflexion of great toe
Reflexes - none
Sensory
Dorsum of foot in midline

58. Neurologic Examination (S1 level)
Motor
Peroneus Longus and Brevis
Resisted eversion of foot,planterflexion
Reflexes
Achilles
Sensory
Lateral side of foot

60. Special Tests Tests to stretch spinal cord or sciatic nerve
Tests to increase intrathecal pressure
Tests to stress the sacroiliac joint

61. Tests to Stretch the Spinal Cord or Sciatic Nerve
Straight Leg Raise
Cross Leg SLR
Kernig Test

63. Test to increase intrathecal pressure
Valsalva Maneuver
Reproduction of pain suggestive of lesion pressing on thecal sac

64. Kernig Sign

65. Tests to stress the Sacroiliac Joint
FABER Test

66. FABER test:
Flexion A-
Bduction
External
Rotation

67. 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

69. 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.

70. 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

71. 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.

72. 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.

73. Investigation X-ray CT Scan MRI
Electromyography (EMG) &Nerve Conduction Velocity (NCV)

74. X-ray
Plain cervical spine radiographs evaluate chronic degenerative changes, metastatic disease,infection, spinal deformity, and stability. But can’t show herniation.

75. 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.

76. 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.

77. 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.

78. Discectomy