1. Primary Care Management of the Degenerative Spine
Jim Messerly D.O.

2. Nothing to Disclose

3. Low Back Pain- Where’s the Pain Coming From???

4. Possible Low Back Pain Generators
Discogenic Pain- With or Without Radicular Pain
Facet Joint Pain- Usually Axial Low Back Pain

5. Most Common Causes of LBP in Adults*
Strain or Sprain 70%
Degenerative 10%
Discogenic 4%
Osteoporotic Fracture 4%
Spinal Stenosis 3%
Spondylolisthesis 2%
Others- Neoplasm, Pelvic/Abdominal pathology
*From the AAFP board review course 2016

6. Red Flags- Indications for Urgent Advanced Imaging
History Findings
Exam Findings
Bladder/Bowel function changes- Retention/ Incontinence
Severe, Unrelenting pain/Night pain
History of Cancer- PbKTL (Prostate, Breast, Kidney, Thyroid, Lung)
Trauma- Falls
Progressive neurologic deficit- Foot Drop (L4,L5), Knee Giving Way (L4,L3)
Major Motor weakness with specific lower extremity manual muscle testing. (Heel/Toe walk, One leg partial squat)
Saddle Anesthesia
Loss of Anal Sphincter Tone

7. Osteoarthritis
Definition- Degeneration of joint cartilage. Also called degenerative joint disease and is the most common chronic condition of the joints, affecting 27 million Americans. OA can affect any joint, but it occurs most often in knees, hips, lower back and neck, small joints of the fingers and the bases of the thumb and big toe. Arthritis Foundation

8. Case #1
55 y/o Hmong male presents to the walk-in with a 2-3 month history of right hip/groin pain with occasional radiation into the right lower extremity. He works at a local window manufacturer with prolonged standing.
PE reveals significant decreased right hip ROM when compared to the left with associated groin pain. SLR were negative BL.

9. Pelvis X-ray

10. Lateral L-Spine

11. Lumbar Spine Anatomy

12. Lumbar Facet Joint Arthritis

13. Degenerative vs Isthmic Spondylolisthesis

14. Degenerative Spondylolisthesis

15. Lumbar Facet Arthritis Pain
Can be difficult to characterize clinically- Nonspecific LBP
In General:
Low back pain worse than lower extremity pain.
Radiates laterally and occasionally to buttocks, but does not follow true radicular pattern.
Pain is worse with standing and walking and better with sitting.
Pain can be worse with spine extension usually more than flexion.
Frequent localized tenderness on exam.
SLR and lower extremity neuro exam usually normal.
Can be associated with Degenerative Spondylolisthesis.

16. Facet Arthritis and Degenerative Spondylolisthesis

17. Severe Facet Arthropathy and Degenerative Spondylolisthesis

18. Facet Arthropathy- MRI Axial View

19. Facet Arthropathy/Degenerative Spondylolisthesis- Sagittal MRI

20. Treatment of Lumbar Facet Arthropathy/ Degenerative Spondylolisthesis Pain
PT for Core Stabilization, Core Stabilization and more Core Stabilization. ?Trial Lumbar Traction.
Cautious use of NSAID’s (Usually older patient’s with concern for GI, Renal and Cardiac issues).
Consider Tylenol ES, 2 tabs TID- regularly, Ask about ETOH intake.
Consider Tramadol. Narcotics last resort.
Injections- Diagnostic Medial Branch Blocks with subsequent Radiofrequency Ablation.
Surgical Fusion last option- ?Better for Degenerative Spondylolisthesis.

21. Degenerative Lumbar Spine with Radicular Pain Nerve Root Distribution

22. Evaluation of Radicular Pain

23. Lumbar Nerve Root Anatomy

24. Lumbar Disc Protrusions- MRI: Need to Correlate Physical and MRI Findings
Lateral Disc Protrusion
Far Lateral/Foraminal Disc Protrusion

25. Lumbar Disc Protrusions- Can Still Occur in the Elderly Patient
Lateral
Far Lateral/Foraminal
Pain generally worse with flexion/sitting/coughing & sneezing.
Pain usually in a predictable radicular pattern- requires careful lower extremity neuro exam.
L3-4 lateral protrusion-L4 radic pain.
L4-5 lateral protrusion-L5 radic pain.
L5-S1 lateral protrusion-S1 radic pain.
Pain generally worse with any prolonged standing and relieved by sitting.
Pain usually in a predictable radicular pattern- requires careful lower extremity neuro exam.
L3-4 foraminal protrusion-L3 radic pain.
L4-5 foraminal protrusion-L4 radic pain.
L5-S1 foraminal protrusion- L5 radic pain.

26. Treatment of Lumbar Disc Protrusions
Lateral
Far Lateral/Foraminal
Physical Therapy- Core stabilization and possible extension exercises.
Oral Steroid Burst
Gabapentin- Start with 100mg and increase slowly.
Transforaminal vs Caudal Epidural Steroid Injections.
Surgery if unrelenting pain, neuro deficit or lack of response to conservative care.
Physical Therapy- Core Stabilization, Avoid extension if aggravates radic pain. ?Traction.
Oral Steroid Burst
Gabapentin 100mg
Transforaminal Epidural Steroid Injections.
Surgery tougher because of facet joint in the way of discectomy.

27. Neuroforaminal Stenosis Secondary to Degenerative Discs and/or Scoliosis-L5

28. Neuroforaminal Stenosis Secondary to Degenerative Scoliosis- L5 Radic

29. Neuroforaminal Stenosis Secondary to Degenerative Scoliosis- L3/4 Radic

30. Treatment for Neuroforaminal Stenosis Due to Degenerative Scoliosis
Same as Far Lateral/Foraminal disc protrusions.
Physical Therapy for Core Stabilization cautious with extension. ?Trial of traction.
Oral Steroid Burst
Gabapentin 100mg
Transforaminal Epidural Steroid Injections
Surgery last resort

31. Spinal Stenosis With and Without Neurogenic Claudication (ICD-10)
Low back pain with or without radicular pain/numbness/weakness in one or both legs that is worse with prolonged standing or walking (with lower extremity pain and cramping relieved by sitting- Neurogenic Claudication). Pain frequently better when leaning forward on shopping cart.

32. Lumbar Spinal Stenosis

33. Lumbar Spinal Stenosis L4-5- MRI

34. Treatment of Lumbar Spinal Stenosis
Physical Therapy- Core Stabilization, Physical Activity Advice- Keep them active! Stationary bike better than walking for fitness.
Oral Steroid Burst
Gabapentin for Radicular Symptoms.
Lumbar Epidural Steroid Injections by Caudal or Transforaminal approach.
Surgery last resort- “We don’t operate on MRI scans” Dr. Ben Hackett, Spine Surgeon. Still follow for progressive lower extremity neuro deficits.

35. Diagnoses of the Degenerative Cervical Spine
Degeneration in the Cervical Spine similar to the Lumbar Spine:
Facet Arthropathy with/without Anterolisthesis with Facet Mediated Pain.
Disc Protrusions with Radicular pain.
Degenerative Discs with Neuroforaminal and Central Canal narrowing with Radiculopathy or Myelopathy.
Be mindful of Cervical Spinal Stenosis with spinal cord compression-Myelopathy. Always ask about problems with gait and balance! Check Hoffman’s Signs.

36. Cervical Spine Facet Arthropathy with Associated Anterolisthesis

37. Cervical Spine Facet Athropathy with Significant Anterolisthesis

38. Cervical Spine Disc Protrusion C5-6 without Spinal Cord Compression

39. Cervical Radiculopathy

40. Cervical Radiculopathy

41. Cervical Disc Protrusion with Spinal Cord Compression and Myelopathy

42. Chronic Cervical Spine Stenosis with Myelopathy

43. Hoffman’s Sign for Myelopathy/Upper Motor Neuron Lesion

44. Other Signs of Myelopathy/Upper Motor Neuron Lesion
Hyperreflexia
Sustained Clonus
Babinski Sign
Romberg’s Testing
Heel/Toe Walk
Tandem Gait
Lhermitte’s Sign

45. That’s All Folks