1. Back Pain Neck and Back Pain Study Day January 2013

2. Anatomy of the Lumbar Spine

4. Anatomy: Ligaments

6. Anatomy: Spinal Musculature

7. Assessment: Diagnostic Triage Simple backache (95% of cases) Nerve root pain (<5% of cases) Red flag serious spinal pathology (<1% of cases) (Clinical Standards Advisory Group,1994)

8. Subjective Assessment Site, nature and type of pain +/- altered sensation Aggravating and easing factors Diurnal pattern Special questions / red flags History of present episode and previous episodes PMH DH SH – Yellow flags

9. Hierarchical List of Red Flags (Greenhalgh and Selfe, 2010) 4 red flags – Age >50 years + history of cancer + unexplained weight loss + failure to improve after 1 month of evidence-based conservative therapy. 3 red flags – Age 51 years – Medical h/o (current or past) of: Ca, TB, HIV/AIDS or IVDU, Osteoporosis – Weight loss >10% body weight (3-6 months) – Severe night pain affecting sleep – Loss of sphincter tone and altered S4 sensation – Bladder retention or bowel incontinence – Positive extensor plantar response

10. Hierarchical List or Red Flags 2 red flags – Age 11-19 – Weight loss 5-10% body weight (3-6 months) – Constant progressive pain – Abdominal pain and changed bowel habits, but with no change in medication – Inability to lie supine – Bizarre neurological deficit – Spasm – Disturbed gait

11. Hierarchical List of Red Flags 1 red flag – Loss of mobility,difficulty with stairs,falls,trips – Legs misbehave, odd feelings in legs, legs feeling heavy – Weight loss <5% body weight (3-6 months) – Smoking – Systemically unwell – Trauma – Bilateral pins and needles in hands and/or feet – Previous failed treatment – Thoracic pain – Headache – Physical appearance – Marked partial articular restriction of movement

12. Group Exercise In your groups you will be given a spinal condition. Discuss: – How you would expect a patient with the condition to present: Subjectively Objectively – Would any investigations be required – How would you manage a patient with this condition Present findings back for wider discussion

13. Acute LBP At least 80% of individuals will experience a significant episode of LBP in their lifetime LBP for up to 6 weeks Variable type and severity and can fluctuate Can radiate into buttocks and upper legs Sudden or gradual onset Insidious or jarring/strenuous incident Difficult to identify exact cause Management Reassure: usually benign and self-limiting Pain relief Advise to keep as active as tolerated Physiotherapy

14. Chronic LBP LBP present greater than 3 months Variable type, nature and severity of pain Source of pain not known and original injury/source may be completely healed Exact mechanism not fully understood but thought to be due to sensitisation of nerve pathways Management ? Investigations /referral to MSK CATS service Reassure / empathise Physiotherapy Medications Pain Clinic

15. Degenerative Disc Disease

16. Sciatica / Radiculopathy Commonly due to a prolapsed disc impinging a nerve root or due to degenerative changes Pain usually unilateral spreading through the buttock and down the back of the leg into the calf or foot Often associated with paraesthesia and occasionally with weakness Severe, shooting in nature aggravated by cough/sneeze Management Pain medication Reassurance as usually resolves in 2-3 months Cauda Equina symptoms: emergency admission Progressive worsening neuro: refer neurosurgeon Physiotherapy ? MRI Nerve root block Surgical miscrodiscectomy

17. Disc Prolapse

18. Cauda Equina Syndrome Acutely due to large central disc prolapse or more gradually due to degenerative central changes causing compression of the cauda equina or due to sinister causes Bilateral radiating leg pain Saddle Anaesthsia Progressive motor weakness affecting more than one nerve root +/- gait disturbance Urinary retention, altered micturation, overflow incontinence or reduced bladder or urethral sensation Bowel disturbance and loss of anal tone / sensation Sexual dysfunction Management Emergency admission to A&E for further investigations

19. Spinal Stenosis / Claudication Radiating leg pain, paraesthesia aggravated by walking and standing and distance - limiting Pain progression usually from buttocks to periphery Relief gained by sitting and bending forwards Neurological symptoms (paraesthesia, numbness and/or muscular weakness) also resolve with rest Peripheral pulses normal Management Medication Physiotherapy ? MRI Referral to neurosurgeon if symptoms severe for possible decompression +/- fusion

20. Osteoporotic Wedge fractures Sudden LBP in patients at risk or with osteoporosis May be associated with radicular pain May be no history of injury Management X-ray, bone density scan If symptoms severe and failing to improve consider referral for vertebroplasty with MRI (to check whether #’s have healed) Physiotherapy

21. Objective Assessment: Practical Observations: deformity, gait, balance Movement: quality, range, limiting factors Neurological assessment: relexes, SLR, PKB, myotomes, dematomes, plantar reflexes Hips SIJ’s Palpation and percussion

22. Sensory, motor and reflex distributions Nerve root/nerve DermatomeMyotomeReflex L1Back, over greater trochanter and groinHip flexionnone L2Back, anterior superior thigh and medial thigh above knee Hip flexion(patellar tendon) L3Back, upper gluteal, anterior thigh, medial knee and lower leg Knee extension (quads)Patellar tendon L4Medial gluts, lateral thigh and knee, ant medial lower leg, dorsomedial aspect of foot and great toe Ankle dorsiflexion and inversion (tibialis anterior) Patellar tendon L5Lateral knee and upper lateral lower leg, dorsum of foot Great toe extension (extensor hallucis) Medial hamstring tendon S1Buttock, posterolateral thigh, lateral side and plantar surface of the foot Ankle plantarflexion (gastroc, soleus) and ankle eversion, hip extension, knee flexion Achilles tendon S2Buttock, posteromedial thigh, post medial heel Knee flexion, great toe flexionLateral hamstring tendon

23. General Exercises Practical exercise to go through general exercise advise for patients with acute and chronic LBP Discussion on role of Physiotherapy Core stability Pilates and Yoga

24. Referral Guidelines to Neurosurgery for Patients with Simple Lumbar or Cervical Discogenic/Degenerative Spinal Disease Who Should be Referred? Acute severe radicular arm or leg pain, not showing any improvement with conservative measures (such as physiotherapy) by six weeks following onset. Note that some improvement is likely to imply eventual resolution without requirement for surgery. Pain will be in a nerve root distribution. Neurological symptoms (paraesthesia, numbness and/or muscular weakness) will be in a nerve root distribution and normally exacerbated by cough and/or movement. Progressive neurological symptoms and/or severe radicular pain are indications for urgent referral. Refractive longer term radicular pain (i.e. greater than three months) significantly interfering with lifestyle, disturbing sleep, or causing extended periods off work. Significant spinal claudication, (i.e., radiating leg pain/paraesthesia/numbness coming on with walking and distance-limiting). Pain progression is normally from buttocks to the periphery. Relief is gained by rest and bending forwards. Neurological symptoms (paraesthesia, numbness and/or muscular weakness) also resolve with rest. Peripheral pulses are normal. Patients with signs of myelopathy. All patients should be referred, whether asymptomatic or not, with positive long tract signs or when an MRI has been done and where, even in the absence of long tract signs, there is cord signal change at a stenotic spinal level. Symptoms include numb, clumsy hands, jumping, stiff legs, falls, poor balance and urinary frequency.

25. Who Shouldn’t be Referred? Patients with referred pain. For the purposes of differential diagnosis, referred arm, leg or neck pain is more generalised in distribution and does not follow a specific nerve root distribution. Pain does not generally spread below the elbow or knee. Patients with degenerative neck or back pain generally have no surgically remedial cause and so should not be referred. Patients should be managed with analgesia, advice and physiotherapy. Patients with non-specific neurological symptoms/somatisation disorder. Such patients should be referred to a neurologist or to the pain clinic. Where radicular pain is significantly improving or resolved. Where there is residual dermatomal numbness following a previous radicular pain episode. Where the patient does not want any surgery (other than patients who are considered to be myelopathic).

27. Any Questions? Thank you