1. Examination and Treatment of the Lumbar Spine William L. Tontz, Jr., MD

2. Physical Examination History –Mechanism onset of symptoms –PQRST –Family History (Genetic Twin Studies) –Smoking

3. Physical Examination Range of motion Muscle strength Atrophy Sensory exam Specialized tests

4. Imaging Studies Upright radiographs Flexion/Extension views Advanced imaging –MRI –CT –Bone scan

5. Aging Disc Boden study Disc Herniation Spinal Stenosis Segmental Instability Discogenic

6. Herniated Disc Annular tear Posteriolateral herniation nucleus pulposus Pain Neurologic deficit Improvement

7. Spinal Stenosis Pathophysiology Symptoms Low back pain Claudication Leg pain Weakness Co-existent cervical stenosis

8. Segmental Instability Abnormal motion two vertebral segments Retrolisthesis, spondylolisthesis 3-4 mm translation 10-15 degrees angular displacement Chronic and repetitive nerve root irritation

9. Discogenic “Internal disc disruption” Diagnostic dilemma Radial tearing in annulus fibrosis Advanced imaging –MRI –Discogram

10. Spinal Fractures Denis column classification Vacarro/Anderson classification Compression fractures –Traumatic –Pre-existing –Pathologic –Burst Fractures

11. Treatment Non-operative –Calendar –Medications –Physical therapy –Injections Epidurals

12. Operative Treatment 3 general indications –Persistent or progressive neurological deficit Functional –Segmental Instability –Intractable pain despite 3-6 month non-operative care

13. Case Studies