Dabbas W, M.D. Neurosurgeon Dept. of Neurosciences, School ... · arthritis 2% visceral 1% tumor, infection, inflammatory arthritis 7 97% “mechanical” ... Non-narcotic analgesics:

Dabbas W, M.D.

Neurosurgeon

Dept. of Neurosciences,

School of Medicine, Al

Balqa University

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

3

Disability Age and LBP:

Leading cause of disability of adults < 45 years old

Third cause of disability in those > 45 years old

Prevalence rate: Increased 140 % from 1991 to 2000 with only 125 %

population growth

Nearly 5 million people in the U.S. are on disability for LBP

4

Lifetime Return to Work

Success of < 50 % if off work > 6 months 25 % success rate if off work > 1 year Nearly 0 % success if return to work has not

occurred in 2 years

5

Differential Diagnoses Lumbar Strain

Disc Bulge / Protrusion / Extrusion producing Radiculopathy

Degenerative Disc Disease (DDD)

Spinal Stenosis

Spondyloarthropathy

Spondylosis

Spondylolisthesis

Sacro-iliac Dysfunction

6

Frequency of Back Pain Types visceral 2% ,tumor 1%

,infection

inflammatory

arthritis

2% visceral 1% tumor,

infection,

inflammatory

arthritis

7

97%

“mechanical”

Better anatomy knowledge =

Better diagnoses and treatments

Vertebra

Body, anteriorly

Functions to support weight

Vertebral arch, posteriorly

Formed by two pedicles and two laminae

Functions to protect neural structures

Biomechanics

www.brain101.info 13

80% Anterior

20% Posterior

The 80-20 rule of Spine loading

Ligaments

Anterior longitudinal ligament

Posterior longitudinal ligament

Ligamentum flavum

Interspinous ligament

Supraspinous ligament

Anterior longitudinal ligament

Ligamentous

Sciatica is defined as… 1. Pain radiating up the back

2. Pain radiating to the thigh

3. Pain radiating below the knee

4. Pain in the butt

Pain

radia

ting u

p the b

ack

Pain

radia

ting to

the th

igh

Pain

radia

ting b

elow th

e knee

Pain

in th

e butt

25% 25%25%25%

•L4

•L5

•S1

PATIENT HISTORY “OPQRSTU” Onset

Palliative/Provocative factors

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

Age > 50 History of Cancer Weight loss Unrelenting night pain Failure to improve

Infection

IVDU Steroid use Fever Unrelenting night pain Failure to improve

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 month unless with red flags • Specifics:

WBC ESR or CRP HLA-B27 Tumor markers: Kidney Breast Lung Thyroid

Prostate

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2. Radiographs:

• 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

29

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5. Myelogram:

Procedure of injecting contrast material into the spinal canal

with imaging via plain radiographs versus CT

31

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

32

7. CT: Best for bony changes of spinal or foraminal stenosis

Also best for bony detail to determine:

Fracture

Degenerative Joint Disease (DJD)

Malignancy

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9. MRI • Best diagnostic tool for:

Soft tissue abnormalities: • Infection • Bone marrow changes • Spinal canal and neural foraminal contents

Emergent screening: • Cauda equina syndrome • Spinal cord injury • Vascular occlusion • Radiculopathy

Benign vs. malignant compression fractures Osteomyelitis evaluation Evaluation with prior spinal surgery

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Break for Physical Examination Hands-on Session

Inspection Observe for areas of erythema

Infection

Long-term use of heating element

Unusual skin markings

Café-au-lait spots

Neurofibromatosis

Hairy patches, lipomata

Tethered cord

Dimples, nevi (spina bifida)

http://www.viewingmedicine.com/catalogue/thumb/1641-MW03614R.jpg

Inspection (cont.) Posture

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

PID L3-L4 L4-L5 L5-S1

Compressed

root

L4 L5 S1

% 5-10% 40-45% 40-45%

Reflex affected Knee - Ankle jerk

Motor Q. Femoris

(knee ex)

EHL & tibialis

(foot drop)

Gastrocnemiu

s

(plantarflexion)

Sensory M. maleolus Dorsum of

foot

L. maleolus

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

dorsifexion

Reflexes - none

Sensory

Dorsum of foot in midline

Neurologic Examination (S1 level) Motor

Peroneus Longus and Brevis

Resisted eversion of foot

Planter flexion

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

Kernig Sign

Pain present Pain relieved

Test to increase intrathecal pressure

Valsalva Maneuver

Reproduction of pain suggestive of lesion pressing on thecal sac

Tests to stress the Sacroiliac Joint

FABER Test

FABER test:

Flexion

A-

Bduction

External

Rotation

Disc Degeneration: Findings?

56

Narrowing

Endplate sclerosis

Osteophyts

Degeneration & Tears


Disc Classification

58

Protrusion Extrusion

Canal

Disc

Bony

Endplate

Normal Bulge

Bulging


Protrusion


Protrusion


Extrusion



Extrusion


Extrusion

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)

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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

66

Epidural Steroid Injections Indicated for radiculopathy not responding to

conservative management

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)


Management of an acute low back muscle strain should consist of all the following EXCEPT:

1. X-rays to rule out a fracture

2. Educate the patient on generally good prognosis

3. Non-opiate analgesics

4. Remain active

Your patient with LBP has paresthesias in the lateral foot, decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?

1. L4

2. L5

3. S1

4. S2

Thank you

Documents

Dabbas W, M.D. Neurosurgeon Dept. of Neurosciences, School ... · arthritis 2% visceral 1% tumor, infection, inflammatory arthritis 7 97% “mechanical” ... Non-narcotic analgesics: