Medical management - Lumbar spine

lumbar central spinal stenosis definition

“lumbar myelopathy”

• narrowing of vertebral foramina as a result of space occupying lesion

  • osteophytes

  • disc herniation

  • ligamentous thickening or calcification

  • tumor

lumbar foraminal spinal stenosis definition

• narrowing of the intervertebral foramina often due the result of

  • a loss of disc height of a spinal segment

  • osteophytes

  • disc herniation

  • ligamentous thickening or calcification

  • tumor

lumbar spinal stenosis epidemiology/etiology

leading cause of mobility impairment and spinal surgery in the geriatric population

• affects 5/1000 adults >50 years old

• most affected age group: 50-60

• AMAB>AFAB

how to rule out vascular pathology vs spinal stenosis

vascular pathology symptoms go away with rest and present with cold feet

lumbar central spinal stenosis signs and symptoms

vary depending on extent of severity

• numbness, tingling in lower extremities

• muscular dysfunction in lower extremities - weakness, cramping deep muscle ache

• Gait abnormalities - decreased stride length, increased BOS

• increased or decreased DTRs

• bowel and bladder dysfunction

• deep LBP

lumbar foraminal spinal stenosis signs and symptoms

vary depending on extent of severity

• numbness, tingling in lower extremities following a dermatome

• muscular dysfunction in lower extremities following a myotome

• Gait abnormalities

• decreased DTRs associated with spinal NR

• pain described as shooting, burning, zapping in a dermatomal pattern

• may or may not present with LBP

Lumbar spinal stenosis medical management

• diagnositic imaging

  • radiograph

  • CT myelogram

• PT

• NSAID, muscle relaxants, narcotics prn

• epidural injection - (foraminal stenosis)

• surgery

  • discectomy, miscodiscectomy, foramentomy, laminectomy

    • with or without segmental fusion

degenerative joint disease (DJD) definition

“spondylosis” - OA of facet joints

breakdown of lumbar facet articular surface resulting in loss of cartilage

• articular breakdown leads to

  • inflammatory response

  • osteophyte formation

• can occur with DDD

degenerative joint disease (DJD) epidemiology

• rarely symptomatic in people <40

• commonly symptomatic in people >60

• AMAB > AFAB

• lower lumbar segments more common than upper lumbar segments

degenerative joint disease (DJD) signs and symptoms

• unilateral pain in low back and gluteal region

• stiffness in lumbar spine

• possible nerve root involvement

  • osteophyte formation

  • inflammation

degenerative joint disease (DJD) medical management

• PT

• NSAIDs

• epidural injections (foraminal)

• narcotics

• surgery

  • foraminotomy

  • laminectomy

  • with or without segmental fustion

spondylolysis definition

a defect (fracture) in the pars interarticularis

spondylolysthesis

displacement of a superior vertebrae on an inferior vertebrae due to a fracture in the pars interarticularis

anterolisthesis

spondylolisthesis with anterior displacement

(most common)

restrolisthesis

spondylolisthesis with posterior displacement

grading of spondylolisthesis

Grade 1: 0%-25%

Grade 2: 25%-50%

Grade 3: 50%-75%

Grade 4: >75%

When is paralysis possible with spondylolisthesis

Grade 3-4

Dysplastic spondylolisthesis

true congenital spondylolisthesis

isthmic spondylolisthesis

resultant of stress fracture caused by repetitive hyperextension

degenerative spondylolisthesis

slippage due to facet arthritis and not a pars defect

traumatic spondylolisthesis

due to an acute fracture of the facets or pars

pathological spondylolisthesis

damage due to tumor, metastases, or metabolic bone disease

spondylolysis/spondylolisthesis epidemiology

• most common at L5, then L4

• most spondylolisthesis are isthmic or degenerative

  • isthmic: 5% - 7% in 6-16 year olds

    • 90% are grade 1-2 and asymptomatic until age 40-50

  • degenerative: adults >65 years old

spondylolysis/spondylolisthesis signs and symptoms

• mild to moderate back, buttock, leg pain with lumbar extension

• degenerative spondy presents similar to foraminal stenosis

• depending on grade, catching or shifting in low back present with movement

• possible radiculopathy or neurogenic claudication

degenerative disc disease (DDD) definition

degeneration of intervertebral disc due to aging or disc herniation

Protrusion (disc herniation)

nucleus pulposus bulges outward into annulus fibrosis

• no damage to annulus fibrosis

distance between the edges of the disc material is less than the distance between edges of the base

Prolapse (disc herniation)

nucleus pulposus bulges outward into annulus fibrosis

• damage to annulus fibrosis occus

Extrusion (disc herniation)

nucleus pulposus breaks past the outer lamina and into space beyond

distance between edges of the disc material is greater than the distance at the base

Sequestration (disc herniation)

nucleus breaks free of annulus fibrosis

displaced disc material has completely lost continuity with parent disc

annular tears/fissures

separations between annular fibers, avulsions of fibers from their vertebral body insertions, or breaks through fibers involving one or many layers of annular lamellae

disc herniation

displacement of disc material beyond the limits of the IVD space

can be contained (covered by outer annulus fibrosis) or uncontained

focal herniation

herniated disc less than 90 degrees of the disc circumference

broad based herniation

herniated disc between 90-180 degrees of the disc circumference

bulging disc

presence of disc tissue (180-360 degrees) beyond edges of the ring of apophyses

not considered herniation

degenerative disc disease (DDD) epidemiology/etiology

• 90% of herniations occur at L4/L5 and L5/S1 IVD

• rarely due to acute trauma, usually degenerative

• initial injury usually occurs between 30-40 years

• most herniations are asymptomatic

• 50% recover within 1 month

• 96% recover within 6 months

degenerative disc disease (DDD) signs and symptoms

• dull, deep, poorly localized central LBP

• stiffness with sit←→stand

• persistent pain with sequestration due to leaking nucleus pulposus

• symptom response with sneezing, coughing, bearing down with bowel movement, prolonged sitting, lifting

degenerative disc disease (DDD) medical management

• NSAIDs, muscle relaxants, narcotics prn

• diagnostic imaging

  • radiographs - decreased disc space and DJD

  • MRI - disc desiccation

• PT

• Surgery

  • discectomy, miscrodiscectomy, laminectomy

lumbar radiculopathy definition

spinal nerve root dysfunction due to mechanical or chemical irritation

• results from other lumbar pathologies that have potential to compromise the size of intervertebral foramen

lumbar radiculopathy epidemiology/etiology

• 30% of those is LBP have radiculopathy

• AMAB = AFAB

• symptomatic in 40 year old AMAB and 50 year old AFAB

lumbar radiculopathy signs and symptoms

• pain, numbness, tingling in dermatomal distribution

• weakness in myotomal distribution

• Acute:

  • extremely painful

  • can involve entire dermatome

    • symptoms usually worse at distal end

    • may present with lateral shift deformity

• Chronic:

  • less severe and patchy pain following dermatome

  • permanent neurological changes

lumbar radiculopathy medical management

• diagnostic imaging

  • radiographs - decreased disc space and DJD

  • MRI - disc herniation

• NSAIDs, muscle relaxants, narcotics prn

• oral prednisone

• epidural injection

• PT

Cuada equina syndrome definition

serious dysfunction of cauda equina due to mechanical compression

cauda equina syndrome signs and symptoms

• saddle paresthesia or anesthesia

• difficulty with initiating urine flow or loss of control

• loss of bowel control (late sign)

cauda equina syndrom etiology

• traumatic injury

• disc herniation

• spinal stenosis

• spinal tumors

• meningiomas

• inflammatory conditions

• infectious conditions

• anything that may cause stenosis of central canal

Ankylosing spondylitis definition

chronic, life long inflammatory arthritis affecting axial joints

• inflammation, fibrosis, calcification of attachment points for skeletal mm., ligaments, synovium, and cartilage

• late stage: fusion of vertebrae (bamboo spine)

ankylosing spondylitis signs and symptoms

ossification of annulus fibrosis, anterior longitudinal ligament, apophyseal joints

-Radiograph: bamboo appearance

• acute, painful episodes - “flares”

• back pain and stiffness

  • lumbar often worse in the morning and eases with movement

• SIJ pain

• Hip pain

• Reduced mobility/ROM

  • loss of lumbar lordosis, increased thoracic kyphosis

• chest pain, shortness of breath

• uveitis

Patient interview information supporting ankylosing spondylitis

• onset of gluteal pain >3 months

• dull and hard to localize

• may spread to iliac crests, hip region, and thighs

• begins intermittent but can progress to constant

ankylosing spondylitis epidemiology

• AMAB 2x-3x > AFAB

• AFAB likely to have atypical presentation, often not diagnosed

• symptom onset 17-45 years old

ankylosing spondylitis medical management

• diagnostic imaging

• NSAIDs prn

• PT

Ankylosing spondylitis prognosis

• 10-20% become significantly disabled 20-38 years after initial diagnosis

• 80-95% maintain participation despite severe spinal movement restrictions

Goals of medical management for lumbopelvic pain

• rule out serious pathology

• relieve symptoms

• improve function and limit impact on lifestyle

• refer for ongoing interventions prn

  • PT

  • surgery

  • wellness programs

  • chiropractic

  • acupuncture