CM II Week 8 (Orthopedic Back Pain)

spine anatomy review

dermatome picture

Torticollis is caused by

abnormal contraction of SCM (head tilted to side of involvement)

Torticollis epi/RF

•More common in Males 3:2

•Common in infants and children

•Risk Factors: oligohydramnios, first pregnancy, traumatic delivery, breech delivery

Torticollis History

•Parents stating child only looking towards one side

•Difficulty turning head when cued

•Upset with tummy time

Torticollis PE

•Inspection: visible contraction of the SCM muscle, neck tilt toward effect side and chin rotated away from effected side

•Palpable neck mass along SCM

•Older children will have a tight band at the SCM resulting in rotation and lateral bending restriction

Imaging for torticollis

•X-ray: cervical spine films. Rule out bony pathology.

•CT: Rule out atlantoaxial (C1-C2) instability

•Ultrasound: Helpful to differentiate congenital muscular torticollis vs. neurologic abnormalities

Conservative tx for torticollis

Passive stretching within the first year of sx

when to initiate surgical tx for torticollis? what is surgery?

•Failed conservative management with at least 1 year of stretching

•Release of SCM or Z-lengthening

Thoracic Outlet Syndrome

•Compression of the neurovascular structures of the brachial plexus and/or subclavian vessels between the neck and axilla

•Neurogenic is most common (95%)

Thoracic Outlet Syndrome epi

•More common in females 3:1

•Thin, long neck, and drooping shoulders

Thoracic Outlet Syndrome hx

•Pain, weakness, numbness and paresthesias over the trapezius, neck, chest, shoulder and/or arm

•Intermittent discoloration and swelling of the upper limb (venous involvement)

•Raynaud-type symptoms: coolness, pallor, erythema, symptoms associated with temperature change (arterial involvement)

Thoracic Outlet Syndrome PE

• sposture that may increase load on brachial plexus

• skin, hair and nail changes.

• muscle atrophy

• pain or palpable mass over the supraclavicular region

*special tests have high false positive rates*

Imaging needed for Thoracic Outlet Syndrome

X-ray

CT

MRI - soft tissue

EMG

Doppler US

what are you looking for on X-ray in thoracic outlet syndrome

chest/cervical spine films

prominent C7 transverse process or low hanging shoulder girdle

what are you looking for on CT in thoracic outlet syndrome

space occupying lesion

malunion of clavicle/rib fracture

What test can be used in thoracic outlet syndrome to detect neurogenic compromise?

EMG

What is used in thoracic outlet syndrome to detect obstruction such as emboli & thrombus?

Doppler US

Evaluate obstruction, embolic and thrombosis of venous or arterial structures

Thoracic Outlet Syndrome: Special Test

Supraclavicular pressure test: Compression at the interscalene triangle

https://youtu.be/ZRKPVtlN59k

Adson test: Compression at the interscalene triangle

https://youtu.be/BnwwvuSagIU

Costoclavicular maneuver: Compression at the costoclavicular space

https://youtu.be/XEWO_cFy5YI

Wright test:  Compression at the retropectoralis minor space

https://youtu.be/e-6AiDPyd2Q

Roos test: Evaluates the entire thoracic outlet

https://youtu.be/0oGGdcQsBKY

Cyriax release test: evaluates the result of unloading the brachial plexus

https://youtu.be/kX1mUhyjZwk

NOTE: Special test have a high rate of false positives!

Conservative Treatment for Thoracic Outlet

NSAIDs, muscle relaxers, limiting over head ROM

PT: back, shoulder girdle and core strengthening

Anterior scalene blocks: US-guided lidocaine or Botox injections

Surgical management of thoracic outlet

Thoracic outlet decompression if conservative treatment failed for 6 months

Treat any vascular event appropriately (stenosis, aneurysm, thrombosis/ischemia, embolism)

Most common cause of lower back pain? RF?

Muscle strain

•Risk factors: obesity, smoking, gender, heavy lifting, vibration, prolonged sitting, poor posture

•90% of low back pain resolves w/in one year

low back pain hx considerations

•Mechanism of injury

•Location and description of pain

•Radiating pain

•Severity and duration of pain

•Time of day

•Neurological symptoms

•Aggregating and relieving factors

•PMH: Cancer, herniated disc, OA, RA, trauma

•Social history: Stress, IVDA, work, domestic issues

low back pain PE

•General: weight, temperature, posture

•Inspect: muscle spasm, lumbar lordosis or kyphosis

•Gait: normal, limp, walking on heels or toes

•Palpate: paraspinal/paravertebral muscles, local tenderness, trigger points, spinous process/step offs, sacroiliac joints

•ROM: forward flexion, extension, lateral bending, rotation

•Neurological: nerve root compression tests, reflexes, sensory, muscle strength

•Consider rectal, pelvic, abdominal or breast with suspicious history

imaging for lower back pain

x-ray

mri

low back pain red flags (summary)

Pt presents with:

- fecal incontinence

- loss of sensation in "saddle" area

- urinary retention

What are you concerned about?

Cauda equina syndrome

Cauda Equina Syndrome

•Lumbar compression of the nerve root in the thecal sac

•Commonly caused by an acute lumbar disc herniation

Cauda Equina Syndrome epi/location

•More common in males

•Commonly occurs at L4-L5

Cauda Equina Syndrome Hx

•Back pain with heavy lifting with lumbar spine flexed

•Unilateral/bilateral leg pain

•Saddle anesthesia

•Bladder/bowel dysfunction

PE of cauda equina syndrome

•Unilateral/bilateral lower extremity weakness

•Decreased rectal tone on voluntary contraction

•Decreased/no sensation to sharp touch in the perianal region (S2-S4 dermatomes)

•Decreased/absent lower extremity reflexes

Gold standard imaging of cauda equina?

other?

Urgent MRI: Gold Standard. Central disc herniation with complete spinal canal compromise

You suspect cauda equina syndrome, but pt has cardiac pacemaker (CI for MRI). What imaging can you perform?

CT myelography

Treatment of cauda equina

surgical decompression within 24 hours!

No later than 48 hours... an emergency, delays in dx and tx lead to permanent impairment!

Define lumbosacral sprain

•Acute or chronic muscle tendon or ligamentous strain

•Most common cause of lower back pain

PE of lumbosacral sprain

•Slow/antalgic gait

•Tenderness to palpation over muscular structures

•Pain with lumbar ROM: flexion, extension, ipsilateral bend or rotation

•Normal neurologic exam

back pain that worsens with bending, twisting, and lifting, coughing or sneezing is indicative of

lumbosacral strain

hx may include +/- pain radiating down legs but does not pass the knees

Lumbosacral Strain Imaging

Xray: rule out degenerative cause of lower back pain.

Normal if lumbosacral strain is the primary cause

treatment of lumbosacral strain

•1-2 days of bed rest for severe pain

•NSAIDs/Acetaminophen

•+/- Muscle relaxers

•Physical therapy (Williams Flexion Exercise)

NO Narcotics!

Willams Flexion Exercise

Set of physical exercises that help to improve:

1. Lumbar flexion

2. Avoid lumbar extension

3. Strengthen abdominal and gluteal muscles

lifting techniques...

lift with your legs not your back

Positive Waddell Signs may indicate...

psychological cause of back pain (possible malingering)

these are test to assess for nonorganic lower back pain

What are the Waddell Signs

1. Tenderness that is not anatomic (superficial/diffuse)

2. Axial loading (should not cause low back pain)

3. Distraction on straight leg raise while in seated position

4. Nonanatomic or breakaway weakness that do not follow neuroanatomy

5. Overreaction (most important Waddell sign)

Kyphosis "Hunch Back"

•Anterior wedging of >5 degrees in at least 3 vertebrae

•Thoracic spine commonly effected

epi kyphosis

•10-12 y/o common age of onset

•More common in males

hx kyphosis

•Thoracic or lumbar pain

•Cosmetic complaints

PE kyphosis

•Visible deformity which is worsened with leaning forward

•Normal kyphosis between 20-45 degrees

•Tight hamstrings, iliopsoas, and anterior shoulder

•+/- hyperlordosis of the cervical and/or lumbar spine

Imaging necessary for kyphosis & findings

Xray w/ AP & Lateral view

Anterior wedging & disc narrowing

Conservative tx of kyphosis

Kyphosis <60 degrees and mild symptoms

PT: postural improvement exercises and back extensor strengthening

Bracing: kyphosis between 60-80 degrees.. usually does not lead to correction but can stop progression

when is surgical intervention indicated in kyphosis?

kyphosis >75 degrees

neurologic deficit

spinal cord compression

severe pain in adults

Surgical tx of kyphosis

Posterior spinal fusion +/- osteotomy +/- anterior releass

Scoliosis involves what plane

Coronal plane spinal deformity

What portion of the spine is affected by scoliosis (common)

Thoracic spine commonly effected

epi of scoliosis

•More common in females

•More common in adolescent 10-18 y/o

•Right sided thoracic curve most common

•Four common types of scoliosis: congenital (malformation), neuromuscular (cerebral palsy, polio, neurofibromatosis), degenerative and idiopathic

hx scoliosis

•Dorsalgia or lumbar pain

•Uneven shoulders

•Radiating pain down legs (impingement)

•Fatigue

PE of kyphosis

•Visible deformity of spine with +/- uneven shoulder and/or pelvic height

•Often picked up during school screening. Adams forward bending test >7 degrees on scoliometer

•Hairy patches on back or cafe-au-lait spots  (neurofibromatosis)

•Respiratory restriction in severe cases (PFT)

Gold standard imaging for scoliosis

X-ray: standing AP & lateral view

What measurement tool is used to determine the severity of scolosis curvature & determine tx plan?

Cobb angle

angle between 2 lines perpendicular to the upper and lower most involved endplate vertebrae. Helps determine severity of curvature and facilitate tx plan

Conservative tx of scoliosis

Observation (mild, <25 degrees of curvature) with serial xrays

Bracing & PT (Moderate, 25-45 degrees of curvature). Bracing won’t fix deformity but will help stop progression.

Posterior spinal fusion is indicated in what degree of scoliosis

Scoliosis cobb angle >45 degrees

Spinal stabilization of the curve > correction.

Degenerative disorder of the spine

Osteoarthritic changes of the spine over time that can affect surrounding structures and lead to chronic neurological symptoms

degenerative disorders of the spine

insidious onset of neck or lumbar pain

radiating pain that follows a dermatome (impingement)

no associated injury w/ onset of symptoms

degenerative disorders of the spine - PE

Slow/wide gait

"Step off" second to spondylolisthesis

ROM: Pain with flexion, extension, and radicular pain

Neurological: Weakness, sensory changes and decrease strength with resisted strength testing. Diminish/hyper reflexes

Differentiate PE findings between degenerative disorder & lumbosacral pain

In degenerative you WILL see NEURO changes and RADICULAR pain (none in lumbosacral pain)

Gold standard testing for Degenerative Disorders of the Spine?

MRI

MRI + contrast to evaluate infection or tumor

other imaging for Degenerative Disorders of the Spine

•Xray: Decreased disc space, instability (anterolisthesis), obvious deformity

•CT Myelogram: If MRI is contraindicated (pacemaker, metallic implants)

Treatment of degenerative disorder

•Oral steroid taper (Medrol Dose pack)

•NSAIDs

•Activity modification

•Physical therapy

•Often effective in the first 6 weeks of sx onset

•Epidural steroid spine injections

Surgery --> Refer to ortho for definitive tx

What is spinal stenosis?

degenerative spinal condition characterized by the narrowing of the central spinal canal, lateral recess or neural foramen

What structures may cause spinal stenosis?

Facet Osteophytes

Spondylithesis

Herniated Disc

Ligamentum flavum hypertrophty

spinal stenosis epi/RF

•Most common reason for lumbar spine surgery in patients > 65 years old

•Most commonly occurs at L4-5 (91%)

•Risk factors: Caucasian, increased BMI, congenital spine anomalies (20%)

spinal stenosis hx

•Back pain (referred pain to gluteal region)

•Unilateral leg pain

•Pain worse with extension (walking, standing upright)

•Pain relieved with flexion (sitting, leaning over shopping cart, sleeping in fetal position)

•Weakness

PE spinal stenosis

•Limited physical findings

•Kemp sign = Positive

•Straight leg raise = Negative

•Valsalva test = Negative (+ in herniated disc!)

Kemp sign

Unilateral radicular pain from foraminal stenosis made worse by extension of the back

+ IN SPINAL STENOSIS

Valsalva test is negative in ____ and postive in ______

spinal stenosis; herniated disc

Gold standard imaging for spinal stenosis

MRI

MRI findings in spinal stenosis

•Central stenosis with a thecal sac

•Obliteration of perineural fat and compression of lateral recess or foramen

•Facet and ligamentum hypertrophy

other imaging for spinal stenosis

Xray

•Nonspecific arthritic changes (disk space narrowing, osteophyte formation)

•Degenerative scoliosis

•Degenerative spondylolisthesis hypertrophy

CT Myelogram

•If MRI is contraindicated (pacemaker, metallic implants)

Conservative management of spinal stenosis

•NSAIDs

•Physical therapy

•Weight loss

•Bracing

•Steroid injections (epidural and transforaminal)

spinal stenosis - surgery

refer to orthopedics if failed conservative management or severe leg symptoms interfere with activities of daily living

define disc herniation

part or all of the soft, gelatinous central portion of an intervertebral disk is forced through a weakened part of the disk

epi of disc herniation

•Peak incidence in 40s and 50s

•More common is males 3:1 ratio

etiology disc herniation

•Recurrent torsional strain leads to tears of the outer annulus resulting in herniation of nucleus pulposis

•L4-L5 or L5-S1 are the most common levels affected 95%

disc herniation history

•Lower back pain

•Radicular pain. Worse with sitting, coughing or sneezing and improved with standing.

•Pay attention to possible cauda equina symptoms (Bilateral leg pain, LE weakness, saddle anesthesia or bowel/bladder incontinence)

Special Tests for Disc Herniation

•Straight leg raise (SLR)

•Cross straight leg raise (CSLR)

•Sitting root test (SRT)

•Kernig test - Rule out meningitis

Straight leg test

•Puts tension on L5 or S1 nerve root

•May be done sitting or supine

•Positive with pain and paresthesia down the leg at 30-70 degrees hip flexion

•Most important test for identifying who is a good candidate for surgery

Identify the type of prolapse:

•Back pain only

•Can associate with cauda equina syndrome

Central prolapse (disc herniation)

Identify the type of prolapse:

•Most common (90-95%)

•Weak posterior longitudinal ligament (PLL)

•Affects the descending/lower nerve root

•at L4-L5 affects L5 nerve root

Posterolateral prolapse (disc herniation)

Identify the type of prolapse:

•Affects exiting/upper nerve root

•at L4-L5 affects L4 nerve root

Foraminal prolapse (disc herniation)

Gold standard for disc herniation

MRI

•Highly sensitive and specific

•Red Flags = MRI ASAP!

treatment of disc herniation (conservative)

•Couple days of bedrest followed by activity as tolerated

•Medications: NSAIDs, Muscle relaxers/Gabapentin, Oral steroid taper (Medrol Dose pack)

•PT: Focus on extension exercises

•Corticosteroid injection: epidural injections and nerve blocks

treatment of disc herniation (surgical)

•Failed conservative management or red flags are present

•Refer to orthopedics (laminotomy and discectomy)