Lecture 4 and 5 - Lumbar Spine and SIJ

What is the prevalence of Lumbar Strains?

70% of MECHANICAL LOW BACK pain

7-13% of all sport injuries are LOW BACK INJURIES....BUT 60% of them are low back strains

What is the prevalence of Lumbar Sprains?

80% of people will have LBP

What is the Prevalence of Lumbar instability?

20-30 years of age

>60 due to degenerative changes

What is the Prevalence of Lumbar Facet Syndrome?

>50 year old due to osteoarthritis

31% of of all LBP are from facets

What is the Prevalence of Spondylolisthesis?

Childhood-adult

Young athletes with HYPEREXTENSION movements - also rotation

What is the Prevalence of Discogenic Low Back Pain?

20-50 Year old ages

98% happen at L4-L5 and L5-S1

What is the Prevalence of Sciatica?

22% of MALE machine operators

24% of MALE carpenters

14% of MALE Office Workers

What is the Prevalence of Spinal Stenosis?

MOST COMMON in people >50

Effects of 1/1000 people will need surgery

What is the Prevalence of Spondylosis (DDD/DJD, Spinal Arthritis)?

People >40, can start at 20

People who work heavy loads

What is the Prevalence of Ankylosing Spondylitis?

Develop 2nd-3rd Decades

Male > Female

What are Symptoms of Lumbar Strains?

Pain over relatively broad area of the back

USUALLY NO RADICULAR PAIN INTO LEGS

MAYYYYYY have radicular pain into the Buttocks

TENDER TO THE TOUCH

Localized spasm

What are Symptoms of the Lumbar Sprain?

Localized LBP WITHOUT referral into LE

Pain INCREASED with stretching of Ligament

Pain with SUSTAINED postures, movement OUT of sustained postures, of motion

Partial vs Complete Tear

What are Symptoms of Lumbar Instability?

LOCALIZED lumbar pain with history of Recurrent/Episodic locking, catching, or giving way during ACTIVE motion

"Clicking. clunking, or slipping" or feeling instability

SHARP pain with ARC OF MOTION

LONG history of episodic back pain with INCREASAED frequency and INTENITY

INCREASED back pain AFTER prolonged positioning and/or pain at END RANGE of lumbar motion

What are Symptoms of Lumbar Facet Syndrome?

NSLBP with DEEP and ACHY quality, usually localized to UNI or BILATERAL vertebral Area (NSLBP Due to Tri-innervation)

Pain WORSE with Hyperextension, twisting, stretching, lateral bending AND torsional load (Stretching can hurt facet due to facet capsule irritation)

Pain WORSE in the morning, aggravated with rest

RELIEVED with repeated motions

What are Symptoms of Spondylolisthesis?

LBP....WITH Spasms

Pain WITH activity

Tender to the touch over LEVEL OF INVOLEMENT

BELT LIKE PAIN into gluteus muscle

What are Symptoms of Discogenic Low Back Pain?

Cumulative: History of increase flexion position

INITIAL low back pain = Centralized

PROGRESSIVE peripheralization (Indication of impingement or irritation of nerve root)

HYPOMOBILITY (Extension most common)

Pain with RISING from sitting

Pain IN sitting

What are Symptoms of Sciatica?

RADIATING pain in leg BELOW the knee in 1 or more lumbar or sacral dermatomes

PSYCHOLOGICAL distress in women

HYSTERIA significantly associated with Sciatic pain among blue-collar workers

What are Symptoms of Spinal Stenosis?

Lumbar pain with PROGRESSION of LE Pain (Unilateral or Bilateral)

POSTURE dependent, increased pain in LUMBAR EXTENSION

LE NUMBNESS OR TINGLING

LE Muscle CRAMPING

NO PAIN when seated

What are Symptoms of Spondylosis (DDD/DJD, Spinal Arthritis)

LBP especially with CARRYING heavy loads or repetitive twisting

Lumbar STIFFNESS

Possible Sciatic Pain

Feeling of "catching" or "clunking" in lumbar Spine with forward Flex/Ext

What are Symptoms of Ankylosing Spondylitis?

FIRST SYMPTOMS in LATE adolescence or early adulthood

Pain felt in DEEP BUTTOCK and/or in LUMBAR REGIONS WITH morning stiffness in SAME area that lasts for few hours

INTERMITTENT pain ~ weeks for months

Improves WITH activity

Pain usually WORSE at night

Neck pain and stiffness is characteristic of ADVANCED DISEASE

What are signs of Lumbar Strain?

Pain REPRODUCED with RESISTED extension

PASSIVE trunk extension is usually PAIN FREE and UNRESTRICTED

UNABLE to straighten up

INCREASES symptoms with lifting, twisting, forward bending, standing

There may be pain with sustained postures or positions

What are signs of Lumbar Sprain?

END RANGE positions or sustained postures aggravating the symptoms of pathology

PAIN and LIMITED trunk ROM in a particular direction

SUSTAINED or end-range postures will FATIGUE or OVERSTRESS the ligament

EASES with rest, neutral postures

ANY FORCE (passive, active, or resisted) the stresses/stretches the INVOLVED ligament may elicit pain and/or excessive motion

If the ligamentous tear leads to SEGMENTAL INSTABILITY, the physical exam will include findings of instability

ACTIVE TRUNK motion may have a "hitch" or "catch" to the motion, and a Gower's sign may be present - included in Strain as well

What are signs of Lumbar Instability?

Pain in END RANGE positions, SUSTAINED postures, and RAPID movements

Moving slowly in midrange usually ALLEVIATING symptoms

AVOIDING sustained activates or postures

They MAY demonstrate excessive ROM

ABNORMAL quality of movement with hinging or catching

May need to use hands to walk up thighs on the return from a forward bent position (Gower's Sign)

What are signs of Lumbar Facet Syndrome?

Rotation and/or extension

Pain with QUADRANT

Pain WORSENED with extension from a FLEXED position

Pain radiates ACROSS back and often to PROXIMAL THIGH, GROIN, and UPPER LUMBAR

PRIOR hx of LBP

What are signs of Spondylolisthesis?

Lumbosacral Kyphosis at LEVEL of slip resulting in Lumbar Lordosis ABOVE that level

TIGHT hamstrings (To cause PPT to decrease Lordotic Strain)

Cauda Equina Syndrome - IF NERVE INVOLEMENT

RESTRICTED ROM in L/S

PAIN with extension and flexion (Both will cause shearing, Ext > Flex)

STEP OFF DEFORMITY (Due to Pars Fracture)

What are signs of Discogenic Low Back Pain?

Sitting: Slumped posture

USES HAND to take weight off low back

Standing: LATERAL SHIFT (50% of patients) - disc herniation with nerve root compression

DECREASED lumbar lordosis

POSTERIOR pelvic tilt

DECREASE lumbar extension ROM

What are signs of Sciatica?

NERVE ROOT TENSION

NEUROLOGIC Deficits

What are signs of Spinal Stenosis?

Thigh pain WITH lumbar extension (sometimes a time component)

DECREASED muscle stretch reflexes

DECREASED LE Strength (may be L5 myotome specifically)

DECREASED lumbar extension and decrease lumbar lordosis

Pain RELIEVED with Flexion

DECREASED LE Sensation

Consider neurogenic/vascular claudication with ambulation - bicycle test

What are signs of Spondylosis (DDD/DJD, Spinal Arthritis) in the Lumbar Spine?

Pain reproduction with rotation, extension, flexion, or ANY combination

Segmental Hypomobility (possibly hypermobility**)

RADIATING PAIN with SLR if disc herniation

INCREASE pain with lifting/carrying heavy loads, extreme forward bending

What are signs of Ankylosing Spondylitis?

Lumbar HYPOMOBILITY

LOSS of spinal mobility with restriction in flexion and extension, and chest expansion (Decreased Chest Expansions due to attachments to Ribs)

Muscle SPASMS (Overworking of the muscles to move spine?)

Pain in SIJ joint WITH direct pressure OR movement

INFLAMMATION in peripheral joints (They have to move MORE)

MILD Stiffness to total fusion of spine

DECREASED lumbar lordosis (INCREASE thoracic kyphosis and cervical hyperextension) - Fusing will decrease the curvature

What are the layers of the Annulus Fibrosus?

Outer Most

Inner Portion of Annulus

Transition Zone

Nucleus Pulposus

Detail the Outer Most layer of the Annulus Fibrosus

DOUBLE PATTERN INNERVATION - Dorsal Root and Paravertebral Sympathetic --> cause vague and DIFFUSE location and quality of pain

Reinforced by ALL and PLL

Location of Neurovascular Strucutres

STRONGLY bound to the periphery of Vertebral Body and OUTER margins of the end plate

DEENNSSEEEE fibers of Type 1 Collagen fibers

Detail the Inner Most layer of the Annulus Fibrosus

Contains thick type 1 collagen fibers

Progressively LESS dense CENTRALLY and lacks parallel organization of the OUTER MOST ANNULUS

Detail the Transition Zone of the Annulus Fibrosus

THIN fibrous tissue surround and encompass the NP (Nucleus Pulposus)

Detail the Nucleus Pulposus

Gel like composed primarily of water held in suspension

What is the role of the Vertebral End Plate?

Nutrition for the Disc

Regulate production and turnover of Collagen and Proteoglycans

In terms of MRI intensity, what do discs look like compared to over adults in the morning?

Younger adults have higher intensity in the morning

What is the most common reason for spinal surgeries?

Disc Degeneration (90% of SPINAL surgeries)

When does disc degeneration start to present?

When are they almost universal?

3rd Decade (30 Years old)

7th-8th Decade (70-80 Years old)

What are Main Risk factors for Degenerative Disease?

Behavioral and Environmental - Smoking, Occupations w/Heavy lifting, Exposure to vibration

Genetic - Identical Twins have a higher increased chance of DD or DDD (74%+)

Mechanical Factors - Even small structural changes can spread throughout the disc

In Competitive Weightlifters, what degree of degeneration do they have?

Lower than Expected

What is the innervation of the Intervertebral Discs?

Double Innervation (Dorsal Root, Parasympathetic Chain)

What is the Innervation of the Facet Joints?

TRIPLE Innervation sharing AFFERENT innervation with spinal segments ABOVE and BELOW

LBP is the most common cause of what?

(Not pain)

Disability and lost work

Intervention and Prognosis of LBP depends largely on what?

Timeframe

Acute vs Chronic

What is the time frame for "Acute" LBP?

<3 Months

What is the time frame for "Chronic" LBP?

>3 Months

People with Acute LBP will have recovery around what timeframe?

Of those people how many would return to work within 2 Weeks?

What about 3 months?

6-8 Weeks

50% returned to work after 2 Weeks

80% returned to work after 3 Months

Those with Acute LBP are known to have what kind of "episodes"?

What about these flare ups do we need to make clear for patients?

Recurrent condition of "Flare Ups"

Flare Ups do not mean that treatment has failed - they can be managed

Chronic Low Back pain is known to have what type of Prognosis?

Poor :(

Costa et all found how many people with Chronic Low Back pain were pain free and fully functional within 12 months?

33% (Yay!)

Chronic Low Back Pain has hope

For Fracture of Lumbar Vertebrae, what are Red Flags you would obtain from the interview?

History of trauma (minor falls, or heavy lifts for osteoporotic or elderly people)

Prolonged use of steroids

Age of 70

Loss of Function or Mobility

For Fracture of Lumbar Vertebrae, what are Red Flags you would obtain from the Physical Exam?

Point of tenderness over fracture site

Increased pain with WB

Edema in local area

For Fracture of Osteomyelitis of the Vertebrae, what are Red Flags you would obtain from the interview?

Recent infection (UTI, Skin infection)

IV drug user/abuser

Concurrent immunosuppressive disorder

For Osteomyelitis of the Vertebrae, what are Red Flags you would obtain from the Physical Exam?

Deep Constant pain, increases with weight bearing; may radiate

Fever, Malaise, and swelling

Spine rigidity; accessory mobility may be limited

For Spinal Cord Tumor, what are Red Flags you would obtain from the interview?

Age over 50 years (axial skeleton pain)

Age <20-25 years (pain in long bones of extremities)

History of Cancer

Unexplained Weight Loss (5-10% over 4 weeks to 6 months)

Failure of Conservative Therapy

For Spinal Cord Tumor, what are Red Flags you would obtain from the Physical Exam?

Ambiguous presentation in early stages

Constant pain not affected by position or activity; worse with WB, worse at night

Neurological Signs in LE

Increased Lordosis causes what position of the SIJ?

Decreased Lordosis?

Nutation

Counternutation

What are the 3 ways the SIJ achieve stability?

Form Closure

Force Closure

Motor Control Component

For SIJ Form Closure, what strucutres give the SIJ its stability?

Fibro/Hyaline Cartilage Design

Interlocking Ridges and Grooves of Joint surface

Short/Long SIJ ligaments, Sacrotuberous

For SIJ Force Closure, what structures give the SIJ its stability?

Glute Max

Piriformis

TA

Obliques

For SIJ Motor Control, how does this give stability to the SIJ?

Core muscles contract BEFORE load reaches the low back and pelvis = prepare system for incoming force

What plane does the SIJ move?

TRICK QUESTION

Multi-Planar Motion = SIMULTANEOUS rotation and translation through the 3 axes

What are the SIJ "Positions"

Anterior Rotation

Posterior Rotation

Inflare

Outflare

Upslip

Downslip

COMBINATION OF THE ABOVE

What is the most common CAUSE of SIJ pain?

Aka: "Largest Prevalence"

Post Lumbar Fusions - 75% of patients within 5 Years

What are main prevalences of SIJ pain?

Post Lumbar Fusion (75%)

Pregnancy (20%-76%)

Specific Rotation or in One Motion Populations (Baseball Players, Hurdlers, Kicking Activites)

Where is SIJ Referral Pain?

Primary:

Buttocks and Posterior thigh

AT or LATERAL to PSIS

Secondary:

Lateral Thigh

Groin (Be aware of Hip Intraarticular Pathology)

Lateral Calf (Rare)

What are SIJ Aggravating Factors?

Unilateral WB (Standing on 1 Leg) - Putting on socks/shoes, Asc/Desc Stairs, Getting in and out of car, Prolonged Walking (SLS)

Pain with Transitional Motions - Supine to Painful Side, Sit to Stand, Rolling over in bed, Getting in and out of bed

What are SIJ Alleviating Factors?

Bearing weight on UNAFFECTED side

Lying on unaffected side

Manual or Belt Stabilization - Pts will LOVE if joint moves too much, will HATE if Degeneration is present

Injections

Better after 30 minutes in the morning = mechanical

What are the Gradual Onset causes of SIJ pain?

Laxity of SIJ/Pregnancy

Repetitive forces on SIJ and Supporting Structures

Biomechanical Abnormalities (leg length, pelvic obliquity/scoliosis, Iliac crest bone graft)

Adjacent Segment Degeneration - (Post Lumbar Fusion)

What are the Traumatic Onset causes of SIJ pain?

MVA: Foot on Brake

Slip and Fall

Lifting and Twisting

Traction Injuries

What is the Fortin Finger Test for SIJ?

When Pt points at pain while testing

Finger is within 1 cm of PSIS

What pathologies must be Differentiate between when considering SIJ?

Facet

Discogenic

Hip (FAI, Piriformis Syndrome, Intraarticular, Hip OA)

What are Objective Tests that can done to rule out discogenic pain?

SLR

Neuro Exam

Slump Test

What are Objective tests that can be done to rule out Facet pain?

Quadrant

Unilaterals

What are signs of hip OA?

Hip Pain (duh)

Morning Stiffness for <60 min

>50 years old

Hip IR <15 degrees

What are FAI symptoms?

Deep Groin Pain

Lateral Hip Pain

Buttocks Pain

Pain increase w/prolonged sitting or standing and hip flexion movements

Decreased Hip ROM

What are Hip Labral Tear Symptoms?

Anterior Groin Pain

Clicking

Locking

Catching

Instability

Giving Way

Stiffness

What are MOI of Hip Labral Tears?

Direct Trauma

Abnormal Loading Patterns

Hip ER + Extension

What are special tests that can be done for Hip Differential Diagnosis from SIJ?

FABER = Pain if anterior

Scour = 62-91% Sensitivity (SnOut), 43-75% Specificity (SpIn)

FADIR = 75% Sensitivity (SnOut)

What are the 4 Anatomical Positions we look at for SIJ positioning?

ASIS

PSIS

Medial Malleolus

Iliac Crest

What is the SIJ Provocation Cluster?

Which have the Highest Sensitivity?

How many of the 5 do we need to be positive?

Compression

Distraction

Posterior Thigh Thrust

Faber's

Gaenslen's Maneuver

*Need 3/5 positive*

How do we interpret the SIJ cluster results?

1 Positive = Suspicion

2 Positive = Fair Confidence

3 Positive = High Confidence

What TBC process is used for SIJ Treatment?

Low Back

What are the conservative treatments for SIJ?

Medication

Injections

External Stabilization

PT

Functional Training (bed Mobility, Transfers, Sit to Stand)

What are the Operative Treatments for SIJ?

Fusion