Lecture 14: Fundamentals of Spine Pain

Does not include surgeries

Low Back Pain Stats

• 2nd most common symptom-related reason to visit a physician

• Lifetime prevalence 70-90%

• Often resolves spontaneously, but high rate of recurrence

Biopsychosocial impact of pain

• Physical impairment

• Emotional burden

• Decreased quality of life

• Occupational impact

  • Cost of loss of productivity time among US workers from common pain conditions is > 61 billion dollars/year

• Large burden financially & on resources

  • Patients with chronic pain use health care services up to 5X more frequently

Spine Anatomy Sections

1. ANTERIOR COMPARTMENT

   1. VERTEBRAL BODIES

   2. DISCS

2. NEURAXIAL COMPARTMENT

   1. SPINAL CORD

   2. CAUDA EQUINA

   3. NERVE ROOTS

3. POSTERIOR COMPARTMENT

   1. FACET JOINTS

   2. MUSCLES

Differential Diagnosis of Back Pain

• Mechanical

• Non-mechanical

>90% of back pain is mechanical

Mechanical Causes of Back Pain

1. Lumbar strain

2. Herniated nucleus pulposus

3. Internal disc disruption

4. Compression fractures

5. Spondylolysis

6. Facet arthropathy

7. Spondylolisthesis

8. Sacroiliitis

Non-Mechanical Causes of Back Pain

1. Tumor

2. Infection

3. Inflammatory Arthritis

4. Visceral Diseases

5. Misc

Causes of Back Pain - Tumor

PRIMARY SPINAL TUMOR, METASTASES, MULTIPLE MYELOMA, LYMPHOMA

Causes of Back Pain - Infection

Vertebral osteomyelitis, diskitis, HIV, shingles, TB

Causes of Back Pain - Inflammatory Arthritis

Ankylosing spondylitis

Causes of Back Pain - Visceral Diseases

Nephrolithiasis, Prostatis, PID

Causes of Back Pain - Misc

• Hemoglobinopathies

• Psychosomatic D/O

• Neuropathic Joints

• More

Need of immediate spine imaging for mechanical low back pain?

• Immediate routine lumbar spine imaging in patients with low back pain and without features indicating a serious underlying condition did not improve outcomes compared with usual clinical care without immediate imaging.

• Routine lumbar imaging is associated with radiation exposure (radiography and CT) and increased healthcare costs

Red Flags for back pain

• Unexplained fever

• Unexplained weight loss

• Neurologic deficit

• Incontinence

• Saddle anesthesia

• Trauma

• Age > 50

• Night pain (laying down removes gravity)

• History of IVDU

• History of cancer

• Immunosuppression

• Prolonged use of corticosteroids

Facet Joint Pain

• Posterior Compartment Pain

• 15-40% of non-radicular low back pain

• 40-60% of non-radicular neck pain

• Can co-exist with other pain generators

• H&P & imaging often unable to predict if pain originates from the facets

Lumbar Facet Joint Pain

• With prolonged standing in lordotic posture, 16% of axial load assumed by facets

• With lumbar spondylosis and degenerative disc disease → up to 70% of axial load can be transmitted to the facets

• Facets are subject to microtrauma, capsular tears, synovial inflammation, degenerative arthritis, segmental instability, and post-surgical adjacent level stress

• Low back pain with possible radiation into the buttocks, groin, and proximal leg

• Dull, achy, deep, difficult to describe

• Worse with twisting, bending, & standing

• No neurologic deficit

• Degenerative changes may be seen on radiologic studies

Neuraxial Compartment Pain

• Typically causes radicular > axial pain

• Causes:

  • Disc herniation into central canal or foraminal zone

  • Ligamentum flavum thickening, facet hypertrophy, and/or spondylosis

• Can lead to:

  • Radiculopathy

  • Spinal stenosis

    
    

Protrusion vs Extrusion

• PROTRUSION –DEPTH IN ANY PLANE < BASE OF HERNIATION IN SAME PLANE

• EXTRUSION –DEPTH IN ANY PLANE > BASE OF HERNIATION IN SAME PLANE

Lumbar Disc Sequestration

Fragment of HNP is separated from main part of the disc

Nerve Root Pain

• Mechanical Irritation:

  • Disc herniation or foraminal stenosis can compress the nerve root and/or DRG, causing abnormal neuronal discharges along the nerve root

• Chemical Irritation:

  • Disc degeneration releases inflammatory mediators resulting in abnormal discharges from the DRG

  
  

Symptoms of Radiculopathy

• Sharp, stabbing, shooting pain in affected extremity

• Worse with coughing, sneezing, or straining

• May have +SLR and neurologic deficit

• May have loss of reflex, weakness, and/or gait impairment

Common Mechanisms Radiculopathy

• lifting heavy object while bending and twisting at the waist

• Repetitive spinal motions can be causative

L4 or L5 radiculopathy can cause

Foot drop

Etiology Spinal Stenosis

• CONGENITALLY SMALL CANAL SIZE

• DEGENERATIVE OSTEOPHYTES

• SPONDYLOLISTHESIS

• FACET JOINT HYPERTROPHY

• THICKENING OF LIGAMENTUM FLAVUM

• DISC HERNIATION

Spinal Stenosis

• Hallmark symptom: Neurogenic claudication

• Pain, fatigue, and/or paresthesias in lower extremities

• Pain provoked by prolonged standing or walking

• Relieved by rest or leaning forward on objects (shopping cart sign)

Anterior Compartment Pain: Discogenic pain

• Disc degeneration can spread radially into the annulus fibrosis causing annular fissure

  • Nerve endings are only in the outer 1/3 of the annulus

• Worsens with prolonged sitting, stooping forward, bending/twisting at the waist, valsalva maneuvers

• Excessive axial compression may result in endplate edema and fracture

Posture and Back Pain

Anterior Compartment Pain: VERTEBRAL COMPRESSION FRACTURES

• Most common fracture in osteoporotic patients

  • ~ 700,000 fractures annually

  • ~ 260,000 patients with 1st painful fracture diagnosed each year

  • After 1st vertebral compression fracture, the risk of subsequent fracture increases 5-FOLD

Vertebral Compression Fractures

• Acute > chronic back pain

• Can be traumatic or related to minor activity

• Sharp mechanical pain, difficulty finding a comfortable position

• Pain typically improves with rest or lying down

Location of vertebral fractures

• MOST COMMON LOCATIONS:

  • MIDTHORACIC REGION (T7–T8) THORACOLUMBAR JXN (T12–L1)

• MIDTHORACIC REGION

  • THORACIC KYPHOSIS IS MOST PRONOUNCED & LOADING DURING FLEXION IS HEIGHTENED

• THORACOLUMBAR JUNCTION

  • THE RELATIVELY RIGID T-SPINE CONNECTS TO MORE FREELY MOBILE LUMBAR SEGMENTS

Bracing for Compression Fractures

• CASH or Jewett Brace for thoracic compression fractures

• Lumbosacral Orthosis (LSO) for lumbar compression fractures

Management of Spine Pain

• REHABILITATION & MODALITIES

• PHARMACOLOGIC THERAPY

• PSYCHOLOGICAL THERAPY

• INTERVENTIONAL PROCEDURES

Postural Training

Physical Therapy

1. Hamstring Stretches

2. Psoas Stretches

3. Dynamic Lumbar Stabilization

4. McKenzie Exercises

5. Aquatic Exercises

Hamstring Stretches

• defined connection between tight hamstrings and low back pain

• Tight hamstrings → limited pelvic motion → increased strain on the lumbar spine

Psoas Stretches

• Psoas: Primary hip flexor

• Bilateral Psoas muscle action → efficient stabilization of lumbar spine in frontal plane

• Range of exercises that aim to maintain the spine in neutral position, while progressing from:

  • static (lying) to dynamic (standing or jumping)

  • resisting gravity to resisting additional force

  • predictable to unpredictable movements

• Muscular control of spine & core strengthening can reduce pain

McKenzie Exercises

Aquatic Exercise

• Water-based exercises produced better improvement in disability and quality of life of the patients with CLBP than land-based exercise