T&L spine

low back pain

common, affects 60-70% of the adult population
-most resolve within 30 days, some chronic lasting over 90 days
-some experience flares thru-out life
-pain in the lumbar paraspinal muscles that can radiate to the buttocks, hips, proximal thighs
-possible muscle spasms
-unilateral radicular pain in a dermatome distribution

causes of lower back pain

underlying cause normally not found, but can be
-*mechanical*
-infections such as spondylodiskitis, neoplasms, bone diseases, fibromyalgia

workup for low back pain

full PE: posture, gait, palpation, ROM, strength, sensation, DTRs, special tests such as straight leg raises, FABER, Waddell, look for red flags

myotome

group of muscles that a single spinal nerve root innervates

elbow flexion

C5 myotome

wrist extension

C6 myotome

elbow extension

C7 myotome

finger flexion

C8 myotome

finger abduction

T1 myotome

hip flexion

L2 myotome

knee extension

L3 myotome

ankle dorsiflexion

L4 myotome

great toe extension

L5 myotome

plantar flexion

S1 myotome

C5, C6

spinal roots for biceps reflex

C6

spinal root for brachioradialis reflex

C7

spinal root for triceps reflex

L4

spinal root for patellar reflex

S1

spinal root for achilles tendon reflex

back pain red flags

be sure to be attentive to:
-onset

lumbar strain

injury to the paravertebral spinal muscles, strain of the lower lats
-ligamentous injury that can affect the facet joints, annulus fibrosis, spinal longitudinal ligament
-diffuse pain
-often with history of lifting or twisting injury
-can radiate to the buttocks, hips, proximal thighs

lumbar strain presentation

pain that is hard to pinpoint on palpation, with associated spasms and trigger points
-pt may have difficultly standing erect, changes positions frequently for comfort
-referred pain in the buttocks or thighs

bed rest, NSAIDs, muscle relaxants, heat/ice, stretching, PT, massage

treatment for lumbar strain

superficial or nonanatomic tenderness

Waddell signs of malignering for tenderness

axial loading test

Waddell's sign: light vertical loading over the pts spine in standing position causes lumbar pain

acetabular rotation

Waddell's sign: pain is reported when the pelvis and shoulders are passively rotated in the same plane as the pt is standing
-*positive test if pain within the first 30 degrees*

straight leg raise discrepancy

Waddell's sign: marked improvement of straight leg raising on distraction compared with formal testing

double leg raise

Waddell's sign: organic response is greater with after both legs are raised than with single leg raising

regional disturbances

Waddells sign: weakness, cogwheeling, giving way of many muscle groups that cannot be explained on neuro bases
-sensory disturbances, overreaction to sensation

chronic low back pain

pain lasting more than 3 months
-usually pts are 30-60yo
-recurrent and episodic pain caused by degenerative changes
-radiate into the buttocks, worse with bending, twisting, lifting, stooping
-stiffness, decreased ROM
-back and leg fatigue
-often relieved by lying down

XR, MRI

imaging for chronic low back pain

NSAIDs, muscle relaxants, heat/ice, PT, activity modification

treatment for chronic low back pain

no need to image

Pt presents with low back pain without traumatic onset, no indications of serious underlying pathology. Do you image?

lumbar spondylosis

degeneration of the lumbar spine, usually onsets \>40yo
-may be asymp or cause pain in various locations
-may be due to degenerative disk disease, facet arthropathy, spondylolisthesis, stenosis

intradiscal vacuum phenomenon

gas seen in the disks of the spine seen in degenerative changes

spondylolisthesis

forward slip of one vertebra onto another
-usually *L5-S1*
-most common cause of LBP in teens, due to spondylolisthesis after 40yo
-can be congenital, degenerative, isthmic due to stress fractures, traumatic

spondylolisthesis presentation

pt presents with LBP that radiates down into the buttocks or leg, possible leg weakness
-pain with ROM, worse while standing and better with sitting
-may have a palpable gap along the vertebra

medical treatment

treatment for grade I and II spondylolisthesis
(25-50%)

surgery

treatment for grade III-V spondylolisthesis (\>50%)

XR for spondylolisthesis

AP/lateral, oblique shows "scotty dog view", flexion/extension images to eval for instability

MRI or CT myelogram

imaging to detect canal stenosis in spondylolisthesis

NSAIDs, PT

treatment for spondylolisthesis

surgery

treatment spondylolisthesis if neurological compromise or failed conservative treatment

lumbar stenosis

narrowing of the central spinal canal and/or neuroforamen with compression of the cauda equina and exiting nerve roots
-usually due to bulging discs, osteophyte formation, thick and hypertrophic ligaments, facet arthropathy
-pts \>60yo
*L4-L5 most common*, then L3/4, L2/3, L5/S1

lumbar stenosis presentation

pt presents with slowly progressive LBP with leg pain/cramping/numbness/weakness
-symptoms are worse standing and walking, relieved bending and sitting

XR, MRI, CT myelogram

workup for lumbar stenosis

NSAIDs, PT, epidural steroid injections

conservative treatment for lumbar stenosis

laminectomy, foraminotomy, fusion surgery

treatment for lumbar stenosis if conservative fails

lumbar disc herniation

weakening in the annulus leads to nucleus pulposis bulging out
-most common at *L5-S1*, then *L4-L5*
-pain and numbness in a dermatomal distribution with possible weakness

lumbar disc herniation presentation

pt presents with abrupt unilateral leg pain in a dermatomal distribution
*will often complain of leg pain over back pain*
-pain is worse sitting, better standing or walking

PE for lumbar disc herniation

perform motor and sensory exam, DTRs, straight leg raise test for radiculopathy

30-70 degrees

Pain in what range indicates radiculopathy in the straight leg raise test?

MRI, CT myelogram

workup for lumbar disc herniation

NSAIDs, Medrol (oral steroids), muscle relaxants, PT with traction, nerve root block, epidural steroid injections

treatment for lumbar disc herniation

cauda equina syndrome

*surgical emergency*
-L2-S5 nerve roots compressed, causing weakness or paralysis, impaired bladder/bowel control, loss of sexual function
-due to a sudden decrease in the size of the lumbar canal and compression of the nerve roots

lumbar disc herniation, epidural hematoma, epidural abscess, trauma

possible causes of cauda equina syndrome

cauda equina syndrome presentation

pt presents with sudden onset bilateral leg pain and numbness, perineal numbness in saddle distribution
-leg weakness and stumbling gait
-loss of urinary and anal sphincter control

PE for cauda equina syndrome

perform PE with DTRs, lower extremity sensation, motor strength, gait
-test ability to rise from a chair, walking on the heels and toes
-test perineal sensation and sphincter tone

MRI, CT myelogram

workup for cauda equina syndrome

emergency surgery to decompress nerve roots

treatment for cauda equina syndrome

trauma, cancer, osteoporosis, chronic steroid use

causes of fractures in the lumbar spine

compression fracture

usually due to axial loading, can be traumatic or idiopathic
-common in older adults with osteoporosis
-thoracolumbar junction most common
-usually stable fractures

compression fracture presentation

pt presents with thoracolumbar pain with movement, standing, or walking
-worse with coughing, sneezing, straining
-better when supine
-percussion and palpation of suspected vertebrae is extremely painful
-increased kyphosis or burst fracture development can impinge spinal cord

wedge compression fracture

fracture that typically results from flexion forces, the anterior column is compressed while the middle column remains intact
-usually causes no neuro deficits

XR, MRI, myelogram

workup for compression fractures

post menopausal females, females with predisposing medical conditions, aging males

What patient populations should be investigated further in terms of suspicion of malignant fractures?

osteoporosis

radiography may be hard to detect with, but can see increased radiolucency and cortical thinning
-invagination of the end plates into the weakened vertebral bodies in a "fish deformity"

NSAIDs, acetaminophen, narcotics

treatment of acutely symptomatic compression fractures

early mobilization, soft bracing, muscle relaxants, treat underlying osteoporosis

treatment of moderately severe compression fractures

vertebroplasty

surgical repair of the vertebra, inject artificial cement into the vertebral bodies

kyphoplasty

surgical repair of the vertebra that restores original vertebral height

risks of vertebro/kyphoplasty

cement can escape the vertebral body and cause neuro impairment, increased risk of adjacent vertebral fracture

6-10 weeks

How long does it take for compression fracture pain to resolve?
-any longer suspect multiple myeloma or other underlying conditions

chronic pain after vertebral fracture

can happen even after vertebral fractures are healed, due to abnormal strain on muscles, ligaments, tendons
-facet-joint arthritis can occur

back and core strengthening exercises, transcutaneous nerve stimulation, heat treatments

management of chronic pain following vertebral fracture

transverse process fracture

fracture of the transverse process only, no lamina, pedicle, body or facet complex involvement
-often associated with other injuries such as organ injury or pelvis fractures

pain control

treatment for transverse process fracture

flexion-distraction injury

flexion with axis of rotation between the anterior and posterior longitudinal ligaments
-compression fracture of the anterior column, distraction failure in the middle/posterior columns
-rupture of the posterior longitudinal ligament with instability

chance fracture

due to a flexion-distraction mechanism
-horizontal disruption of the spinous process, lamina, transverse process, pedicles and vertebral bodies
-associated with wearing a seatbelt without the shoulder harness

burst fracture

anterior and middle columns of the spine fail under axial compression force
-posterior vertebral body cortex is disrupted, spinal cord at risk of injury from retropulsion of bone fragments into the spinal canal

translational injury

failure of all three columns of the spine due to shearing forces
-displacement of the spinal column in the transverse plane, compromise spinal canal and with neuro def
-slice fractures, rotational fractures, pure dislocations

trauma surgery and neurosurgery

management of major spinal column injuries

CT of the spine, chest, abdomen, pelvis, MRI if any neuro def or concerns for ligamentous injury

imaging for major spinal column injuries

bracing, surgical spinal stabilization

treatment for major spinal column injuries

sacroiliitis

inflammation of one or both sacroiliac joints
-due to trauma, infection, degenerative disease, pregnancy, spondyloarthopathies such as ankylosing spondylitis and reactive arthritis

sacroiliitis presentation

pt presents with pain in the low back, buttocks, thigh that worsens with prolonged sitting or walking
-tenderness on the SI joint in the back dimples
+FABER test
-erosion, calcifications, sclerosis in the SI joint

MRI with contrast

imaging for sacroiliitis

IV antibiotics, surgery if failure or abscess

treatment of sacroiilitis due to infection

rest, activity modification, NSAIDs, corticosteroid injections

treatment of sacroiilitis due to trauma or overuse

observation

treatment of sacroiilitis during pregnancy

agressive PT, NSAIDs, TNF inhibitors, treat underlying cause

treatment of sacroiilitis due to a larger spondyloarthropathy

scoliosis

the spine becomes abnormally rotated and curved due to congenital malformation, *idiopathic*, degenerative changes, neuromuscular probs such as cerebral palsy or muscular dystrophy
-adolescent age, F progress faster than males, family history significant
-worsen progressively as the child grows

scoliosis presentation

pt presents with uneven shoulders, head not centered above the pelvis, raised hips, uneven waist
-Cobb angle on XR \> 10 degrees

XR, CT, MRI if neuro symptoms

workup for scoliosis

none needed

treatment for scoliosis with Cobb angle under 25 degrees

brace

treatment for scoliosis with Cobb angle 25-45 degrees

fusion surgery

treatment for scoliosis with Cobb angle over 45 degrees

kyphosis

abnormal rounding of the upper back due to congenital changes, postural changes, Scheuermann's disease, *degenerative changes*

age-related kyphosis

changes in the thoracic spine due to underlying osteoporosis and fractures, F\>M

Scheuermann's kyphosis

changes in the thoracic spine that develops in teens, M\>F
-multiple consecutive vertebrae are wedge-shaped