Rheum: 4M1: Back Pain

Front 1

Related disc herniation loation to affected nerve root

Back 1

VERY TESTABLE

Front 2

Spine is composed of:

* _ cervical segments.

* __ thoracic segments.

* _ lumbar segments.

* ______ (fuse sacral segments).

* _______.

Back 2

Spine is composed of:

* 7 cervical segments.

* 12 thoracic segments.

* 5 lumbar segments.

* Sacrum (fuse sacral segments).

* Coccyx.

* (Transitional levels common).

Front 3

Pars Interarticularis

in latin, "Part between the joint"

Back 3

involved in a lot of the spondolithesis

Front 4

Cauda Equina

Back 4

The cauda equina is a structure within the lower end of the spinal column of most vertebrates, that consists of nerve roots and rootlets from above. The space in which the cerebrospinal fluid is present is actually an extension of the subarachnoid space.

Front 5

Disc degeneration/herniation most common at

Back 5

L4/L5 (90%) > L5/S1

Front 6

Low Back Pain - Epidemiology

Prevalence

Back 6

Affects 85% of popoulation during lifetime
26% occurrence per year

Mean age = 35

M:F = 1:1

Front 7

Factors associated with an increased risk of spine pain, independent of herniation, include:

(8)

Back 7

o Increasing age.
o Obesity.
o Height above 6 feet in men and above 5 feet 7 inches in women.
o Previous episodes of spine pain.
o Exposure to vibration (industrial, vehicular).
o Sagittal malalignment.
o Pregnancy.
o Smoking.

Front 8

Causes of low Back Pain:

>90% of cases caused by? (3)

<10% caused by? (5)

Back 8

>90% caused by:
- degenerated changes
- traumatic fractures
- soft tissue injuries (FOCUS ON THESE)

<10% caused by:
o Infections such as those resulting from tuberculosis or staphylococcus.
o Metabolic disorders such as osteoporosis, hyperparathyroidism, renal osteodystrophy, malabsorption and other nutritional deficiencies, all of which may result in osteopenia and secondary compression fractures.
o Primary tumors of the spine, paraspinous soft tissues, or neural tissues.
o Metastatic tumors from breast, lung, prostate, kidney, myeloma, or thyroid, all more common in patients older than 50.
o Inflammatory arthritis such as rheumatoid arthritis or ankylosing spondylitis.
o Sacroiliac joint disease, hip pathology.

Front 9

The large majority of spine pain problems arise from:

(4)

Back 9

o Acute and chronic sprains.
o Acute and chronic fractures.
o Degenerative disc and facet-joint disease.
o Disc herniations.

Front 10

Low Back Pain - Treatment Rationale

There are several “red flags” to look out for that warrant early imaging. The red flags and the reasoning behind them are:

Back 10

o Trauma—risk of fracture.
o Age greater than 50—lower bone quality and higher risk of cancer.
o History of cancer—risk of cancer metastasis.
o Unexplained weight loss—risk of cancer.
o Fever or immunosuppression—risk of infection.
o IV drug use—risk of infection/cancer.
o Neurological Deficit—risk of nerve root compression.
q

Front 11

One reason not to image is that in a study of normal patients over the age of 40 without any complaints of back or leg problems, 29% will have ______________ (symptomatic/asymptomatic?) nerve root compression.

Back 11

One reason not to image is that in a study of normal patients over the age of 40 without any complaints of back or leg problems, 29% will have ASYMPTOMATIC nerve root compression.

Front 12

If pain continues despite __ weeks of conservative treatment, then imaging is warranted.

Back 12

If pain continues despite 4 weeks of conservative treatment, then imaging is warranted.

Front 13

T/F
If there is a red flag, then you image

Back 13

True

Front 14

No red flags: what do you do?

Acute pain?

Sub acute pain ?

Chronic pain?

Chronic intermittent pain?

Back 14

Acute pain - conservative treatment for 4 weeks, re-evaluate. image if pain continues

Sub acute pain - pain for >4 weeks, failed symptomatic treamtnet. image

Chronic pain - no imaging unless changein sx

chronic intermittent pain - treat as acute pain patients (go a year or 2 between episodes)

Front 15

Plain xrays

___ yield as screening for acute LBP

AP/lateral x-rays better in what patient position?

AP/lateral x-rays (supine)
oblique xrays will show _______

Back 15

low yield as screening for acute LBP

upright standing is preferred

oblique xrays will show pars defect

Front 16

Pars defect

Back 16

fractured neck between superior/inferior facet (look up again)

An oblique x-ray of the lumbar spine shows what appears to be a "scotty dog" first described by Lachapelle. The nose of the dog is the costal/transverse process; the ear, the superior facet; the neck, the pars interarticularis; the collar, the pars defect (dark on x-ray); the eye, the pedicle seen end on; the body, the lamina; the hindefoot, the spinous process; the tail if pointing straight up=opp. superior articular facet and if pointing horizontally is the transverse process of the opposite side; and the forefoot, the inferior articular process

Front 17

MRI w/out contrast
- invasive?
- shows soft tissue well/poorly?, bony anatomy well/poorly?
- contrast for (3)

CT myelogram
- invasive/non-invasive?
- visualizes bony anatomy well/poorly? and ___ spaces
- indirectly shows?

Back 17

MRI w/out contrast
- non-invasive
- shows soft tissue well, bony anatomy poorly
- contrast for tumor, infeciton, scar tissue

CT myelogram
- invasive - lp
- visualizes bony anatomy well and CSF spaces
- indirectly shows canal soft tissue compression

Front 18

Imaging

MRI without contrast
- cost?
- is an (cost?) test, but is not very (invasiveness?) and gives a (high/low?) yield of clinical information. It shows _____ tissues the best of any studies, and is good for demonstrating ___ _______, canal _______ and ________ changes of the disc space or facet complexes.

It is not great at examining ______ anatomy. Contrast is not routinely given and is most helpful in looking for (3) after a previous operation.

Back 18

When imaging the low back, MRI without contrast is an expensive test, but is not very invasive and gives a high yield of clinical information. It shows soft tissues the best of any studies, and is good for demonstrating disc herniation, canal stenosis and arthritic changes of the disc space or facet complexes. It is not great at examining bony anatomy. Contrast is not routinely given and is most helpful in looking for tumor, infection or scar tissue after a previous operation.

Front 19

Imaging CT:

CT myelogram is an (cost?) test and is probably (more/less?) sensitive than MRI is showing subtle nerve root compression.

It is an (invasive/non-invasive?) test. Dye is injected into the _____ ____ and the course of the nerve roots can be well visualized.

CT shows (good/poor?) detail of bony structures.

_____ _______ outside of the canal are more difficult to see when compared to MRI.

Back 19

CT myelogram is an expensive test and is probably more sensitive than MRI is showing subtle nerve root compression. It is an invasive test. Dye is injected into the thecal sac and the course of the nerve roots can be well visualized. CT shows very good detail of bony structures. Soft tissue structures outside of the canal are more difficult to see when compared to MRI.

Front 20

Treatment

For axial low back pain, radiculopathy without neurological deficit and spinal stenosis, the mainstays of initial conservative management are:

(5)

Back 20

For axial low back pain, radiculopathy without neurological deficit and spinal stenosis, the mainstays of initial conservative management are:

o Anti-inflammatories including NSAIDS, oral steroids.
o Muscle relaxants.
o Narcotic analgesics.
o Oral steroids
o Back excercises

Adjuvant
o Therapy (physical, massage, chiropractic).

Front 21

Specific Low Back Diagnoses

Back 21

Mechanical low back pain
Radiculopathy
Spinal Stenosis
Spondylolisthesis
Cauda Equina Syndrome

Front 22

Mechanical low back pain

o Symptoms/complaints?
o Pathophysiology?
o Neurological findings?
o Radiographic findings?
o Treatment?

Back 22

o Symptoms/complaints—Low back pain much greater than leg symptoms, muscle spasm.

o Pathophysiology—Complex and multifaceted (we don’t know). Can be related to trauma or degenerative changes of the bones, ligmaments, discs, joints.

o Neurological findings—No true motor weakness, numbness. Negative straight leg raise, reverse straight leg raise, FABER sign.

o Radiographic findings—No fracture, instability, nerve root compression, stenosis.


o Treatment—Best treated with conservative treatment or possible injections. Surgery indicated in rare circumstances.

Front 23

Mechanical Low Back Pain

Avoid _________

_______ treatment preferred

Back 23

surgery

conservatice

Front 24

Radiculopathy

o Symptoms/complaints?
o Pathophysiology?
o Neurological findings?
o Radiographic findings?
o Treatment?

Back 24

o Symptoms/complaints—Severe leg pain, numbness and/or weakness. Variable back symptoms.

o Pathophysiology—Chemical irritation of a nerve root (from annular tear) or direct compression of a nerve root.

o Neurological findings—Possible weakness, numbness or pain in radicular pattern. Positive straight leg raise for L5 or S1 nerve roots. Postive femoral stretch for higher nerve roots. Negative reverse straight leg raise, FABER sign.

o Radiographic findings—Sometimes normal. Often with impingement of affected nerve root.

o Treatment—Conservative treatment and injections are option in absence of weakness. Surgery is option for weakness or debilitating symptoms.

Front 25

Radiculopathy can be predicted with high success based on the:

(5)

What herniations are most common?

Back 25

* History.

* knowledge of muscle innervation.

* knowledge of dermatomes.

* knowledge of reflexes.

* Physical examination.

Central canal herniations are the most common and usually affect the nerve root that exits at the level below (for example a central L4/5 disc herniation usually pinches the L5 nerve root—pictured on right).

Far lateral disc herniations are much rarer and affect the nerve root exiting at that level (L4 nerve root in example on right).

Front 26

Cauda Equina Syndrome

o Symptoms/complaints?
o Pathophysiology?
o Neurological findings?
o Radiographic findings?
o Treatment?

Back 26

o Symptoms/complaints—Severe bilateral leg pain and distal weakness. Urinary retention or incontinence.

o Pathophysiology—Large disc herniation causing compression of the lower lumbosacral nerve roots causing weakness and bowel/bladder dysfunction.

o Neurological findings—True motor weakness. Increased post void residual.

o Radiographic findings—Large disc herniation filling most of canal.

o Treatment—Urgent surgery indicated.

Front 27

Cauda Equina Syndrome = ______ emergency

______ work up necessary

Back 27

surgical!

Urgent!

Front 28

Lumbar Stenosis
o Symptoms/complaints?
o Pathophysiology?
o Neurological findings?
o Radiographic findings?
o Treatment?

Back 28

o Symptoms/complaints—Tiredness of legs with activity relieved quickly by leaning forward or sitting down (neurogenic claudication).

o Pathophysiology—Usually arthritic degeneration of the spine with hypertrophy of the facets and ligamentum flavum as well as osteophyte formation along the disc space.

o Neurological findings—Usually no motor or sensory deficits. Negative straight leg raise, reverse straight leg raise, FABER sign.


o Radiographic findings—Degeneration of the disc space and facets causing narrowing of the canal (stenosis) centrally or in the lateral recesses.

o Treatment—Conservative management, injections and surgery are options.

Front 29

Lumbar Stenosis - Neurogenic Claudication

Different from vascular claudication which affects distal legs more than proximal legs, unlike neurogenic claudication which is proximal more than distal

tiredness/pain in ____ and _____

vascular -- ____ rest
neurologic -- ____ rest

Secondary back pain from ______ _____

Back 29

back and buttoms/proximal legs


vascular -- long rest
neurologic -- short rest

Secondary back pain from bending forward

Front 30

Lumbar Stenosis - Neurogenic Claudication

Symptoms often improve with _____

examples? (look in ppt again)

Back 30

Symptoms often improve with flexion

Front 31

o Radiculopathy (radiculitus)

—Disease of a _________. This most commonly is used to describe irritation of a _______________ occurring from _________ or __________ of the nerve root.

Back 31

—Disease of a spinal nerve root. This most commonly is used to describe irritation of a single nerve root occurring from compression or chemical irritation of the nerve root.

Front 32

o Spinal Stenosis

Narrowing of the _____ ________. Some people are born with a narrow canal (congenital stenosis), but it is most commonly caused by _____ __________ (acquired stenosis).

Back 32

Narrowing of the spinal canal. Some people are born with a narrow canal (congenital stenosis), but it is most commonly caused by arthritic degeneration (acquired stenosis).

Front 33

o Neurogenic claudication

Painful cramping and/or weakness caused by ___________. Typically patients describe this as a tired feeling in their ____ with ______ and _________ (proximal vs. distal?) which quickly goes away with ______ or __________. This is differentiated from vascular claudication caused by poor circulation with (distal vs. proximal?) leg symptoms, leg pain while ____________ and a (shorter/longer?) recovery time with rest.

Back 33

Painful cramping and/or weakness caused by compression of the nerve roots. Typically patients describe this as a tired feeling in their legs with standing and activity (proximal greater than distal) which quickly goes away with sitting or leaning forward. This is differentiated from vascular claudication caused by poor circulation with distal greater than proximal leg symptoms, leg pain while lying down and a longer recovery time with rest.

Front 34

o Pars interarticularis

In Latin, literally the part (pars) in between (inter) the facets (articularis). This region can originally not form (congenital pars defect) or can be injured with trauma (pars fracture).

Back 34

In Latin, literally the part (pars) in between (inter) the facets (articularis). This region can originally not form (congenital pars defect) or can be injured with trauma (pars fracture).

Front 35

o Spondylosis

Degenerative _______ of the spinal _______ and related tissue.

It is a general term to describe _______________ changes in the spine.

Back 35

Degenerative arthritis of the spinal vertebrae and related tissue. It is a general term to describe non-specific arthritic changes in the spine.

Front 36

o Spondylolysis

—A defect in the ______________ of a vertebra.

Back 36

—A defect in the pars interarticularis of a vertebra.

Front 37

o Spondylolisthesis

Used to most commonly describe _________ ___________ (anterolisthesis) of a vertebra in relationship to the vertebra below.

There are different grades (I-IV) to describe how far the vertebra has slipped (in 25% increments).

Back 37

Used to most commonly describe anterior displacement (anterolisthesis) of a vertebra in relationship to the vertebra below. There are different grades (I-IV) to describe how far the vertebra has slipped (in 25% increments).

Front 38

o Spondyloptosis

Sometimes used as a synonym for ____________ . It is most often used to describe greater than ____% anterior displacement of one vertebral body compared to the vertebral body below.

Back 38

Sometimes used as a synonym for spondylolisthesis. It is most often used to describe greater than 100% anterior displacement of one vertebral body compared to the vertebral body below.

Front 39

Spondylolisthesis

o Symptoms/complaints ?
o Pathophysiology ?
o Neurological findings ?
o Radiographic findings ?
o Treatment ?

Back 39

o Symptoms/complaints—Mixture of above symptoms from radiculopathy, spinal stenosis and mechanical back pain.

o Pathophysiology—Severe degeneration and failure of the facets or defect in the pars interarticularis (congenital or traumatic).

o Neurological findings—Possible weakness or numbness. Possible positive straight leg raise, reverse straight leg raise, FABER sign (test for hip function/flexion/extension).

o Radiographic findings—Anterior migration of one vertebral body on another (anterolisthesis) with either severe degeneration of the facets or a pars defect.

o Treatment—Conservative management, injections and surgery are options.

Front 40

Disc Arthroplasty - new technology

Replacing damaged disc with an _________ disc

Advantage of maintaining ______ mobility

Back 40

Replacing disc with an artificial disc

Advantage of maintaining segmental mobility

Front 41

Plain xrays

Commonly ordered for low back pain and tend to show _______ stage degeneration of the discs or facets, fractures and malalignment of the vertebral bodies.

Their utility as a screening mechanism for low back pain is of (high/low?) yield.

The pars fracture can be well seen on __________ films and has a very classic appearance (thus ending up on many tests).

Back 41

Commonly ordered for low back pain and tend to show later stage degeneration of the discs or facets, fractures and malalignment of the vertebral bodies.

Their utility as a screening mechanism for low back pain is of very low yield.

The pars fracture can be well seen on oblique lumbar spine films and has a very classic appearance (thus ending up on many tests).