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Functional Anatomy

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  • Onset Palliative/Provocative factore Quality Radiation Severity/Setting in which it occurs Timing of pain during day Understanding - how it affects the patient
  • Transcript

    • 1. Lower Back Pain MS3 Sports Medicine Workshop
    • 2. Objectives
      • Review the functional anatomy of lumbo-sacral spine
      • List essential components of a LBP history, including RED FLAGS
      • Describe common causes of LBP
      • Review proper indications for imaging and referral
      • Review Physical Examination of LS spine
      • Correlate pathology with pertinent physical findings
    • 3. “ Red Flags ” in back pain
      • Age < 15 or > 50
      • Fever, chills, UTI
      • Significant trauma
      • Unrelenting night pain; pain at rest
      • Progressive sensory deficit
      • Neurologic deficits
        • Saddle-area anesthesia
        • Urinary and/or fecal incontinence
        • Major motor weakness
      • Unexplained weight loss
      • Hx or suspicion of Cancer
      • Hx of Osteoporosis
      • Hx of IV drug use, steroid use, immunosuppression
      • Failure to improve after 6 weeks conservative tx
    • 4. Epidemiology of back pain
      • Fifth most common reason for all physician visits in US
      • Second only to common cold as cause of lost work time
      • 25% of US adults have LBP x1d in last 3 mos
      • The most common cause of disability in persons under the age of 45
    • 5. Your patient with LBP has paresthesias in the lateral foot, decreased toe-raise strength, diminished sensation lateral foot, and diminished Achilles reflex. This is suggestive of dysfunction of which nerve root?
      • L4
      • L5
      • S1
      • S2
    • 6. Better anatomy knowledge = Better diagnoses and treatments
    • 7.  
    • 8.  
    • 9.  
    • 10.
      • Vertebra
        • Body, anteriorly
          • Functions to support weight
        • Vertebral arch, posteriorly
          • Formed by two pedicles and two laminae
          • Functions to protect neural structures
    • 11.  
    • 12. Ligaments
      • Anterior longitudinal ligament
      • Posterior longitudinal ligament
      • Ligamentum flavum
      • Interspinous ligament
      • Supraspinous ligament
    • 13. Anterior longitudinal ligament Ligamentous
    • 14.  
    • 15. Muscles
      • Spinalis
      • Longissimus
      • Iliocostalis
      • Quadratus lumborum
        • Ilium to lumbar TPs
      • Intertransversalis
      • Interspinals
      • Multifidus
      • Erector spinae
    • 16. Sciatica is defined as…
      • Pain radiating up the back
      • Pain radiating to the thigh
      • Pain radiating below the knee
      • Pain in the butt
    • 17. Neuro-anatomy
    • 18.  
    • 19.
      • L4
      • L5
      • S1
    • 20. PATIENT HISTORY “OPQRSTU”
      • Onset
      • Palliative/Provocative factors
      • Quality
      • Radiation
      • Severity/Setting in which it occurs
      • Timing of pain during day
      • Understanding - how it affects the patient
    • 21. Which one is NOT considered a “red flag” of LBP?
      • History/suspicion of cancer
      • Age over 50
      • Fever or chills
      • Sciatica
    • 22. “ Red Flags ” in back pain
      • Age < 15 or > 50
      • Fever, chills, UTI
      • Significant trauma
      • Unrelenting night pain; pain at rest
      • Progressive sensory deficit
      • Neurologic deficits
        • Saddle-area anesthesia
        • Urinary and/or fecal incontinence
        • Major motor weakness
      • Unexplained weight loss
      • Hx or suspicion of Cancer
      • Hx of Osteoporosis
      • Hx of IV drug use, steroid use, immunosuppression
      • Failure to improve after 6 weeks conservative tx
    • 23. Onset
      • Acute - Lift/twist, fall, MVA
      • Subacute - inactivity, occupational (sitting, driving, flying)
      • ?Pending litigation
      • Pain effect on:
        • work/occupation
        • sport/activity (during or after)
        • ADL’s
    • 24. Other History
      • Prior h/o back pain
      • Prior treatments and response
      • Exercise habits
      • Occupation/recreational activities
      • Cough/valsalva exacerbation
    • 25. Diagnoses & Red Flags
      • Cancer
        • Age > 50
        • History of Cancer
        • Weight loss
        • Unrelenting night pain
        • Failure to improve
      • Infection
        • IVDU
        • Steroid use
        • Fever
        • Unrelenting night pain
        • Failure to improve
      • Fracture
        • Age >50
        • Trauma
        • Steroid use
        • Osteoporosis
      • Cauda Equina Syndrome
        • Saddle anesthesia
        • Bowel/bladder dysfunction
        • Loss of sphincter control
        • Major motor weakness
    • 26. Physical Examination Msk Big-6
      • Inspection
      • Palpation
      • Range of motion
      • Strength testing
      • Neurologic examination
      • Special tests
    • 27. Approach to LBP
      • History & physical exam
      • Classify into 1 of 4:
        • BAD: LBP from other serious causes
          • Cancer, infection, cauda equina, fracture
        • LBP from radiculopathy or spinal stenosis
        • Non-specific LBP
        • Non-back LBP
      • Workup or treatment
    • 28. BAD low back pain (examples)
    • 29. What to do about Possible BAD Low Back Pain
      • Cauda Equina:
        • MRI STAT  Neurosurgery consult
      • Fracture: x-rays
        • MRI/CT if still suspect
      • Cancer: x-rays + CRP, ESR, CBC (+/- PSA)
        • MRI if still suspect
      • Infection: x-rays; CRP, ESR, CBC, +/- UA
    • 30. Radiculopathy, Spinal Stenosis
      • Sciatica (pain below knee)
      • May have abnl neuro exam
      • Radiates to leg
      • Pain worse walking, better sitting (pseudo-claudication)
    • 31. What to do about Suspected Radiculopathy or Spinal Stenosis
      • Refer to Physical Therapy
      • Follow in 2-4 weeks for progress
      • If no improvement by 6-12 weeks
        • Plain films, MRI, +/- EMG/NCV
        • Refer for interventions
          • Epidural steroid injections for radiculopathy
    • 32. Causes of “Non-specific LBP”
      • Spondylosis (Osteoarthritis of facet/disk)
      • Spondylolysis/-listhesis
      • Kyphosis/scoliosis
      • Acute lumbar strain
      • Facet pain
      • Discogenic pain
      • Ligamentous pain
    • 33. Management of an acute low back muscle strain should consist of all the following EXCEPT:
      • X-rays to rule out a fracture
      • Educate the patient on generally good prognosis
      • Non-opiate analgesics
      • Remain active
    • 34. What to do about Non-specific Low Back Pain
      • Educate patient about expected good prognosis
      • Advise to remain active as tolerated
      • Provide analgesics and self-care directions
      • FU in 2-4 weeks; adjust tx as needed
      • Don’t do x-rays unless it becomes chronic
      • WU if no improvement
    • 35. “ Think Outside the Back”
      • Renal dz (pyelo, stones, abscess)
      • Pelvic dz (PID, endometriosis, prostate)
      • Gastrointestinal dz (cholecystitis, ulcer, cancer)
      • Retroperitoneal dz
      • Aortic aneurysm
      • Zoster
      • Diabetic radiculopathy
      • Rheumatologic disorders
        • Reiters
        • Ankylosing Spondylitis
        • Inflammatory bowel dz
        • Psoriatic spondylitis
      • Neoplasia (multiple myeloma, metastatic CA, lymphoma, leukemia, spinal cord tumors, vertebral tumors)
    • 36. What to do about Non-back LBP
      • WU and tx as appropriate for suspected diagnoses
    • 37. Diagnostic Studies
      • Radiographs
        • Early if RED FLAGS
        • Symptoms present > 6 weeks despite tx
    • 38. Diagnostic Studies
      • MRI indications
        • Possible cancer, infection, cauda equina synd
        • >6-12 weeks of pain
        • Pre-surgery or invasive therapy
      • Disadvantages
        • False-positives; may not be causing pain
        • More costly, increased time to scan, problem with claustrophobic patients
    • 39. Diagnostic Studies
      • Bone Scan indications
        • Adolescent LBP (r/o spondy)
          • SPECT scan
      • Cost ~$300
    • 40. Diagnostic Studies
      • EMG/NCV
        • r/o peripheral neuropathy
        • localize nerve injury
        • correlate with radiographic changes
        • order after 6-12 weeks of symptoms
        • Pre-surgical or invasive therapy
    • 41. Lab Studies
      • Indications
        • Chronic LBP
        • Suspected systemic disease
      • CBC, CRP, ESR, +/- UA, SPEP, UPEP
      • Avoid RF, ANA or others unless indicated
    • 42. Issues specific to CHRONIC LBP (>6 weeks and/or non-responsive)
      • Evaluation
        • X-rays, labs
        • Evaluate for “YELLOW FLAGS”
      • Management
        • Medication selection
        • Interventions
    • 43. YELLOW FLAGS in Chronic LBP
      • Affect: anxiety, depression; feeling useless; irritability
      • Behavior: adverse coping, impaired sleep, treatment passivity, activity withdrawal
      • Social: h/o abuse, lack of support, older age
      • Work: believe pain will be worse at work; pending litigation; workers comp problems; poor job satisfaction; unsupportive work env’t
    • 44. Medications in Chronic LBP
      • FIRST: Acetaminophen
      • Second: NSAIDs
        • If one fails, change classes
          • Meloxicam  naproxen  COX2’s
      • Third: tramadol
      • Fourth: tri-cyclic antidepressants
        • Radiculopathy: gabapentin
      • LOATHE: narcotics
    • 45. Non-pharmacologic treatments
      • EFFECTIVE
      • Acupuncture
      • Exercise therapy
      • Behavior therapy
      • Massage
      • TENS
      • Spinal manipulation
      • Multidisciplinary rehab program
      • NOT EFFECTIVE/
      • CONFLICTING EVIDENCE
      • BACK SCHOOLS
      • LOW-LEVEL LASER
      • LUMBAR SUPPORTS
      • PROLOTHERAPY
      • SHORT WAVE DIATHERMY
      • TRACTION
      • ULTRASOUND
    • 46. Epidural Steroid Injections
      • Indicated for radiculopathy not responding to conservative mgmt
        • Conflicting evidence
        • Small improvement up to 3 months
        • Less effective in spinal stenosis
    • 47.  
    • 48. Surgery for Chronic LBP
      • Most do NOT benefit from surgery
      • Should have ANATOMIC LESION C/W PAIN DISTRIBUTION
      • Significant functional disability, unrelenting pain
        • Several months despite conservative tx
      • Procedures: spinal fusion, spinal decompression, nerve root decompression, disc arthroplasty, intradiscal electrothermal therapy
    • 49. Break for Physical Examination Hands-on Session
    • 50. Inspection
      • Observe for areas of erythema
        • Infection
        • Long-term use of heating element
      • Unusual skin markings
        • Café-au-lait spots
          • Neurofibromatosis
        • Hairy patches, lipomata
          • Tethered cord
        • Dimples, nevi (spina bifida)
    • 51. Inspection (cont.)
      • Posture
        • Shoulders and pelvis should be level
        • Bony and soft-tissue structures should appear symmetrical
      • Normal lumbar lordosis
        • Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall
    • 52.
      • Posture
        • Shoulders and pelvis should be level
        • Bony and soft-tissue structures should appear symmetrical
      • Normal lumbar lordosis
        • Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall
    • 53.  
    • 54. Bone Palpation
      • Palpate L4/L5 junction (level of iliac crests)
      • Palpate spinous processes superiorly and inferiorly
        • S2 spinous process at level of posterior superior iliac spine
      • Absence of any sacral and/or lumbar processes suggests spina bifida
      • Visible or palpable step-off indicative of spondylolisthesis
    • 55.  
    • 56.  
    • 57.  
    • 58.  
    • 59. Soft Tissue Palpation
      • 4 clinical zones
        • Midline raphe
        • Paraspinal muscles
        • Gluteal muscles
        • Sciatic area
        • Anterior abdominal wall and inguinal area
    • 60.  
    • 61. ANTERIOR PALPATION
    • 62.  
    • 63. Flexion - 80º Extension - 35º Side bending - 40º each side Twisting - 3-18º Range of Motion
    • 64. Neurologic Examinaion
      • Includes an exam of entire lower extremity, as lumbar spine pathology is frequently manifested in extremity as altered reflexes, sensation and muscle strength
      • Describes the clinical relationship between various muscles, reflexes, and sensory areas in the lower extremity and their particular cord levels
    • 65. Neurologic Examination (T12, L1, L2, L3 level)
      • Motor
        • Iliopsoas - main flexor of hip
        • With pt in sitting position, raise thigh against resistance
      • Reflexes - none
      • Sensory
        • Anterior thigh
    • 66. Neurologic Examination (L2, L3, L4 level)
      • Motor
        • Quadriceps - L2, L3, L4, Femoral Nerve
        • Hip adductor group - L2, L3, L4, Obturator N.
      • Reflexes
        • Patellar - supplied by L2, L3, and L4, although essentially an L4 reflex and is tested as such
    • 67. L2, L3, L4 testing
    • 68. Neurologic Examination (L4 level)
      • Motor
        • Tibialis Anterior
          • Resisted inversion of ankle
      • Reflexes
        • Patellar Reflex ( L2, L3, L4 )
      • Sensory
        • Medial side of leg
    • 69.  
    • 70. Neurologic Examination (L5 level)
      • Motor
        • Extensor Hallicus Longus
        • Resisted dorsiflexion of great toe
      • Reflexes - none
      • Sensory
        • Dorsum of foot in midline
    • 71.  
    • 72. Neurologic Examination (S1 level)
      • Motor
        • Peroneus Longus and Brevis
        • Resisted eversion of foot
      • Reflexes
        • Achilles
      • Sensory
        • Lateral side of foot
    • 73.  
    • 74. Special Tests
      • Tests to stretch spinal cord or sciatic nerve
      • Tests to increase intrathecal pressure
      • Tests to stress the sacroiliac joint
    • 75. Tests to Stretch the Spinal Cord or Sciatic Nerve
      • Straight Leg Raise
      • Cross Leg SLR
      • Kernig Test
    • 76.  
    • 77. Test to increase intrathecal pressure
      • Valsalva Maneuver
        • Reproduction of pain suggestive of lesion pressing on thecal sac
    • 78. Kernig Sign Pain present Pain relieved
    • 79. Tests to stress the Sacroiliac Joint
      • FABER Test
      • Gaenslen sign
    • 80. FABER test: F lexion A - B duction E xternal R otation
    • 81. Gaenslen sign
    • 82. Non-organic Physical Signs (“Waddell’s signs”)
      • Non-anatomic superficial tenderness
      • Non-anatomic weakness or sensory loss
      • Simulation tests with axial loading and en bloc rotation producing pain
      • Distraction test or flip test in which pt has no pain with full extension of knee while seated, but the supine SLR is markedly positive
      • Over-reaction verbally or exaggerated body language
      Waddell, et al. Spine 5(2):117-125, 1980.
    • 83.  
    • 84.  
    • 85.  
    • 86.  
    • 87. Hoover Test
      • Helps to determine whether pt is malingering
      • Should be performed in conjunction with SLR
      • When pt is genuinely attempting to raise leg, he exerts pressure on opposite calcaneus to gain leverage
    • 88.  
    • 89. Other
      • Rectal tone
      • Anal wink
      • Cremasteric reflex
    • 90. Questions?