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Functional Anatomy

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Functional Anatomy

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

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