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Spine clinical approach (basic spine 2009)

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Evaluation of Lumbar Spine Disease starts with understanding the clinical back grounds. It starts with good history and physical examination. This is a teaching lecture given twice by Prof. Dr. Mohamed Mohi Eldin, professor of neurosurgery, in the Basic Spine Course, Egyptian Medical Syndicate, Cairo, March 2009 and in 2010.

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Spine clinical approach (basic spine 2009)

  1. 1. BBaassiicc IInnttrroodduuccttiioonn iinn SSppiinnee ((UUnnddeerrssttaannddiinngg SSppiinnee PPrroobblleemmss)) DDrr.. MMoohhaammeedd MMoohhii EEllddiinn ,, MB-BCH , M.Sc., MD PPrrooff.. ooff NNeeuurroossuurrggeerryy,, FFaaccuullttyy ooff MMeeddiicciinnee,, CCaaiirroo UUnniivveerrssiittyy CCoonnssuullttaanntt NNeeuurroossuurrggeeoonn Basic Spine Course 3/18/2009
  2. 2. Low back pain 15% 85% no specific specific pathology pathology NSLBP (mechanical)
  3. 3. “Mechanical” NSLBP • pain is worsened with movement • pain is improved with rest
  4. 4. Triage • Is the LBP due to serious pathology? • Duration of the LBP? • What treatment is indicated for the LBP?
  5. 5. Hypotheses generated about: • diagnosis • physical examination • treatment • prevention • contra-indications/precautions
  6. 6. Need knowledge about: • causes of LBP • pathology • tests (odds ratio, sensitivity and specificity) • treatment effects and efficacy
  7. 7. Serious spinal pathology • Cancer • Infection eg osteomyelitis • Cauda equina syndrome • Cord compression • Fracture (osteoporotic) • Inflammatory diseases/arthritides • Abdominal or cardio-thoracic pathology
  8. 8. Eliminate serious pathology (red flags) • unexplained weight loss • night pain • poor general health/systemic symptoms • fever • previous history of cancer • failure to improve with bed rest & therapy • history of trauma • steroid use (osteoporosis) • very severe pain/muscle spasm • Pain that worsens in supine • bowel/bladder frequency (cauda equina syndrome) • widespread neurological symptoms • non-mechanical behaviour of symptoms • Age > 50 years • Constant progressive non-mechanical pain • Persisting severe restriction of lumbar flexion
  9. 9. Typical Non-typical Presentation Presentation Kathryn Refshauge 13
  10. 10. Decisions • If suspect pathology, refer patient to appropriate health professional • If NSLBP, use knowledge (evidence-based practice) seriousnesss probability
  11. 11. Yellow flags • Previous history of LBP • Radiating leg pain, NR involvement • Poor fitness • Poor extensor endurance • Poor general health • Psychological distress (fear avoidance behaviour, depressed) • Much time lost from work • Disproportionate illness behaviour • Low job satisfaction • Personal problems (alcohol, marital, financial) • Adversarial medico-legal proceedings
  12. 12. Clinical Course acute sub-acute chronic 6 weeks 3 months Time acute sub-acute chronic most recover without intervention some recover very few recover psychosocial domain fear of activity acute sub-acute chronic Rx: spinal manual therapy McKenzie exercises spinal manual therapy exercises exercise cognitive behavioural therapy
  13. 13. Clinical Examination · observation · active movements · tension tests *** · palpation As applicable: · stress active movements · neurological examination · muscle performance · passive tests
  14. 14. Biering-Sorensen test
  15. 15. multifidus
  16. 16. LLuummbbaarr SSppiinnee DDiisseeaassee • Low back pain is second to upper respiratory problems as a reason for visits to a physician • In the U.S., back pain is the most common cause of activity limitation in people younger than 45 years • Cost of low back pain to industry estimated $35- 75 billion
  17. 17. EEvvaalluuaattiioonn ooff LLuummbbaarr SSppiinnee DDiisseeaassee • Where to start? • What do we know? • What to do? • Who to consult? • What will they do?
  18. 18. What we know v. wwhhaatt wwee tthhiinnkk wwee kknnooww** % answering % very Topic ?s correctly confident SI joint pain 4.4 32.2 Lumbar stenosis 12.6 28.6 Leg length differences 42.0 27.0 Fibromyalgia 57.1 35.5 Myofascial pain (piri) 68.7 8.5 *J Am Geriatr Soc 54:1772-1777; 2006
  19. 19. EEvvaalluuaattiioonn ooff LLuummbbaarr SSppiinnee DDiisseeaassee From the top • Patient History: – Location of pain – Duration of pain – Character/quality of pain – Weakness – Numbness
  20. 20. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee • Bowel, bladder or sexual dysfunction • Prior or current treatments including medication • Smoking (smokers complain of more severe symptoms and have less improvement postsurgically) • Obesity (obese patients more likely to suffer radicular pain or neurologic symptoms and carry more comorbidities) • Diabetes (may need neurophysiology testing) • Psychological factors: anxiety, depression, somatization symptoms, stressful responsibilities, job dissatisfaction, mental stress at work, negative body image, weakness in ego functioning (prospective predictors of developing back pain) • Activities that affect pain (e.g. leaning forward in spinal stenosis, sitting down, coughing, sneezing, Valsalva for herniated discs)
  21. 21. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee • Physical Exam: – Strength – Sensation – Reflexes – Range of Motion – Palpation
  22. 22. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee • Strength exam: – L3 - iliopsoas muscle (hip flexion), adductor longus (hip adduction) – L4 - quadriceps femoris (knee extension), tibialis anterior (dorsiflexion and inversion) • L5 - gluteus medius/minimus (thigh abduction and medial rotation), extensor hallicus longus (big toe extension), peroneus longus and brevis (plantar flexion and eversion) • S1 - gluteus maximus (thigh abduction), biceps femoris (hip extension), gastrocnemius (plantar flexion)
  23. 23. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee LLoowweerr eexxttrreemmiittyy sseennssaattiioonn
  24. 24. EEvvaalluuaattiioonn ooff LLuummbbaarr SSppiinnee DDiisseeaassee • Reflexes: – L3 - iliopsoas reflex (meaningful?) – L4 - knee jerk – L5 - extensor hallicus reflex (meaningful?) – S1 - ankle jerk – Babinski - in adults, UMN lesion from motor strip to lower spinal cord
  25. 25. EEvvaalluuaattiioonn ooff LLuummbbaarr SSppiinnee DDiisseeaassee • Range of Motion: – Straight leg raise - most sensitive for sciatic pain syndromes – Pain in contralateral leg with straight leg raise is most specific for sciatic pain syndromes – Lumbar flexion/extension (lumbar stenosis worse with extension, better with flexion)
  26. 26. EEvvaalluuaattiioonn ooff LLuummbbaarr SSppiinnee DDiisseeaassee • ROM to rule out other causes of back/leg pain: internal and external hip rotation • Palpation over spine, SI joint, pelvis and hip
  27. 27. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee • Clinical impression: – lumbar disc herniation: pain, paresthesias, weakness, depressed DTRs in an anatomic distribution (i.e. down lower extremity) – lumbar stenosis: diagnosis made mainly by history; low back/leg pain with walking or standing improved by sitting or lying down (not just standing still); no severe cramping in calf; no trophic changes in skin; a.k.a. neurogenic claudication
  28. 28. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee • Clinical impression: – lumbar instability: pain with motion; improved with lying down; >5 mm motion on flexion/extension x-rays indicates unstable motion segment; look for defects in neural arch (lamina, pedicle, pars interarticularis); 30% of patients with degenerative spondylolisthesis (subluxation) will have progressive slippage – compression fracture: acute to subacute onset of pain, pain to palpation; +/- history of trauma/cancer – musculoskeletal: pain with active but not passive motion; point tenderness over joint; +/- history of trauma
  29. 29. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee • If clinical suspicion high for ‘soft tissue’ (i.e. muscle, tendon, joint, ligament) source of symptoms then: NSAIDS, narcotics, antidepressant, cox-2 inhibitor, PT (exercise), +/- muscle relaxants, +/- chiropractor referral, +/- acupuncture, +/- behavioral therapy, ? corsets, ?massage, ?traction, ?TENS, ?epidural/facet injections, BUT…continue ordinary activities in the acute period* AND in the post-acute period begin conditioning activities to strengthen back, legs, abdomen to prevent recurrence^ • +/- = some evidence; ? = unknown • *NEJM 332:351-5, 1995 • ^JAMA 272:1286-91, 1994
  30. 30. Evaluation ooff LLuummbbaarr SSppiinnee DDiisseeaassee • Options when clinical suspicion low or diagnosis unclear: – 1. Observe (80-90% will resolve in <6 weeks) • most common diagnosis of acute (i.e. <6 weeks) back pain = “lumbar strain” • pathobiology ( any pain sensitive structure): muscle, tendon, ligaments, disc, facet joints, periosteum, meninges, blood vessels, or ‘degenerative changes*’ • NSAIDS, narcotics, antidepressant, cox-2 inhibitor, PT while you are observing – 2. Imaging • BUT ASK THE PATIENT: are you willing to have surgery or other invasive procedure if we do this work up? • For back pain pts: 4% will have compression fx, 1% will have a tumor, 3% will have a herniated disc
  31. 31. Imaging ooff LLuummbbaarr SSppiinnee DDiisseeaassee • If clinical suspicion high for intraspinal source of symptoms – i.e. radiculopathy, neurogenic claudication, lumbar instability, compression fx then: – 1) MRI, MRI, MRI unless there is a contraindication (see next slide) • Add contrast only if patient has had prior surgery or a history of cancer; perhaps with a demyelinating process like multiple sclerosis • If not sure; order without contrast and radiology will pick up the ones that do need it
  32. 32. Imaging ooff LLuummbbaarr SSppiinnee DDiisseeaassee – 2) If there is a contraindication to MRI then CT myelogram (contraindications to MRI = heart stent < 2 weeks old, defibrillator, pacemaker, pain pump, spinal cord or deep brain stimulator, prior lumbar spine instrumentation, programmable shunt) • Questions?: call radiology or specialist involved in placing device or hardware • If patient is too large for closed MRI then order open MRI • CT is WAY OVERUTILIZED as a spine diagnostic test and delivers A LOT of radiation to the patient
  33. 33. Imaging ooff LLuummbbaarr SSppiinnee DDiisseeaassee – 3) if signs of spondylolisthesis then flexion/extension x-rays (lateral) – 4) pain medications (NSAIDS, narcotics, +/- oral steroid taper, +/- muscle relaxant) – 5) Consultation after MRI or CT myelogram results show something other than ‘degenerative changes’*
  34. 34. Consultation aatt tthhee SSppiinnee CCeenntteerr • ‘Who’ should I send ‘what’ to? • General recommendations: – Acute pain problems – surgeons & pain management • Surgeons – usually after imaging – Active smokers will be strongly encouraged to stop – Poorly controlled diabetics (Hgb A1C > 7) will result in re-evaluation request with primary care prior to surgery • Pain management – does not require imaging – Chronic pain problems – physiatry & neurology • Does not require imaging
  35. 35. SSPPOORRTT SSttuuddyy** • Conservative therapy isn’t the worst idea for patients with a herniated disc and mild to moderate symptoms • 2-year prospective randomized trial of patients with radicular symptoms > 6 weeks and imaging evidence of a herniated disc – Randomized to surgery or PT, exercise, NSAIDS • LOTS of patients cross-over to opposite group if symptoms are too mild or too severe • BUT at 2-year follow-up, both surgery and conservative management was effective • *JAMA 2006;296:2451-2459
  36. 36. SShhoouulldd II rreeiimmaaggee?? • Have symptoms or signs changed significantly? • Has there been a recent intervention (e.g. surgery) or trauma? • Look at patient’s chart – has it been >1 year since last imaging? • If the answer to these 3 questions is “no” then reimaging is not indicated
  37. 37. SSuummmmaarryy • Start with good history and physical • Is this emergent, urgent or routine? • Is the cause most likely disc, stenosis, instability, compression fracture or soft tissue? • Typically start conservative and escalate as necessary
  38. 38. CClliinniiccaall HHiissttoorryy and Physical Examination on Spine Injury (Part I)
  39. 39. The Importance of History and Physical Examination • The most valuable service the correct diagnosis the magnitude of the problem the appropriate treatment
  40. 40. Image studies • Image studies Vs. Time-consuming process of history taking and P.E. • High false positive rate for spinal disease • No information about the source of pain • To confirm the diagnosis • To help guide any surgical procedure
  41. 41. History • Structural spine: vertebrae, joints  Symptoms: axial • Neurologic spine: cord, cauda equina, nerve root  Symptoms: peripheral, radicular
  42. 42. History • Backache  In the lumbosacral junction?  In the thoracolumbar junction?  In the buttock and thigh? • Sciatica?
  43. 43. History • The ratio of back pain to leg pain symptoms • The pain intensity on a scale 1 to 10 • Functional impairment:  Stable  Deterioration • Psychosocial issues
  44. 44. Axial Symptoms: Back and Neck Pain • To characterize the nature of the pain  Location  Onset  Duration  Character  Periodicity  The precipitating factors  The aggravating factors  The relieving factors
  45. 45. Location • Local or diffuse, midline or paraspinous • Midline pain: spondylolisthesis or bony pathology • Paraspinous pain: muscular and spasm • Focal, highly localized pain: fracture, tumor, infection or single-level arthrosis or instability • Diffuse symptoms: DDD • Chronic, diffuse symptoms are seldom likely to warrant surgical treatment
  46. 46. Onset • Acute onset: acute injury • Insidious onset: repetitive trauma, degenerative disease or a progressive disorder • Insidiously but progressive rapidly: more serious underlying causes  Pathological fracture: tumor, infection, or osteoporosis,  Visceral disease: pancreatitis, AAA
  47. 47. Duration • Sprain/strain causing backache usually improves within 6 to 8 weeks of onset • Degenerative disease pain waxes and wanes over a period of years or decades • New pains, or pains that are new to longstanding backache
  48. 48. Character • Most backache: fairly focal pain intensified by activity and fatigue, improved by rest • Neoplasm/infection: boring, deep pain unrelieved by rest or recumbency • Instability: sharp, stabbing, incapacitating pain superimposed on a baseline ache a shift or “catch” with motion
  49. 49. Character • Discogenic pain: intensified by sitting and vibration exposure, flexion/extension, and axial loading • Discitis, osteomyelitis greater intensity, absolute intolerance of motion
  50. 50. Periodicity • Symptoms recur more frequently • To miss work several times in a given year Need further evaluation and more aggressive treatment
  51. 51. Factors that Precipitate, Aggravate, Relieve pain • Flexion: aggravate disc-related symptoms • Extension: irritate the facets • Motion: trigger instability, causing acute giving out or stabbing pain. • Whole body vibration: precipitate neuropeptide release that can sensitize nerve endings and directly irritate the disc
  52. 52. Factors that Precipitate, Aggravate, Relieve pain • Mechanical disorder: Pain caused by bending, lifting, twisting, or axial loading, and relieved by recumbancy • Discogenic pain: Pain aggravated by flexion, or by prolonged sitting or riding in a car  Back pain caused by hypertension may be facet-related  Leg pain in extension usually is a result of spinal stenosis
  53. 53. Factors that Precipitate, Aggravate, Relieve pain • Profound morning stiffness: requiring 30 mins to an hour to “loosen up” (inflammatory arthropathy) • Inquires about injury and the circumstances associated with the pain first appearing • Did pain come on immediately after an accident? • Was there an examination or radiography at that time?
  54. 54. Peripheral Symptoms: Arm and Leg Pain • Radiculopathy: Painful, hyperesthetic, numb, tingling, burning • HIVD Vs. Central spinal stenosis • Thoracic spine disorder: Belt-like radicular symptoms Herpes zoster; the pain is severe and predates the vesicles
  55. 55. Peripheral Symptoms: Arm and Leg Pain • Neurogenic Vs. Vascular claudication (The spine in flexion or extension)  Walk  Stand still  Sit  Uphill  Downhill  Pedaling a bicycle  Lean forward over a shopping cart (on a counter)
  56. 56. Peripheral Symptoms: Arm and Leg Pain • Radicular pain reproduced by coughing, sneezing, or straining at stool (increasing intrathecal pressure) • Lhermitte’s sign • Resting the forearm over the head
  57. 57. Peripheral Symptoms: Arm and Leg Pain • Loss of bowel continence, urinary retention, and saddle anesthesia (accompanied by varying degrees of leg weakness) ---Cauda Equina Syndrome • Spasticity, and urinary incontinence (diffuse lower and upper extremity weakness) ---Spinal Cord Injury
  58. 58. Clinical History and Physical Examination on Spine Injury (Part II)
  59. 59. Lumbar Spine Assessment
  60. 60. Low Back Pain (LBP) • 90% of all Americans • Minor insultsmajor injuries • Maintain normal lordotic and kyphotic curves to avoid injury
  61. 61. Clinical Anatomy • 5 vertebrae=lumbar spine • P.320, fig. 10-2 – Facets – Processes – Foramen – “Scotty Dog”
  62. 62. Evaluation • Primary role of ATC: – On-field evaluation: • Rule out (R/O) bony trauma which has, or may, damage to spinal cord – Clinical evaluation: • Evaluate specific cause of injury and devise a rehabilitation plan
  63. 63. History • Location of pain: – Localized or radiating? • Onset of pain: – Acute, chronic, insidious? • Consistency of pain: – Constant/intermittent? – Improves/Worsens with activity? • Mechanism: – Flex, ext, rotation, lat. Flex – Direct blow/trauma
  64. 64. History • PMH of injuries/surgery? • Smoker? • Bowel/bladder symptoms? – Incontinence or Ý frequency – Immediate referral • Referral history – Time in the medical system? – # of physicians seen?
  65. 65. Inspection/Observation • Sagittal curvature • Scoliosis • Frontal curvature • Normal curves • Standing posture • Shoulders • Head • Walking posture (gait)
  66. 66. Observation/ Inspection • Paravertebral muscles • Symmetry / spasm • PSIS level • Overall attitude
  67. 67. Palpation • Transverse processes • Spinous processes • PSIS • Paravertebral musculature – Symmetry – spasm
  68. 68. Functional testing • Gross ROM assessment only • Trunk Extension = 45º – Lordosis should increase • Trunk Flexion = 9045º – Lordosis should decrease • Rotation • Lateral flexion • Symmetry > Goniometry
  69. 69. Pathologies/Injuries • Muscle strains—p.353 • Facet joint syndrome-p. 353 • Disk lesion—p. 354 • Spondylopathies— p.292
  70. 70. Muscle Strains • Pain localized to paraspinal musculature & PSIS • Spasm probable • Limited flex. & ext. (pain) • No radiating pain • May not correlate to specific mechanism
  71. 71. Facet Joint Syndrome • Table 10-10,p.354 • ~40% of all LBP • Vague symptoms that mimic other pathologies • Common with repeated spine-loading activities • Localized pain • Often improves with activity • Nerve entrapment may result from compensatory posturing • Worsened by: – Repeated spine-loading activities (ext, side bending, rotation) – Poor LE flexibility – Poor Trunk strength
  72. 72. Disk lesion • Crack in annulus fibrosus herniation of nucleus pulposus • Pressure on nerve rootpain/burning sensation • “Bulge” ¹ pathology • Radiating pain into buttocks and down leg • MRI for best diagnosis • Altered standing posture • Symptoms Ý with activity • Bilateral or unilateral symptoms • Usually acute onset
  73. 73. Spondylopathies • Vertebral defect • May occur at any age/sports • Congenital? • Stress fx? • Common is sports with forced hyperextension • Generally occurs at L4- L5 or L5-S1 levels
  74. 74. Spondylolysis • Defect at pars interarticularis • Unilateral or bilateral • Signs/ Symptoms: – NL spinal alignment – LBP Ý during & after activity – Localized lumbar spine pain – NL flex; restricted ext. – (-) neuro. Test • X-rays show “collared” Scotty Dog
  75. 75. Spondylolysthesis • May occur with spondylolysis • Anterior displacement of proximal vertebrae on distal • Pain more intense/constant than spondylolysis • Neuro signs sometimes (+) if displacement worsens • Possible step-off deformity • X-rays show “decapitated” Scotty Dog • (+) Stork test
  76. 76. Straight leg raise test (SLR)— p.347, fig. Box 10-9 • Supine with knees extended • PROM hip flexion to point of discomfort or end of range • ß hip flexion and move into passive dorsiflexion • (+) = pain reproduced and recurs with reduced SLR • (-) =pain reproduced but does not return with reduced SLR • If pain does not recur: – Tight hamstrings
  77. 77. Well-leg SLR test p.348, Box 10-10 • Supine with knees extended • Passively raise one leg – Similar to SLR test – Raise leg with symptoms – Provocation test • (+)=Symptoms felt in the other leg (“well” leg)
  78. 78. Valsalva maneuver p. 344, Box 10-6 • Increasing intrathecal pressure to reproduce symptoms • (+)=Reproduced symptoms : Radiating pain or Numbness
  79. 79. Kernig’s Test—p. 346 • Box 10-8 • Provocation test to elongate the spinal cord • Active SLR until point of pain (knee straight) • Flex knee @ point of pain • (+)= pain in LB or radiating pain in LE • Brudzinski’s Test=Kernig with cervical flexion
  80. 80. Hoover test p.351, Box 10-13 • Tests compliance & effort • “Malingering” • Procedure: – Supine with knees extended – Active hip flexion – Pressure should be felt on opposite leg as SLR is attempted • (+)=No pressure=low effort
  81. 81. Babinski test p. 383, Box 11-3 • Tests presence of upper motor neuron pathology • Blunt device moved across plantar aspect of foot from calcaneus to 1st metatarsal head (great toe) – (-)=toe flexion – (+)=great toe extension with splaying of other toes • Normally (+) in newborns
  82. 82. Hamstring flexibility • Tripod sign • 90-90 position for testing • Tight hamstrings pelvic tilt Stretched extensors Pain/spasm
  83. 83. Strength tests • Isometric strength tests • Held for 60 sec. • Flexor strength testing • Extensor strength testing
  84. 84. Lifting Technique • Maintain natural curves – Sitting, standing, walking, lifting • 10:1 ratio • Use large LE muscles • Keep items close to body • Hip = axis (not LS) • Avoid rotating spine • Get help when needed

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