4. MRI StudyMRI Study
• 98 asymptomatic patients98 asymptomatic patients
• 52% had disc bulges52% had disc bulges
• 27% had disc protrusions27% had disc protrusions
• 1% had disc extrusions (outside the1% had disc extrusions (outside the
annulus)annulus)
• 14% had annular defects14% had annular defects
• 8% had facet pathology8% had facet pathology
• 7% had spondylolithesis7% had spondylolithesis
• 7% had stenosis (central or foraminal)7% had stenosis (central or foraminal)
Jensen
NEJM July 1994
5.
6. A treatment method can onlyA treatment method can only
be as specific as thebe as specific as the
diagnosis that accompanies itdiagnosis that accompanies it
8. ““The cause of a disorder isThe cause of a disorder is
hidden in the patient’s historyhidden in the patient’s history
and the site of the lesion isand the site of the lesion is
detected by examination.”detected by examination.”
A. Staal
9.
10. ““Disorders unknown to theDisorders unknown to the
physician are notphysician are not
unearthed.”unearthed.”
14. Diagnostic Injections
• Based on history and physical exam
• Small volumes
• Precision is key for diagnosis
– Landmarks
– Nerve stimulator
– Fluoroscopy
16. Lumbar FacetLumbar Facet
• Classically taught
that pain radiates
only to knee but
may radiate to
foot
• Twisting injury or
flexion/extension
• “pop and lock”
• Increased pain
with extension
24. • Twisting/bending injury or
fall on buttocks
• Pain from buttocks to foot
• Increased with standing and
walking, better with sitting
• Difficulty getting out of a
chair or climbing stairs
Superior Gluteal NerveSuperior Gluteal Nerve
32. Cluneal NeuralgiaCluneal Neuralgia
• Usually starts as a
“pulled muscle”
sensation
• Common after iliac graft
• Sometimes associated
with Maigne’s
syndrome
• Can refer to the foot
48. • Twisting while
lifting, or carrying a
load in an awkward
position
• Pain with hip
internal rotation (so
foot is inverted)
• “entire foot and
leg”
Piriformis SyndromePiriformis Syndrome
69. Interspinous LigamentInterspinous Ligament
• Sudden midline
pain with bending or
lifting
• Often associated
with “pop”or “tear”
• Pain down one or
both legs
• Loss of lumbar
lordosis
70. Interspinous LigamentInterspinous Ligament
DiagnosisDiagnosis
• Tenderness to palpation over the
ligament
• Edema or palpable defect
• MRI may show ligament defect
• Central disc bulge
• Resolution of back and leg pain with
small dose of local anesthetic
