Dr. Mark Young emphasizes the assessment, diagnosis, and management of non-operative spinal patients at SpinePlus, focusing on holistic care for spinal disorders. A survey of 200 referrals revealed that most patients had complex pathologies, with lumbar issues being predominant, and highlighted the significance of recognizing non-lumbar conditions that can mimic lumbar pain. Key takeaways include the need to consider pelvic pathology when patients present with leg pain and the importance of identifying red flags in spinal assessments.

1. What Else Could it Be?
Dr Mark Young FACSP
SpinePlus

2. Role in SpinePlus
• To assess, dx and treat likely non-operative patients
• Prescribe exercise rehabilitation, injection therapies
and advice
• Fast track possible surgical patients to PL, and other
specialists if required
• See emergency referrals
Goal – to provide best possible holistic and integrated
care to patients with spinal disorder

3. Demography - Survey of 200 Referrals
Often had multiple pathologies
Patients 10 Reason for Referral
• 75% Lumbar
• 20% Cervical
• 5% Thoracic
• Final Dx of LxSp Referrals (150)
• 120 had clinically significant 10 Lx pathology
• 30 had 10 non Lx pathology (usually pelvic, occ limb or vascular)

4. Lumbar Conditions
Disc & Facet joint - degenerate or acute injury
Nerve – neuro-foraminal stenosis
Vertebral crush #
Discitis
Metastatic malignancy (2)
Ankylosing spondylitis (1)

5. Red Flags – not to be missed
• Cauda Equina Syndrome (URGENT)
• Constitutional symptoms
• Immunosuppressed, recent infection, IVDU
• Age >50 (or <20)
• Phx of cancer, or osteoporosis
• Recent significant trauma
• Progressive neurology
• AM Stiffness, relief with exercise and NSAIDs/steroids
(Spondyloarthropathy)

6. Non Lumbar Spine Conditions
• 20% - Why so many?
• Key Points
• Both pelvic and Lx spine
pathology are common
• Radiology of Lx spine often has
abnormality - ?conincidental
• Lx spine conditions frequently refers to
pelvis and legs (disc, facet and nerve)
• Some pelvic conditions aggravate LBP

7. Common Pelvic Conditions
that mimic Lx Pathology
• Greater Trochanteric
Bursitis
• SIJ degeneration
• Hip OA
• Hamstring
tendinopathy
• Piriformis syndrome

8. Case 1
• 68 male – retired farmer
• 6 month Hx of LBP and rt buttock pain - only
with walking (RtButtockP >or= LBP), no neuro Sx
• Reduced exercise tolerance
(300 metres)
• Emotionally flat, gaining weight
(aggravating glucose intolerance)

9. CT Lx Spine
• Mod/Sev Degenerate L4/5 facet joint arthritis
• Offered posterior spinal fusion
• Wanted second opinion.

10. Clinical Exam
• Normal gait (not antalgic, trendelenburg – ve, no
foot drop)
• Lx flex & ext - mildly restricted (ext pain +)
• No neuro
• Slightly tender (+) central lower Lx spine. Mildly
tender ant hip, not over lateral hip or pelvis
• Rt hip IR 0 degrees, buttock pain (+++)

11. Hip Xray
• Management –
-refer to hip surgeon
• Why LBP?
• Key Points
• EXAMINE HIP (v. briefly)
• IR is first movement to be lost in hip pathology

12. Case 2
• 54 year old female recreational rower
• 6 mo hx of insidious onset of bilateral
“sciatic pain” - mild LBP and mod hamstring
pain
• Aggravated by sitting, Lx flexion
and rowing
• Some leg weakness, no
paraesthesia

13. MRI Lx Spine
• Seen by PL – no objective
neural findings, several
minor non-compressive
disc bulges
• Suspected pelvic problem

14. Examination
• Mild Lx spine tenderness, good ROM Lx SP
• Mod bilat lower buttock/upper hamstring
tenderness
• Sightly restricted SLR – due to hamstring
tightness, -ve slump test, -ve Lasegues test,
• Weak hamstring curl and bridge

15. Pelvic MRI
• Bilateral hamstring origin degenerative
tendinopathy with intra-substance tears

16. Management
• Modified activity
• Physiotherapy (prescribed hamstring conditioning
program)
• Autologous blood injections
• ?Surgical opinion – if not improving after 3-6
months

17. Case 3
• 65 year old retired nurse –
“nurses back”
• 6 month hx of insidious onset LBP,
rt hip and thigh pain – esp at
night, arising from chair, walking
uphill
• Physio ++ with core stability
exercises
• Referred CT Lx Spine

18. CT Scan
• Chronic L5/S1 broad based
disc bulge with calcification
• No neuro-foraminal
stenosis

19. Examination
• Overweight
• Reasonable ROM Lx Sp – mild end range pain
• No neuro signs
• Mild lower Lx and buttock tenderness (R>L)
• Normal Rt hip IR
• Bilaterally tender over greater trochanters (R>>L)
• Poor Rt abductor strength (Pos trendelenburg
sign & gait)
• Weak on gluteus medius testing

20. MRI Right Hip
• Mild greater trochanteric
bursitis
• Gluteus medius
tendinopathy with intact
tendons

21. Management
• Prescription of abductor conditioning rehab
exercises
• CSI to 20 bursa (to permit enhanced exercise
rehab)
• Advice, weight loss, general light exercise ++
• May need ABI/PRP/?ATI injections
• ?Surgical decompression – last resort (note full
thickness tears need early surgical opinion as poor
outcome)

22. Key Points
Lumbar spine radiological abnormalities are
common - ?coincidental
Lx spine can refer to pelvis, but consider primary
pelvic pathology if pelvic/leg pain > LBP
Do not miss RED FLAGS