Presented by: Dr Mark Young — Sports & Musculoskeletal Specialist Event: GP Education Day - 2013

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