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  1. 1. Neurodiagnosis May 4, 2004 (hr 1 & 2) Joanna Langley 1 CHRIONIC LOW BACK PAIN Chronic Pain = Pain with onset > 3 months o 5% of patients with low back pain o 85% of costs due to loss of work and compensation o 50% have clear structural diagnosis made for cause of their back pain A. DIFFERENTIAL DIAGNOSIS A. Musculoskeletal F. Spinal Stenosis B. Radiculopathy G. Infection C. Compression Fracture H. Malignancy D. Inflam. back disease I. Spondylolithesis/ Spondylosis E. Visceral/Vascular J. Other causes Differential Diagnosis 0. Musculoskeletal (Multifactorial, Layer Syndrome) Module 9 – Last week of classes EVER!
  2. 2. Neurodiagnosis May 4, 2004 (hr 1 & 2) Joanna Langley 2 a. "Mechanical", Overuse Syndromes b. Degenerative Joint Disease (Facets) c. Degenerative Disc Disease d. Muscular Strain and Spasm e. Better with rest, worse with activity May have antecedent trauma Layer Syndrome Hypertrophy Hypotrophy -C/S erectors -lower scap. stabilizers -upper traps -L/S erector spinae -levator scapula -glut. Medius -T/L erector spinae -abd. rectus -hamstrings -abd. obliques Module 9 – Last week of classes EVER!
  3. 3. Neurodiagnosis May 4, 2004 (hr 1 & 2) Joanna Langley 3 Degenerative spondylo-arthrosis and cumulative spinal degeneration A. Chronic Radiculopathy o Old Herniated Nucleus Pulposis (HNP) o Cases of radiculopathy - i.e. Spondylosis, IVF entrapment  L4-S1 in 95%, L2-4 in 5% “Healed Acute Radiculopathy” vs. “Chronic Radiculopathy” ““HealedHealed” Acute Radiculopathy -” Acute Radiculopathy - What has healed? …Influenced by patient factors.What has healed? …Influenced by patient factors. 0. Loss of reflex – 0 or + compared to ++ 0. Residual sensory loss - in small area of dermatome. 0. Muscle atrophy – May see some? 0. Loss of strength – May see some? 0. Muscle tone– possibly slight change in tone 0. Lumbar signs –lordosis, paraspinal tension Module 9 – Last week of classes EVER!
  4. 4. Neurodiagnosis May 4, 2004 (hr 1 & 2) Joanna Langley 4 Chronic Radiculopathy -Chronic Radiculopathy - Many variables…assets/liabilities/recurrences, etc?Many variables…assets/liabilities/recurrences, etc? 0. Often Loss of reflex – 0 0. Often Residual sensory loss – in area of dermatome. Opposite (Mirror) leg loss! 0. Often Muscle atrophy 0. Often Loss of strength 0. Often Muscle tone change 0. Often Lumbar signs –lordosis, paraspinal tension, myalgic pain spots. o Acute disc presentation: age 20-40, back and leg pain o Chronic disc presentation: more often older patient, variable presentation and may have cauda equina syndrome (75% of those with CES saddle anaesthesia) B. Compression Fracture 0. Acute, severe onset of focal pain – aggravated with flexion, stooping, straining. 0. Bilateral splinting/guarding/+ percussion 0. Spinal curvature, gibbous, root compression 0. Predisposing factors; Elderly, Rx prednisone, SLE, osteopenia/osteoporosis? 0. Pain will resolve spontaneously in 3-6 months  Beware of this with elderly patients complaining of T/L pain that you think is T/L syndrome. They may also have regional root signs and symptoms Module 9 – Last week of classes EVER!
  5. 5. Neurodiagnosis May 4, 2004 (hr 1 & 2) Joanna Langley 5 C.Inflammatory Conditions  Ankylosing Spondylitis Morning stiffness 0. Arthritis of Inflammatory Bowel Disease (IBD) Agg. by rest (Crohn’s, Ulcerative colitis) Rel. with activity 0. Psoriatic Arthritis Younger (<40) 0. Reiter's Syndrome Note on Enteropathic Arthritis – Commonly in adults (25-45) - Sx of pain swelling, and stiffness in the joints - Sx frequent “flare ups” and remissions - Dx: when joint pain accompanies Crohn’s or ulcerative colitis D.Visceral/Vascular Referred Pain Tends to be a vague pain as compared to MSK pain which is usually easily localized 0. Abdominal Aortic Aneurysm (AAA) – COMMON!!! 0. Endometrial disease 0. Ovarian disease 0. Perforating duodenal/gastric ulcer 0. Pancreatitis - infrequent E. Spinal Stenosis TypesTypes -- Degenerative (seen in elderly; most common) -- Congenital Module 9 – Last week of classes EVER!
  6. 6. Neurodiagnosis May 4, 2004 (hr 1 & 2) Joanna Langley 6  Pseudoclaudication/Neurogenic claudication  Better with flexion of back  Bilateral neurological deficits  Wide-base gait F. Infection 0. Herpes Zoster – post herpetic neuralgia COMMON!! 0. Intervertebral discitis or osteomyelitis – more common in kids 0. Mycobacterium Tuberculosis (Pott's Disease) 0. Paravertebral Abscess 0. Pyelonephritis G.Malignancy A. Multiple myeloma, lymphoma, pancreatic, mets, breast, prostate, thyroid, etc.  How do you know when you’ve missed one of these diseases? Usually they come back in 2 months and tell you they have been diagnosed with cancer, and then you think… hmmm maybe that was what was causing their pain when they were last here! o See the case in the May issue of the JCCA on prostatic mets Module 9 – Last week of classes EVER!
  7. 7. Neurodiagnosis May 4, 2004 (hr 1 & 2) Joanna Langley 7 I. Spondylolisthesis/Spondylolysis ... Spinal Instability What are signs of Lumbar InstabilityLumbar Instability? What Neurological Signs may occur? Common Instability History 0. Usually no direct trauma, or injury o Often a history of repetitive injury. o Instability may result from a significant trauma 0* e.g. fracture-dislocation. Patient may feel: o Pain-free between exacerbations o Exacerbations becoming more frequent o Trivial incidents bring on symptoms o Lower back is weak Symptoms Commonly in "instability" sufferers 0. An arc of pain (usually into flexion) Patients may "walk up" the legs when returning from the flexed position 0. Pain on relaxed postures (muscles are relaxed) 0. Pain on quick movements A. Excessive range of intervertebral movement at the motion segment 0. Sharp pain or 'catching' on changing positions following a prolonged rest Module 9 – Last week of classes EVER!
  8. 8. Neurodiagnosis May 4, 2004 (hr 1 & 2) Joanna Langley 8 0. Often good range of motion, with some degree of pain at the end range X-ray findings are inconclusive: 0. Traction spurs 0. Posterior subluxation 0. Excessive translation of one vertebral body on another during flexion/extension radiography may suggest instability 'functional instability' may still exist in the absence of x-ray findings. Conservative Treatment Measures 0. Mobilization of the vertebral segment within range, not aiming to "mobilize" the unstable segment but to provide pain relief. 0. Braces or corsets short term assistance to stability, but not longer than 6 weeks. 0. Self-help exercises For spinal stability. These come in the form of dynamic lumbar stabilization exercises for core muscle stability. 0. Failure of conservative treatment spinal fusion J. Others 0. Hip disease, scoliosis, leg-length discrepancy, fibromyalgia, DISH, diabetic radiculopathy CHRONIC RADICULOPATHY & MULTIPLE COMPRSSION SYNDROME In more detail! Module 9 – Last week of classes EVER!
  9. 9. Neurodiagnosis May 4, 2004 (hr 1 & 2) Joanna Langley 9 Lumbar Degeneration (spondylosis, IVF entrapment, stenosis, instability, curvature, osteophytes, etc…)  Many of these come into play wit patients and we need to learn who to prioritize them in terms of what is causing the present acute symptoms? What are the pain sensitive structures? We then need to aim our plan of management to reduce these. Trauma/ DJD / DDD / Nerve Compression Symptoms, Loss of ADLs, Disability Surgery Treatment Rehabilitation Chronic Radiculopathy - Long Term ConsequencesChronic Radiculopathy - Long Term Consequences 0. Chronic recurrent radicular pain episodes Module 9 – Last week of classes EVER!
  10. 10. Neurodiagnosis May 4, 2004 (hr 1 & 2) Joanna Langley 10 0. Structural distortion 0. Chronic spine & SI joint dysfunction 0. Myofascial pain syndromes 0. Lower limb compensation 0. Spinal compensation 0. Chronic pain syndrome Module 9 – Last week of classes EVER!
  11. 11. Case Anne 76 year old female with chronic left buttock, leg and knee pain History Pain for 3 months, increased with prolonged sitting, walking, stair climbing, decreased with heat, ice, hot showers, meds (naprosyn) Examination:  HEENT, Lungs, CV, Abdomen exam-WNL  MFP (3/3- jump sign) – Left side TFL, glut med. These and piriformis are often tight and tender due to detraining.  Left S/I pain with pressure  + Trendelenberg sign  Left hip crepitus with reduced internal and external rotation  Long axis traction easier on left. Common then surrounding joint is atrophied  DTR (L/R): Quad. 0/3, Achilles 0/0. If there is NO left leg pain but there is an objective weakness (drop foot) think about long term radiculopathy (disuse)
  12. 12. Diagnosis: 0. Peri-articular arthritic hip adhesions A. Myofascial pain syndrome B. Longstanding left L4 radiculopathy with left buttock and leg atrophy C.X-Ray: Multiple level degenerative spondylosis of lumbar spine Treatment A. Hip therapy (early signs of OA): Mobs, deep heat, advise to avoid cross-legged sitting. B. Lumbosacral (DJD + Mechanical LBP): End-range mobs, segmental distraction C.Myofascial pain – myofascial release, massage, ice, tennis ball pressure exercise. D.Other: RMT, MD Take-Home Message ~ Establish as complete diagnostic picture as possible, patient assets & liabilities. ~ Identify & Prioritize pain-generators. ~ Begin treatment for simple pain generators first - Joint strain/inflammation - Myofascial pain - Mobilize for joint alignment before use of HVLA - SMT ~ Encourage home care, rejuvenative care and multi-professional care Good Exam Question!
  13. 13. C. POST SURGICAL MANIPULATIVE CARE Indications for Surgery - When Yellow Flags turn into Red Flags o Progressive or severe neurological deficit. o Persistent neuromotor deficit despite 4-6 weeks o Conservative therapy without progress.  Persistent radiculopathy 1* Sensory deficit or reflex loss after 4-6 weeks 2* Conservative therapy with +SLR, (no resolution) 3* Consistent clinical findings 4* Favourable psychosocial circumstances (no depression, substance abuse or somatization disorder) The following is an example from last years notes but it should help… it seems like a logical rationale for one of his questions. Example: A patient is S/S of L5 disc herniation – 1 year history of pain (no prior Tx) increased with flexion, pain on straining, dermatomal pattern of paraesthesia. What are your priorities? Do you accept this patient? ~Establish a diagnosis and determine the extent of damage ~X-Ray ~Identify other pain generators – i.e. myofascial pain spots. Counsel re: positions that relieve/aggravate the pain ~Tx: avoid mechanical devices when patient is acute (eg. Hill table) and stick to things that are in your and the patient’s control so that the patient does not get anxious when something moves and they aren’t expecting it. Try: traction, mobs, SMT, myofascial release, pelvic stabilization exercises, McKenzie (mainly for acute), modalities… SURGICAL PROCEDURES:
  14. 14. Endoscopic Discectomy 0. An outpatient surgical procedure 0. Local anaesthesia with x-ray fluoroscopy 0. Endoscopic probe is inserted between the vertebrae and into the herniated disc space. 0. Small surgical attachments remove a portion of the disc (sucks it out!). 0. Time: ~1 hour. 0. X-ray exposure is minimal. 0. No stitches…a small Band-Aid is placed over the incision. 0. The amount of nucleus tissue removed varies with damage to disc. 0. Supporting structure of the disc is not affected by the surgery. Minimal disruption of the back tissues = reduced rehabilitation time! Risk of complications from scarring, blood loss, infection, and anaesthesia. These were very common in old surgeries but are now minimal with Endoscopic Discectomy! Chiropractic Approach to Post-Surgical Micro-discectomy Patients There is less rehab in hospitals post surgery now, so there is definitely a need for patients to see us post surgically for rehabilitation programs!
  15. 15. a. Rule of thumb: Wait 8 weeks post surgery before performing manipulation. (generally but depends on Pt) b. Patient should have confidence with their active range of motion (may be limited). They need to be able to twist and turn quickly and “gingerly” a Dr. Z term! c. Establish comfort with end-range challenge throughout lumbosacral spine. d. Progress through graded mobilizations (Grade 1,2,3,4) of involved vertebral levels before attempting SMT. Short lever mobs preferably e. Prior to SMT: Patient should be comfortable with the “Test of Manipulation” at the vertebral level to be adjusted. [Test of ManipulationTest of Manipulation Little or no pain with SMT set-up and gentle thrust.] f. “Disc Closure” technique on side of surgery may be advised. (Dr. Z’s opinion only!)
  16. 16. g. McKenzie exercises may be helpful if pelvic shift test minimizes any residual buttock/leg pain. Mainly for younger patients h. Begin pelvic stabilization exercises (“Dying bug exercises”), and aerobics. i. Review ergonomics of sitting, work, etc. j. Examine full spine for spinal compensation, and assess lower limb alignment (pelvis, knee, and ankle). Use their level of confidence as a guide for the progression of your treatment plan Harrington Rod Procedure A. Paul Harrington introduced the Harrington rods in 1949 for the treatment of post polio scoliosis. Its use has expanded to include: 5* Destabilizing cases of tumour 6* Fracture 7* Fracture dislocation of the thoracic and lumbar spine (Riebel, 1993). B. Rods offer structure to spinal structure to improve: Alignment, provide stability, allow earlier rehabilitation, and prevent late deformity. C.Rods act as an internal splint, reducing the dependence on external forms of immobilization. D.The anterior procedure PROs CONs Different incision – on the side, not down Disrupts shoulder muscles
  17. 17. the back Saves 1-2 fusion levels Pseudoarthrosis rate not known Slightly better correction Effect on pulmonary function Slightly better de-rotation Harder to revise Other Surgical Procedures Click: Interactive Spine Animations Epidural steroid injection Kyphoplasty Intradiscal Electrothermal Therapy (IDET) Inter-body fusion Bone fusion Laminaplasty Lumbar microdecompression Spondylolisthesis Lumbar disc herniation Spinal stenosis
  18. 18. Chiropractic Approach to Post-Surgical Patients with fusion or instrumentation fixations k. Apply prior comments 1 –9 except for comments on SMT. l. Choose graded mobilization over HV-SMT. m.If HV-SMT is to be used near surgical instrumentation stay 2 vertebral levels higher or lower and use short lever techniques without long lever thrust. n. Monitor for post manipulation strain, neurological signs, instability and patient apprehension. Judge the confidence of the patient and keep an eye on Red Flags You need to get them back to their normal ADL’s as soon as possible
  19. 19. Failed Back Syndrome …Becoming a rare “syndrome” because of newer micro-surgical techniques! Characterized by: 8* Persistent or recurrent symptoms like back pain and sciatica in patients operated upon for herniated discs. Multiple levels of DJD, continued dis-atrophy or de-training of musculature. 9* Reported in 10–40% of patients following low back surgery 10* A difficult problem both for clinicians and radiologists. Symptoms may occur in postoperative period or later. o May be due to: Epidural hematoma, recurrent herniated disc, retained disc fragments, discitis, spondylosis, arachnoiditis, progressive arthrosis, pseudo- arthrosis, epidural fibrosis. Surgeries and the frequency of side-effects: Fusion, Laminectomy, Discectomy Most common: Foraminal and spinal stenosis (30%) and Painful disc disease (16%) Less Common: Pseudoarthrosis, neuropathic, recurrent Herniated, nucleus pulposis, spinal instability, painful discs plus foraminal or spinal stenosis, painful discs within fusion, psychological, infection.