L4, L5, S1- see pic near end of notes.doc.doc.doc.doc

10/26/04 Week5

Lumbar Spine

Cara Beth Lee, MDFall, 2004

Also Check out Jacob’s Website of Class Notes www.jacobleone.home.comcast.net Exam next weekScantron25 multiple choice 2 points each, 50 points of short answer Examples below5 questions per lecture for M.C. and 10 points per lecture for short answer. The test will be PE stuff, For example: What PE would you do to confirm your DDx? She will be more testing your thought process not how you do a certain test. No x-ray views. Wants the test to be straight forward and test your thought process. So it will be mostly Dx. Red Flags- know theseWon’t ask numbers and percents, won’t be tested on Algorithms at end of these notes. Can switch sections for exam

Sample Question: Multiple ChoiceAfter a PE and Hx you think patient has L5 radiculopathy. On Exam you would expect to find 1. Weakness of ankle dorsiflexion2. Decreased sensation of medial malleolus3. Decreased achilles tendon reflex4. Decreased extension of Great toe

2nd test In that patientWhere would you expect their herniation to be? 1. L4-5 right answer. (b/c it’s the traversing nerve root L4 has already exited so L5 is the nerve that has been compressed)2. L5-S13. L3-4

Sample Question: Short AnswerYou are worried someone has cauda equina syndrometell me 3 things you will see on Hx and Pe? Make sure you know red flags.

Key is to test 3 nerves for Ruling Out Red Flags if a patient comes in with Low Back Pain.

L4, L5, S1- see pic near end of notesTest motor, sensation, and DTR’s of each nerve.L4-

Motor-active and resist ankle dorsiflexion Sensation-medial malleolus DTR-patellar

L5 Motor-big toe dorsiflexion and resist Sensation-dorsum of foot

S1 Motor- plantar flexion and resist Sensation-lateral malleolus DTR- Achilles tendon

Physical Exam she does, R/O red flags first and put patient in gown, (not on test per say but good to know how she does it)

1. Walk- watch and them walk on toes(S1gastroc and soleus’plantar flexors’, and great toe flexors, peroneous longus and brevis), and then on heels (L4’ankle dorsiflexion’ L5 great toes dorsi-flexion), walk as though on balance beam. (balance problems could be a myelopathy not necessarily cauda equina), look if weak mm. weakness.

2. Sit-have feet dangling, test straight leg raise (SLR), at 90 degrees first, a. Motor first have them lift knee and resist, push knees towards away, then with

lower leg extend and flex, lat. And med movement, push against big toe dorsiflexion(L5), sensation at dorsum of foot, push down on gas(S1, peroneus longus and brevis) achilles tendon reflex and sensation- lateral malleolus, curl big toe under, ankle dorsiflexion(L4ant. tibialis) DTR of L4-patellar sensation over medial malleolus,

b. Test goes ankles up, ankles down, big toe up, sensation touch medial malleolus, lateral malleolus, top of foot, two reflexes Achilles and patellar.

c. Sensation, compare feet, test behind knee tood. Patellar, Achilles, and babinski, DTR, clonus(myelopahty)

3. Lay Supine- SLR(straight leg Hip ROM, repeat motor tests if weak sitting.

General Information lifetime prevalence of low back pain 50% - 80% most common cause of disability in age < 45 15 million patient visits per year-many to PCPs total annual health care costs up to $20 billion- includes loss of work 90% spontaneously recover within 1 month- no matter what we do they get better

A little bit about back pain Classification based on duration

o +acute – immediate onset, duration < 3 monthso subacute – slow onset(key diff), duration < 3 months o chronic – duration > 3 monthso recurring – symptoms recurring after interval of no symptoms

Classification based on locationo local – pain in lumbar or lumbosacral area low back paino referred – pain located in area that shares common embryologic origin with the

involved region (myotomal or sclerotomal), ex: heart attack, pain down left arm ex L4 bone pain pattern groin pain is hip joint arthritis for example.

o radicular – pain located along dermatomal distribution due to direct irritation of spinal nerve root (radiculopathy, sciatica)

What hurts?o superficial support structures skin, fascia, muscle and ligaments may produce local

pain if injured or overusedo periosteumo unanesthetized stimulation study-put in sutures and pulled on them did that hurt?

localized back pain annulus fibrosis (not nucleus pulposus) vertebral endplate anterior dura

posterior longitudinal ligament facet capsule

irritated nerve root radicular distribution. Radiation only if irritated if not it just hurt locally. The key is radicular pain. Theory substance P, or immune response-usually non-vascular so when there is immune response there is fluid that usually isn’t there.

mechanical deformation, reduction of blood flow chemical exposure autoimmune or inflammatory response to nucleus pulposus

Osteology: Lumbar spine vertebrae- flexion and extension, rotation is mostly thoracic, Pars interarticularis-a stretch of

bone between the verterbrael bodies(more on this below).

Fracture low energy (osteoporotic)-cough or sneeze too hard can fracture

o stable fractureso treat symptomatically-pain NSAIDs, OTC braces, calcitonin – can help

high energy-MVA, or falls from height.o stable vs. unstable (not on test) dividing up the vertebral o (Not on Test -NOT)three columns anterior, middle, posterior column, post. 1/3 is

spinous process. Ant. 1/3 is post part of vertebral body. o unstable = involvement of more than one columno Ex-snowboarding, burst of disc into spinal canal, Tx-surgery

Spondylolysis-risk factor for spondylolisthesis defect in bony arch between inferior and superior articulating processes (pars interarticularis)

loss of pars interarticularis typically L5-S1 present in 5% of general population-most asymptomatic, less than 1% have sx “congenital “ vs. acute – congenital should be found young gymnasts, football linemen- typically more acquired though. Cause is hyperextension bending

force cracks it. Classic will be gymnast with LBP and increasing pain may be inherited Tx- symptoms may respond to bracing and activity modification, If recurrent rare surgical fusion Dx- oblique x-ray- look for collar of Scotty dog, have to see pic, and x-ray

Spondylolisthesis- a continuation of pathology of spondylolysis, spondylolisthesis- is just movement or slippage of vertebrae. Have to have spondylolysis to have spondylolisthesis. There are other causes of spondylolisthesis. Spondyloptosis is stage 5 of spondylolisthesis all the way slipped off of vertebrae. Spondylolysis- may be able to heal,

forward subluxation of one verterbra on another, post. Elements stay back. implies bilateral spondylolysis vertebral body translation may be acquired, related to disc degeneration and not spondylolysis most slippage occurs during adolescent growth spurt

History and Physical Exam in children May occur at growth spurt- boys 14 girls 12 yo. ± pain, may radiate to buttocks

postural change- increase lumbar lordosis, change in posture, hamstring tightness stiff-legged gait with short stride lengthDx decreased straight leg raise- mild discomfort to palpation increased lumbar lordosis rule out bowel / bladder dysfunction, sacral / rectal dysesthesias

History and Physical Exam in adults usually presents with pain-especially in adults. pain patterns similar to disc herniation or spinal stenosis lumbar lordosis and hamstring tightness

Diagnosis history and physical exam- increase lumbar lordosis standing AP, lateral, oblique can see it laterally and do a grading depending on how far the

vertebrae falls off the vertebrae below it. adults may need CT or MRI to evaluate other sources of pain- they have other things

Treatment incidental finding no restriction especially if no pain. acute symptoms

o immobilizeo activity modification / restriction

hamstring stretching – can help a lot. consider bone scan(only spondylolysis b/c it can heal itself if the vertebrae is slipped off then it

can’t heal) - with a hot bone scan(laying down new bone) then a good sign healing is happening and may heal themselves.

follow with spot lateral x-ray every 6 months until skeletally mature surgery in situ fusion- where it is not move it back b/c the nerves and

o failure of non-operative treatmento slip of greater than 50% in kids- want to stabilize this, don’t want it to progress. o address other pathology in adultso Can screw sacrum and L5 together. o Questions-could this be adjusted- manual adjustment won’t do it. Surgery in situ

fashion is Tx. If you move the verterbrae back the nerves may be impinged because they have grown differently to accomadate, and moved anteriorly with the slippage of the vertebrae. So moving back the vertebrae impinges on the nerves, rather than moving the vertebrae back into place the approach is to not let the vertebrae move any farther. Screw them in place where they are at.

Scoliosis (rotatory kyphoscoliosis)- bend to vertebral elements as well. 80% of cases are adolescent-onset idiopathic some are congenital due to lack of growth of

vertebral bodies. B. is not misshapen- on x-ray looks like loss of disc space(not true though), Soft tissue as well

but not really just that, bottom line-its poorly understood. affects 2%-3% of 10- to 16- year olds few require tx Lower degree curves boys and girls equal. ♀10 : ♂1 for curves > 30° convex to the right If convex to left-- higher associated with other neurological problems need more work up. Can have two curves painless

less than 10% require active treatment risk factors for curve progression:

o younger age at diagnosis- more likely to progress b/c more growth remaining to do . pre-menarche Risser stage- radiographic method of Tanner staging(secondary sex char.) 25%

of iliac crest is covered. Ex 40degree curve and Risser 1 they still have a lot of growth and so will progress.

o double-curved patternso larger curve at detection

scoliosis table:

Curve magnitude Age

at detection 10-12 13-15 16

-------------------------------------------------------------

< 19°                      25% 10% 0%

20° -29° 60% 40% 10%

30° -59° 90% 70% 30%

> 60°                       100% 90% 70%

screening exam indicated in all school age kids scoliometer measurement > 7° an indication for x-ray How to use scoliometer =(pic on

ciprianno238) lay this scoliometer on most curved part of back with patient bent forward minimal asymmetry examine q 4-6 months radiographic curve > 25° begin bracing

o goal is to stop curve progression (not absolute correction)o bracing ineffective with curve > 40°

curve > 50° surgery- long Herrington rods T-5 into lumbar spine hook onto lamina force back straight, diminishes motion,

curves > 50° tend to progress throughout life 90degrees will impinge on pulmonary function. How to look at X-ray- measure with a line Include a diagramTx- Ex- patient at Bastyr clinic who got symptomatic relief with heat, and massage tx spine was

straight on table when she stood it was off center again.

Disc protrusion / herniationNucleos pulposus-90% water,

20% of asymptomatic subjects have protrusion/herniation by age 60 2% lifetime prevalence of symptomatic disc disease

o 10 – 20% with persistent radiculopathy may benefit from surgery bulging but intact annulus fibrosis indicator of wear and tear, and loss of water content, 70%

water content when older gradual loss of disc water content with aging risk factors for protrusion

o sedentary worko family historyo smoking

o occupational exposure to vibration- hard labor in younger years strengthens though. negative risk (i.e., protective) factors

o manual work in younger yearso diabetes (risk factor for degeneration but not protrusion)o spondylolisthesis-not as much of a factor for nerve root compression, slip, it opens up

canal space, reverse of spinal stenosis. symptoms depend on canal space disc herniation nucleus pulposus pushes through a tear in the annulus fibrosis

o typically occur on a side due to thick central PLLHistory (protrusion and herniation)-nucleus material into foramen

acute or subacute low back / buttock pain may radiate in a radicular pattern if compressing nerve root symptoms exacerbated by valsalva (cough, laugh sneeze)

Physical Exam trunk list that improves when supine(leaning off center to relieve compression) limited straight leg raise L4-5 its L5 nerve that’s affected over 80% of patients respond to conservative care no statistically significant difference in long-term outcome of operative vs. conservative

treatment for mild radiculopathy, benefit of surgery is shorter rehab and shorter recoveryTreatment

analgesics, muscle relaxants, NSAIDs epidural steroid injection walking, conditioning Bed rest longer than 3 days is detrimental abdominal and low back strengthening once able return to sedentary work 6 – 8 weeks with lifting restriction surgery

o persistent or recurrent radiculopathyo increasing impairmento gross motor weaknesso resolution of symptoms 90% in appropriately selected patients

Cauda Equina Syndrome RED FLAG of LBP

Key- difference between this and disc protrusion is that this is disc protrusion into whole spinal cord is and so more severe sx and damage.

Cord ends at L1, sacral nerve roots, bowel and bladder control perineal sensation compression of cauda equina typically due midline disc herniation rare, 1% to 2% of lumbar disc herniations can be caused by lifting, or MVA,

common findings urinary retention bowel / bladder incontinence “saddle” anesthesia-sacral nerve roots unilateral or bilateral radiculopathy sensory and motor deficits decreased sensation on wiping, diminished anal sphincter tone

surgical emergencyo deficits untreated > 48 hours may be permanent

Spinal stenosisNarrowing of vertebral canal, due to thickening of lig. Flavum, hard discs btwn vert. bodies. Stable fractures if involve only one column

congenital vs. acquired usually acquired (degenerative)

o vertebral bar (hard disc)o thickened facet joint and capsuleo osteophytes- around facet joints. o ligamentum flavum hypertrophy

degenerative spondylolisthesis – loss of disc height allows anterior-posterior translation of vertebral bodies

spinal stenosis two clinical syndromes (activity-related mechanical back pain in each) syndrome1. root entrapment

o radicular pain – LBP as well, diff from disc herniation o not changed by valsalvao may have normal exam: nl SLR, reflexes, motor and sensory functiono nerve root is tight but not irritatedo symptoms worsened with back extension, flexion or straight leg raise is ok relieves sx. o natural history is improvement

2. neurogenic claudicationo thought to be due to venous congestion in cauda equina which decreases nerve root

conductiono unilateral or bilateralo limitation of walking distance-cauda equine delaying nerve conduction. o DDx from vascular claudication- check peripheral pulses, or stationary bike test no

probl but a vascular claudication will b/c the crouched position. o improved with forward bendo natural history is gradual decrease in activity level

Dx- o CT scan

Treatment activity modification NSAIDs massage ultrasound moist heat isometric flexion exercises-open spinal canal. aerobic conditioning (biking, swimming) surgery

o failure to respond to nonoperative treatmento progressive neurologic deficito leg pain > back pain (back pain comes from different degenerative processes)o success rate 60% - 70% (often because of multi-level stenosis)

Sprain / Strain

indistinguishable from each other clinically manifest as lumbar and paraspinal pain muscle tightness or spasm pain shouldn’t radiate

Treatment 90% get better on their own cold, massage, ultrasound heat after 48 hrs analgesics and muscle relaxants activity modification

Malignancy majority are metastatic If goes to b. it goes to vertebral bodies. nighttime or rest pain, progressive exacerbated with percussion Hx-biggest key hx of malignancy

Dxo x-rays

bone scan

Infection very rare may affect disc space or vertebral body hematogenous or post-surgical in adults kids may not have hx. h/o UTI, urinary surgery, dental abscess, IVDA, immune suppressed nighttime or rest pain, insidious, progressiveDx

pain exacerbated with percussion check CBC, ESR, blood culture biopsy for culture / pathology early antibiotics

Estimated prevalence in 100 primary care patients 85 – nonspecific low back pain- so 4 – vertebral compression fracture(little old ladies with osteoportic compression fracture) 3 – spondylolisthesis 2 – herniated disc ? – spinal stenosis 0.7 – malignancy 0.3 – ankylosing spondylitis 0.01 - infection

AHCPR –agency for health care practice guidelines(developed in 1991)- some patients are over or under studied before Dx, so a group of a bunch of different therapists, from psychologist to massage therapists, to orthopedic surgeons. They reviewed articles, and then presented guidelines of how to manage patients.

AHCPR-since 80% are nonspecific so rule out whats worrisome, most get better with conservative care. Just support people through back pain. This is a list to help you with your thought process as a PCP with a patient who comes in with LBP. Low Back problem =Defined as activity intoleranceFocus on acute sx <4 weeks,

goal – “paradigm shift”-rather than label with multi-disciplinary panel evidence-based guidelines targets primary care provider low back problem: activity intolerance due to back-related symptoms duration less than 3 months avoid labeling- don’t just tag things. seek “red flags”- make sure nothing major going on. medical history guides physical exam just focus in on what you think is going on. focused physical exam regional back evaluation-ROM not helpful (cheating motion through pelvis), look at back look

for mm. spasm, then test following 4 nerve roots with motor, sensory, and reflex. sensorimotor exam of L4, L5, S1- 80% of problems affect these problems reflexes straight leg raise test-most useful test, for rule outs in the absence of red flags, no testing is needed in the first month of symptoms provider’s responsibility is reassurance and education algorithms provide pathway and time frame for next steps

From www.chirobase.org

Red Flags For Conditions(cancer, infection, cauda equina, fracture) If no Red Flags for Low Back Pain then no extra tests are needed, no x-ray, CT, MRI for first month. Instead just reassure them this will get better with time and give back care and education about back care and safety.

Red flags for cancer or infection age > 50 years history of cancer unexplained weight loss immunosuppression / corticosteroids IV drug use urinary tract infection nighttime symptoms

Red flags for fracture age > 70 years history of major trauma in young history of minor trauma in elderly

corticosteroids-osteoporosis

Red flags for cauda equina syndrome saddle anesthesia-area of perineum that’s touching a saddle when sitting on it, affects these

nerves. urinary retention / overflow incontinence fecal incontinence / loss of sphincter tone progressive motor weakness

NPLEX(not tested for- won’t be asked to explain Milgram’s test for example) tests that increase intrathecal pressure to test for space-occupying lesions

o Valsalva test (80,285Ciprianno) – ask patient to bear down as if straining to have a bowel movement, subjective

o Naffziger test (287) – compress jugular veins and hold for one minute pain in lumbar region is positive, may recreate radicular pain if nerve root involved

o Milgram’s test (286) – instruct supine patient to raise legs several inches off table and hold for 30 seconds, pain is a positive result

tests that increase nerve root tensiono Straight leg raise test (266) – patient supine, maintain knee extension, flex hip to point

of pain or 90 ° pain 0 ° – 35 ° suggests extradural sciatic irritation, 35 ° – 70 ° radicular pain from disc pathology, 70 ° – 90° lumbar joint pain

o Kernig’s test (430) – patient supine, flex hip and knee to 90 °, then instruct patient to extend the knee, positive if symptoms occur with extended knee OR flex head

o Bragard’s test (271) – patient supine, raise affected leg to the point of pain, then lower 5 ° and dorsiflex foot dorsiflexion pain from 0 ° – 35 ° suggests extradural sciatic nerve irritation, 35 ° – 70 ° nerve root irritation

o Lasegue’s test (267) – patient supine, flex hip and knee, then, keeping hip flexed, extend the knee positive for radiculopathy or sciatic stretch if symptom free with knee flexed and painful with knee extended

o Minor’s sign – ask seated patient to stand, a patient with radiculopathy will stand with his/her weight on the healthy side and keep affected leg flexed to decrease nerve tension

tests that increase nerve root tensiono Bectherew’s test (274) – patient seated with knees flexed over exam table, ask patient to

extend each knee separately, then together positive is knee extension recreates radicular pain or causes patient to lean back

o Fajersztan’s / well leg raise (273) – patient supine, raise unaffected leg to 75 ° or the point of pain and dorsiflex the foot stretches well- leg AND affected leg nerve root, may help differentiate lateral from medial disc

o Kemp’s test (282) – patient seated or standing, with one hand stabilize PSIS, with the other, reach around the front of the patient and grasp the shoulder, then passively extend the lumbar spine obliquely lateral disc lesion will increase nerve root tension with ipsilateral oblique bend, producing radiculopathy; medial disc lesion will recreate symptoms with motion in the contralateral direction

tests for malingering / symptom magnification

o Hoover’s sign (426) – ask supine patient to raise affected leg while you cup the heel of the other foot, if patient is exerting effort to raise his leg, the opposite foot should press down into your hand

o Burns bench test (427) – have patient kneel on a bench or exam table and bend at waist to touch the floor as you stabilize the legs, patients with low back pain should be able to perform this test because the stress is placed on the posterior leg muscles

REFERENCES Cipriano JJ, Photographic Manual of Regional Orthopaedic and Neurological Tests, 2003. Crowther CL, Primary Orthopedic Care, 2004.

Hoppenfeld S, Physical Examination of the Spine and Extremities, Appleton-Century-Crofts, 1976.Netter F, Atlas of Human Anatomy, Ciba-Geigy Corporation, 1989.Weinstein JN, Rydevik BL, Sonntag VKH, Essentials of the Spine, Raven Press, 1995.www.chirobase.org – AHCPR Clinical Guidelineswww.ncbi.nlm.nih.gov – AHCPR Clinical Guidelines