Download Spinal disorders

Common Disorders of
the Spine
LeAnne Mansberger, MSPAS, PA-C
Penn State Milton S. Hershey Medical Center
Department of Orthopedics
[Abbreviated for 870 – 2016]
Mechanical neck pain
• Local pain in neck that is usually muscular in nature
• Usually paraspinals, upper trapezius, complaint of
tension headaches
• Variety of causes: MVA, excessive physical activity, etc.
• Diagnosis: based on history, will not see much on
physical exam other than muscle spasm
• Imaging: no needed at first however if symptoms persist
or there is a traumatic event x-rays should be obtained.
MRI may ordered if symptoms persist long term but
usually normal
Mechanical neck pain
• Treatment: rest, ice/heat, HEP, physical therapy,
chirotherapy, soft collar
• Know Hoffman’s test:
https://www.youtube.com/watch?v=xfguBiqsoDk
• Know Spurling’s test:
https://www.youtube.com/watch?v=h8GxF73P6GQ
Low back sprain/strain/mechanical
back pain
• Same mechanism of injury as neck strain
• Patient will make statements like “my back locked
up”
• They are often in pain and very inpatient
• Chief complaint is back pain following an incident,
the key is that there are no leg symptoms
AFP Approach to Back Pain:
• Common complaint; usually benign
• Quickly rule out red flags:
•
•
•
•
•
•
•
Trauma (from MVA or fall)
Major or progressive motor or sensory deficit
New onset bladder or bowel incontinence
Loss of anal sphincter tone
Saddle anesthesia
History of CA metastatic to bone
Spinal infection
AFP Approach to Back Pain:
• Acute low back pain: 6-12 weeks of pain between
the costal angles and gluteal folds
• May or may not radiate down legs (sciatica)
• Back pain is usually non-specific, but need to
consider infection, tumor, osteoporosis, fracture,
inflammatory arthritis
Back Pain Differential:
Intrinsic spine
Compression fracture
Herniated nucleus pulposus
Lumbar strain/sprain
Spinal stenosis
Spondylolisthesis
Spondylolysis
Spondylosis (degenerative disk
or facet joint arthropathy)
History of trauma (unless osteoporotic), point tenderness at spine
level, pain worsens with flexion, and while pulling up from a supine to
sitting position and from a sitting to standing position
Leg pain is greater than back pain and worsens when sitting; pain from
L1-L3 nerve roots radiates to hip and/or anterior thigh, pain from L4-S1
nerve roots radiates to below the knee
Diffuse back pain with or without buttock pain, pain worsens with
movement and improves with rest
Leg pain is greater than back pain; pain worsens with standing and
walking, and improves with rest or when the spine is flexed; pain may
be unilateral (foraminal stenosis) or bilateral (central or bilateral
foraminal stenosis)
Leg pain is greater than back pain; pain worsens with standing and
walking, and improves with rest or when the spine is flexed; pain may
be unilateral or bilateral
Can cause back pain in adolescents, although it is unclear whether it
causes back pain in adults; pain worsens with spine extension and
activity
Similar to lumbar strain; disk pain often worsens with flexion activity or
sitting, facet pain often worsens with extension activity, standing, or
walking
Back Pain Differential:
Systemic
Connective tissue disease
Multiple joint arthralgias, fever, weight loss, fatigue, spinous
process tenderness, other joint tenderness
Inflammatory spondyloarthropathy
Intermittent pain at night, morning pain and stiffness,
inability to reverse from lumbar lordosis to lumbar flexion
Malignancy
Pain worsens in prone position, spinous process
tenderness, recent weight loss, fatigue
Vertebral diskitis/ osteomyelitis
Constant pain, spinous process tenderness, often no fever,
normal complete blood count, elevated erythrocyte
sedimentation rate and/ or C-reactive protein level
Referred
Abdominal aortic aneurysm
Abdominal discomfort, pulsatile abdominal mass
Gastrointestinal conditions: pancreatitis,
peptic ulcer disease, cholecystitis
Abdominal discomfort, nausea\vomiting, symptoms often
associated with eating
Herpes zoster
Unilateral dermatomal pain, often allodynia, vesicular rash
Pelvic conditions: endometriosis, pelvic
inflammatory disease, prostatitis
Discomfort in lower abdomen, pelvis, or hip
Retroperitoneal conditions: renal colic,
pyelonephritis
Costovertebral angle pain, abnormal urinalysis results,
possible fever
Back Pain Red Flags:
POSSIBLE ETIOLOGY HISTORY FINDINGS
Cancer
Strong: Cancer metastatic to bone
Intermediate: Unexplained weight loss
Weak: Cancer, pain increased or unrelieved
by rest
Cauda equina syndrome Strong: Bladder or bowel incontinence,
urinary retention, progressive motor or
sensory loss
Fracture
Infection
PHYSICAL EXAMINATION
FINDINGS
Weak: Vertebral tenderness,
limited spine range of motion
Intermediate: Prolonged use of steroids
Strong: Major motor weakness or
sensory deficit, loss of anal
sphincter tone, saddle anesthesia
Weak: Limited spine range of
motion
Weak: Vertebral tenderness,
limited spine range of motion
Weak: Age older than 70 years, history of
osteoporosis
Strong: Severe pain and lumbar spine
surgery within the past year
Strong: Fever, urinary tract
infection, wound in spine region
Strong: Significant trauma related to age*
Intermediate: Intravenous drug use,
Weak: Vertebral tenderness,
immunosuppression, severe pain and distant limited spine range of motion
lumbar spine surgery
Weak: Pain increased or unrelieved by rest
Back Pain Neurologic Findings:
DISK HERNIATION
AFFECTED
NERVE
ROOT
MOTOR
DEFICIT
SENSORY
DEFICIT
L3
Hip flexion
L4
Knee
extension
L5
S1
REFLEX
CENTRAL
PARACENTR
AL
Anterior/medi
al thigh
Patella
Above L2-L3
L2-L3
L3-L4
Anterior
leg/medial
foot
Patella
Above L3-L4
L3-L4
L4-L5
Dorsiflexion\gr Lateral
Medial
eat toe
leg/dorsal foot hamstring
Above L4-L5
L4-L5
L5-S1
Plantar flexion Posterior
Achilles
leg/lateral foot tendon
Above L5-S1
L5-S1
None
LATERAL
Low back sprain/strain/mechanical
back pain - EXAM
Back Pain Specialist Exam
•
https://www.youtube.com/watch?v=FDTulyaRvRw
Clonus – indicates motor neuron lesions
•
https://www.youtube.com/watch?v=UX75k8s5QUE
Exercises for Sciatica – PT
•
https://www.youtube.com/watch?v=htgyPKNHUls
Low back sprain
• Physical exam: normal
• Imaging: no imaging necessary early on, may do
imaging if pain persists and always start with x-ray
• Treatment: rest, ice/heat, physical therapy, muscle
relaxers, pain management for trigger point
injections if spasms are a recurrent issue
AFP: Approach to nonspecific acute low back pain
First visit
- Patient education
Reassure the patient that the prognosis is often
good, with most cases resolving with little
intervention
Advise the patient to stay active, avoiding bed rest
as much as possible, and to return to normal
activities as soon as possible
Advise the patient to avoid twisting and bending
- Initiate trial of a nonsteroidal anti-inflammatory drug or acetaminophen
- Consider a muscle relaxant based on pain severity
- Consider a short course of opioid therapy if pain is severe (ie, 3 days)
- Consider referral for physical therapy (McKenzie method and/or spine stabilization) if it is not the first
episode
Second visit (2-4 weeks later)
- Consider changing to a different nonsteroidal anti-inflammatory drug
- Consider referral for physical therapy (McKenzie method and/or spine stabilization) if not done at
initial visit
- Consider referral to a spine subspecialist if pain is severe or limits function
AFP: Recommended Treatments for
Acute Low Back Pain
•
NSAIDS – (low quality evidence) try one, if not helpful, try a
different one
•
Muscle Relaxants – (moderate quality evidence) cyclobenzaprine,
tizanidine, metaxalone. May help for 2-4 weeks. Cause
drowsiness.
•
Opioids – (little evidence of benefit) 3 studies showed no
difference in pain relief or return to work time between opioids
and NSAIDS/Tylenol.
•
Epidural injections – not helpful for acute pain; may help
radicular pain that does not respond to 2-6 weeks conservative Tx
•
Patient education! Give reassurance. Teach back exercises.
AFP: Acceptable Treatments for
Acute Low Back Pain
• Physical Therapy: The McKenzie method
https://www.youtube.com/watch?v=wBOp-ugJbTQ
• PT Directed Home Exercises (moderate benefit). These reduce
recurrence, increase time between episodes, and decrease
health care needs/costs.
• Application of ice/heat: (low quality evidence) – may be
helpful in first five days
• Epidural injections – not helpful for acute pain; may help
radicular pain that does not respond to 2-6 weeks conservative
Tx
• Patient education! Give reassurance. Teach back exercises.
AFP: Unsupported Treatments for
Acute Low Back Pain
•
Oral Steroids – questionable benefit for acute radicular leg pain. No
studies to support use for acute back pain without radiculopathy.
•
Acupuncture – (low quality) no benefit over NSAIDS
•
Exercise – (aerobic condition ) – no more effective than other treatments
•
Lumbar support – unclear if any benefit
•
Massage – insufficient evidence
•
Chiropractic technics: low quality evidence that it may be more effective
than sham treatments, but no more effice in reducing disabillity. Little
evidence that it is cost effective for low back pain.
•
Traction: no evidence of benefit
Bed Rest: BAD IDEA for
Acute Low Back Pain
• Less effective in improving pain/function at 3-12
weeks than advice to stay active
• Prolonged bedrest causes joint stiffness, muscle
wasting, loss of bone mineral density, pressure
ulcers, and DVT
Radiculopathy
• Radiculopathy
•
•
•
•
Nerve pain in a dermatomal pattern
“pinched nerve”
Can be cervical or lumbar in origin
Usually the result of a herniated disc but can be
osteophyte/tumor/hypertrophied ligamentum
Radiculopathy
• Disc herniation: the annulus tears and the nucleus
pulposus extrudes out into either the central canal or
neural foramen
Nerve Root Motor Function - Cervical
Radiculopathy
• Cervical radiculopathy
• Pain, numbness, tingling, pins/needles in upper
extremities
• Important to differentiate between radicular vs.
peripheral
• Will typically be unilateral
• PE: test all UE major muscle groups, reflexes in both
UE and LE, sensation, Hoffman’s, clonus, Spurlings
• Diagnosis: made by history, PE, and imaging
• Imaging: x-ray, MRI, EMG
Cervical radiculopathy
Cervical radiculopathy
• Treatment: physical therapy, NSAIDs, gabapentin,
steroids, epidural steroid injections, cervical
decompression and fusion (ACDF)
Radiculopathy
• Lumbar radiculopathy
• Pain, numbness, tingling, pins/needles in lower
extremities.
• “sciatica”
• Will complain of increase in pain in LE with straining
• Usually unilateral however can be bilateral
• PE: check all major muscle groups of lower extremities,
neuro exam, straight leg raise, gait assessment
• Diagnosis: made by PE, history, imaging
Nerve Root Motor Function- Lumbar
Radiculopathy
• Treatment: NSAIDs, physical therapy, oral steroids,
gabapentin, epidural steroid injections via pain
management, lumbar discectomy, lumbar
laminectomy
Radiculopathy
• Lumbar discectomy
• Done through small incision depending on patient size
• Only remove the herniated portion, we do not remove
all of the disc
• Slight increased chance of re-herniation immediately
post-op
Spondylosis
• The natural aging process of the spine; disc
degeneration and facet arthropathy
• Most commonly seen at C5-C6 because that is where
the most flexion and extension occur in the subaxial
spine.
•
Can ultimately lead to both central and foraminal
stenosis due to osteophyte formation.
Spondylosis
• Patient can present with various complaints;
anything from axial neck pain to radiculopathy to
myelopathy
• PE: same as radiculopathy exam
• Imaging: x-rays, MRI if radicular complaints
• Treatment: NSAIDs, physical therapy, pain
management (facet injections), surgical
decompression
Spinal Stenosis
• Narrowing of the spinal canal, cervical or lumbar
• Caused by a combination of boney structures and
soft tissues decreasing the diameter of the central
canal.
• 3 types of stenosis: central, lateral recess, and
foraminal
• Central will present with bilateral extremity symptoms
• Lateral recess will affect the lower nerve root
• Foraminal will affect the upper nerve root
Spinal Stenosis
• Symptoms: low back pain with bilateral lower
extremity pain worsened with activity
• Important to differentiate between neurogenic and
vascular claudication
• Neurogenic: pain with walking and standing, relieved
with sitting
• Vascular: pain with walking, relief with standing still or
sitting; weakened pulses
Spinal Stenosis
• Physical exam: May notice sensory deficit, walking in a
hunched over way “shopping cart sign”, may or may not
be weak .
• In vascular claudication: pulses weak, hairless legs
• Imaging: x-rays, MRI
• Treatment: NSAIDs, physical therapy, injections, surgical
decompression via laminectomy
• Video! http://www.webmd.com/painmanagement/video/laminectomy
Post laminectomy
Pre laminectomy
Spondylolisthesis
• Forward subluxation of vertebral body causing
stenosis
• Grading scale 1-5
• Degenerative vs. Isthmic
• Degenerative: spondylolisthesis without a pars defect
• Isthmic: spondylolisthesis with a pars defect
Spondylolisthesis
• Degenerative
• Usually seen at L4/L5
• 8x more common in women
• Caused by degenerative cascade: first the disc
degenerates, which allows the facets to degenerate,
which leads to instability.
Spondylolisthesis
• Isthmic
• Usually seen at L5/S1
• Rarely progress beyond Grade II
• Increased incidence of spondylolysis in athletes who
see a lot of hyperextension (football lineman, gymnast,
weightlifters)
Spondylolisthesis
• Symptoms: low back pain most common complaint,
neurogenic claudication, pain that changes with
position
• Physical Exam
• Imaging: x-rays (AP/lateral/flex/ext),CT scan, MRI
• Treatment: NSAIDs, physical therapy, injections not
all that helpful, surgical decompression and fusion
Ankylosing Spondylitis
• Autoimmune spondyloarthropathy
• Thought to be a genetic component
• 4:1 male to female ratio, usually onsets in 3rd decade
of life
• Spine becomes very stiff which leads to a
susceptibility to cervicothoracic fractures
• Patient will complain of pain and stiffness that is
worse in the morning.
Ankylosing Spondylitis
• Labs with show a positive HLA-B27 and negative
rheumatoid factor
• X-rays will show scalloping of vertebral bodies,
“bamboo spine”, progressive kyphotic deformity
• Diagnostic criteria: sacroilitis, +/- uveitis, positive
HLA-B27
• Physical exam: limited chest wall expansion,
Schober test (shows decreased Lspine ROM)
Ankylosing Spondylitis
• Treatment: NSAIDs, physical therapy, Cox 2
inhibitors (Celebrex), TNF alpha blockers
(inflixamib- remicade; etanercept- Enbrel), usually
not responsive to steroids
Scoliosis
• Deformity of the spine in either the coronal or
sagittal plane
• Curves <30 degrees rarely progress however curves
>50 degrees commonly progress
• Cobb angle: measured on x-ray
Scoliosis
• Most people are diagnosed as young person however
degenerative scoliosis is also common
• Patient will present with low back pain most
commonly. Can have radicular pain.
• Physical exam: will see thoracic prominence with
forward bending
• Treatment: physical therapy, follow yearly with serial
x-rays if concerned for progression, NSAIDs,
bracing, surgical correction
Compression Fractures
• Traumatic vs. Pathologic
• Traumatic: falls, MVCs
• Pathologic: osteoporosis, metastatic cancer
• Patient will present with acute onset localized pain
• If no known event then consider osteoporosis or
mets to the spine. Be concerned if fracture occurs
above T5.
Compression Fracture
• Physical Exam: tender to palpate directly over spine,
some paraspinal tenderness, local pain with
movement
• Imaging: x-rays, CT scan, DEXA scan
Compression fractures
• Treatment: pain medication, bracing?, physical
therapy after bone healed,
kyphoplasty/vertebroplasty
• Kyphoplasty
• A cavity is created within the vertebral body by
inflating a balloon and then cement is injected
• Vertebroplasty
• Not recommended by AAOS anymore due to increased
risk of cement extravasation from increased pressure
occurring due to not making a cavity first
Cauda Equina Syndrome
• Cauda equina is the “horse tail” or the bundle of
nerves that comes off of the spinal cord.
• It consists of nerves L1-S5
• Usually the result of a massive disc herniation
however can be from boney fragment, tumor, or
hematoma
Cauda Equina Syndrome
• Patient will present complaining of bilateral lower
extremity pain, bowel/bladder dysfunction, saddle
anesthesia, motor deficit, sensory deficit
• Physical exam: sensorimotor deficits, decreased or
absent LE reflexes, reduced or completely absent
sensation to pin prick in the perianal region or
perineum, decreased rectal tone, absent
bulbocavernous reflex
Cauda Equina Syndrome
• Imaging: STAT MRI!!
• Send patient to ED because they need an URGENT
surgical decompression!!
Cervical myelopathy
• Compression of the spinal cord at the cervical level
• Can be rapid or slow in progression
• Rapid progression needs to be treated urgently with
surgical decompression
• Patient will present with complaints of bilateral UE
paresthesias, weakness, gait disturbance, loss of fine
motor skills
Cervical Myelopathy
• Physical exam: weakness in UE and/or LE, sensory
deficits, hyperreflexia, positive Hoffman’s sign,
clonus, poor balance
• Imaging: MRI: stat if rapid progression
• MRI will show central stenosis as well as signal
changes within the spinal cord itself
Cervical myelopathy
• Treatment: if slow progression can watch and wait
however should warn patient of increased risk of
catastrophic event
• If rapid progression then decompression with
possible fusion is needed.
Take home points!
• Cauda Equina syndrome is a surgical emergency!
• If your patient complains of saddles anesthesia or
bowel/bladder dysfunction send them to the ED.
• If you see the word HLA-B27 think ankylosing
spondylitis.
• Know the difference between neurogenic and
vascular claudication.
Take home points!
• “shopping cart sign”
• Know your dermatomes and nerve root motor
functions.
• If patient involved in MVC always get cervical x-rays
and check an odontoid view. Odontoid fractures are
hard to see on plain films without that view.
• Compression fracture without known event is
concerning for metastatic CA
Take home points!
• Know what a positive Hoffman’s means as well as
clonus
Thank you!
Any questions?