Download Facet and Axial Spine Pain - American Association of Nurse

Facet and Axial
Spine Pain
Disclosures
• I have nothing to disclose.
Diane M. Rowles, MS, ACNP, BC, CRRN
Nurse Practitioner, University Neurosurgery
Rush University Medical Center
Adjunct Assistant Professor, Feinberg School of Medicine
Northwestern University
Objectives
• Participant will be able to state incidence of back
and neck pain in the US.
• Participant will be able to distinguish symptoms
of axial and facet spine pain.
• Participant will identify key exam components
when assessing neck and back for pain.
Incidence of Pain Compared to other
Major Conditions
Pain affects more Americans than diabetes, heart disease and cancer
combined:
• Chronic Pain - 100 million (Institute of Medicine of The
National Academies)
• Diabetes (diagnosed and estimated undiagnosed) - 25.8 million
(American Diabetes Association)
• Coronary Heart Disease (heart attack and chest pain) - 16.3
million (Americans American Heart Association)
• Stroke - 7.0 million (National Stroke Association)
Incidence of Back and Neck Pain
• Range is inconsistent but in careful review of a lot of
literature at ¼ to over 1/3 of US population report
back and neck pain
• ½ as many neck as back
• Women more neck pain – found in multiple studies
• Computer and office jobs more neck pain
• Upper class more neck pain
• The United States' National Center for Health
Statistics reported 7.0% of men and 9.4% of women
had neck pain in the period between 1976-1980.
Low Back Pain (LBP)
3 things that account for 80% of chronic LBP
#1 disc pain– annular tear; inflammatory process causing
pain. (Not herniated which irritates nerve causing leg
and buttock symptoms). No nerve fibers in center of disc
have nerves in the outside of the disc.
#2 facet joints – become arthritic and painful better with
sitting and worse with standing because facets are
loaded. After age 65 facet pain is more likely.
#3 SI joint - pain in lower portion and buttock 10-20% of
lower back pain.
• Cancer - 11.9 million (American Cancer Society)
Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N. (2007). Systematic review of
tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. October; 16(10): 1539–1550
Anatomy and Physiology
Anatomy and Physiology
FitzGordon J (2012). Spinal Movement: Facet Joints. Core Walking Blog. October 3,
http://blog.corewalking.com/spinal-movement-facet-joints/
Facet Joints in Motion
Facet Pain - Definition
• Deterioration of facet joint
• Lined with cartilage and in a capsule
• Damage from wear and tear, injury,
degeneration of inter vertebral disc
• Can lead to growth of bone spurs
• Cervical – pain in neck, shoulders, upper or
middle back and headaches
• Lumbar - pain in low back, buttocks and
posterior thigh
FitzGordon J (2012). Spinal Movement: Facet Joints. Core Walking Blog. October
3, http://blog.corewalking.com/spinal-movement-facet-joints/
Facet Pain - Symptoms
Ray,CD. (2002). Facet Joint Disorders and Back Pain. www.spinehealth.com/conditions/arthritis/facet-joint-disorders-and -back-pain
Cervical facet pain map
• Acute episodes of lumbar and cervical facet joint pain are typically
intermittent, generally unpredictable
• Persisting point tenderness overlying the inflamed facet joints and some
degree of loss in the spinal muscle flexibility (guarding)
• Typically more discomfort leaning backward than forward (closing up the
space)
• LBP from facet joints often radiates down into the buttocks and back of the
upper leg.
• Rarely presents in the front of the leg, or rarely radiates below the knee or
into the foot, as pain from a disc herniation often does.
• Cervical facet joint problems radiate pain locally or into the shoulders or
upper back, and rarely radiate in the front or down an arm into the fingers
as a herniated disc might
• Lumbar, standing may be somewhat limited but sitting or riding in a car is
the worst.
• Muscle spasm can be constant and fatigue the muscle
Ray,CD. (2002). Facet Joint Disorders and Back Pain. www.spine-health.com/conditions/arthritis/facet-joint-disorders-and -back-pain.
Dwyer AB, Aprill C, Bogduk N. (1990). Cervical zygapophysical joint pain patterns.
1: A study of normal volunteers. Spine; 15:453-457.
Figure 3 Cervical and lumbar facet joint pain referral patterns
Acute Low Back Pain - Axial
• If self limiting, the diagnosis as to which structure is
causing the low back pain rarely has significance to
treatment.
Part a adapted with permission from Lippincott Williams & Wilkins ©
Dwyer, A. et al. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers.
Spine (Phila Pa 1976) 15, 453–457 (1990)
Gellhorn, A. C. et al. (2012) Osteoarthritis of the spine: the facet joints
Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2012.199
Acute Low Back Pain - Axial
• Presence of an anatomical lesion that can be seen on
an MRI scan, such as a herniated disc, may have
nothing to do with the low back pain episode,
making diagnosis difficult.
• Structures in the low back that can cause axial or
mechanical lower back pain:
▫ degenerated disc
▫ facet joint problems
▫ damage to soft tissues – muscles, ligaments, and
tendons
• Can not overlook possible serious conditions, such
as an infection, tumor or fracture.
• Only in chronic and severe cases is further
evaluation and diagnosis helpful.
(Ben-Yishay, 2012)
Do you agree?
Axial Pain - Symptoms
• Varies widely: Sharp or dull pain, constant or
intermittent, mild to severe
• Worse with certain activities
• Worse with certain position
(eg sitting for long periods)
• Relieved by rest
• Confined to the central area (back or neck)
• Often describes as “mechanical”
(Hancock et al 2007)
(Ben-Yishay, 2012)
Back Assessment and Exam
Observation:
•
•
•
•
•
•
•
•
•
General : skin (attention to scars), teeth, hair
Facial characteristics
Body position and posture
Standing posture
Sitting posture
Muscle Atrophy
Fasciculations
Involuntary movements
Deformity
Back Assessment and Exam
Strength
• Unilateral vs. bilateral complaints
• Compare to opposite side
• Describe strength if 0-5/5 is not presenting the
picture
Back Assessment and Exam
Palpation:
•
•
•
•
Hips
SI joint
Sciatic notch
Tenderness: exact location and amount of
pressure
• Patient’s response: withdrawal, grimacing,
guarding
Back Assessment and Exam
Reflex:
• Normal: DTR
• Abnormal:
▫
▫
▫
▫
Hoffman’s
Spurling
Babinski
Others as appropriate pending exam and history
Cervical Assessment and Exam
Palpation:
Tenderness: exact location and amount of
pressure
Patient’s response: withdrawal, grimacing,
guarding
Back Assessment and Exam
Strength
• Unilateral vs. bilateral complaints
• Compare to opposite side
• Describe strength if 0-5/5 is not presenting the
picture
• Transition movements
Cervical Assessment and Exam
Observation:
•
•
•
•
•
•
•
•
General : skin, teeth, hair
Facial characteristics
Head position and posture
Muscle Atrophy
Fasciculations
Involuntary movements
Deformity of neck, body, extremities
Note voice and scars
Cervical Assessment and Exam
Sensory:
• Dull/sharp
• Change in temperature
ROM:
• Smooth and painless
Cervical Assessment and Exam
Strength
• Unilateral vs. bilateral complaints
• Compare to opposite side
• Describe strength if 0-5/5 is not presenting the
picture.
Axial Pain - Diagnostics
• X-ray. These images show the alignment of your bones and
whether you have arthritis or broken bones. X-ray images won't
directly show problems with your spinal cord, muscles, nerves or
disks….include flexion and extension
• Magnetic resonance imaging (MRI) or computerized
tomography (CT) scans. These scans can generate images that
may reveal herniated disks or problems with bones, muscles, tissue,
tendons, nerves, ligaments and blood vessels.
• Bone scan. In rare cases, your doctor may use a bone scan to look
for bone tumors or compression fractures caused by osteoporosis.
• Nerve studies (electromyography, or EMG). This test
measures the electrical impulses produced by the nerves and the
responses of your muscles. This test can confirm nerve compression
caused by herniated disks or narrowing of your spinal canal (spinal
stenosis).
• Myelogram and post myelogram CT
• Some literature supports very little diagnostics.
Cervical Assessment and Exam
Reflex:
• Normal: DTR
• Abnormal:
▫
▫
▫
▫
Hoffman’s
Spurling’s
Babinski
Others as appropriate pending exam findings and
history
Facet Pain - Diagnostics
• Xray: include oblique and flexion/extension views
• CT scan: visualize facet joints and other structures of
the spinal segment
• MRI: not quite as useful for diagnosing this particular
spinal problem, but is extremely helpful when
investigating possible disc or abdominal pain
contributors
• Myelogram and post myelo CT
• Bone scan
• Facet joint injection (or facet joint block): perhaps
the most definitive diagnosis of facet joint. Relief of the
acute or chronic problem during the time of action of
this combination of drugs is diagnostic
Facet Pain - Treatment
Axial Pain - Treatment
• Rest
• Ice/heat
• NSAIDs/
Cox2 Inhibitors
• Oral Meds
• Steroids
•
•
•
•
•
Acupuncture
Therapy
ESI
Fusion
Spinal Cord
Stimulator
•
•
•
•
•
•
•
•
•
•
Rest
Posture (try cervical collar)
Ice/heat
NSAIDs/Cox2 Inhibitors
Oral meds
PT
Manipulation
Facet joint block (diagnose and treat)
Facet rhizotomy (Radiofrequency Ablation-RFA)
Fusion
(Ray,2002)
References
Facet Injection
1.
Ray,CD. (2002). Facet Joint Disorders and Back Pain. www.spine-health.com/conditions/arthritis/facet-joint-disorders-and -back-pain.
2.
Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N. (2007). Systematic review of tests to identify the
disc, SIJ or facet joint as the source of low back pain. Eur Spine J. October; 16(10): 1539–1550.
3.
Berger T. (2013). Facet Injection & Facet Rhizotomy. Mayfield Clinic and Spine Institute. www.mayfieldclinic.com
4.
Ben-Yishay A. (2012). Axial Back Pain: Most Common Low Back Pain. www.spine-health.com
5.
Gore DR. ( 2001). The Evaluation of Patients With Neck Pain. Medscape Orthopaedics & Sports Medicine eJourn;5(4)
6.
NIH ( 2003). Low Back Pain Fact Sheet. National Institute of Neurological Disorders and Stroke (NNINDS).
7.
Strine TW, Hootman JM. (2007). US national prevalence and correlates of low back and neck pain among adults. Arthritis Rheum.. May
15;57(4): 656-65.
8.
Hoy MD, Protani M, De R, Bushbinder R. (2010). The epidemiology of neck pain. Best Pracit Res Clin Rheumatol. Dec;24(6):783-92.
9.
Dwyer A, Aprill C, Bogduk N. (1990). Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine (Phila Pa 1976)
15, 453–457.
10. Gellhorn, A. C. et al. (2012) Osteoarthritis of the spine: the facet joints. Nat. Rev. Rheumatol. doi:10.1038/nrrheum.2012.199
11.
FitzGordon J (2012). Spinal Movement: Facet Joints. Core Walking Blog. October 3, http://blog.corewalking.com/spinal-movement-facet-joints/
Berger T. (2013). Facet Injection & Facet Rhizotomy. Mayfield Clinic and Spine Institute. www.mayfieldclinic.com
Neck Pain
Definitions
• Vertebral body: bony building blocks of the spine
• Facet joint: small stabilizing joints located between and
behind adjacent vertebrae
“small faces” at every spinal level (except top C1) and
provide about 20% of the torsional (twisting) stability in
the neck and low back. Thoracic less mobile with ribs.
• Intervertebral disc: cushion between each of the
vertebral bodies and bindds them together
• Facet pain
• Axial (midline) discs
• Axial pain
•
Ray,CD. (2002). Facet Joint Disorders and Back Pain. www.spine-health.com/conditions/arthritis/facet-
.
joint-disorders-and -back-pain
• Neck pain is common in the general population
and even more common in a chronic pain
management practice.
• Far less common than LBP
• Some epidemiologic studies mostly done in
Europe identify about 1/3 of the population have
neck pain but only about 14% have neck pain
lasting longer than 6 months.