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Functional Anatomy

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Lower Back Pain
MS3 Sports Medicine Workshop
Objectives
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Review the functional anatomy of lumbo-sacral
spine
List essential components of a LBP history,
including RED FLAGS
Describe common causes of LBP
Review proper indications for imaging and referral
Review Physical Examination of LS spine
Correlate pathology with pertinent physical
findings
“Red Flags” in back pain
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Age < 15 or > 50
Fever, chills, UTI
Significant trauma
Unrelenting night pain; pain at rest
Progressive sensory deficit
Neurologic deficits
– Saddle-area anesthesia
– Urinary and/or fecal incontinence
– Major motor weakness
Unexplained weight loss
Hx or suspicion of Cancer
Hx of Osteoporosis
Hx of IV drug use, steroid use, immunosuppression
Failure to improve after 6 weeks conservative tx
Epidemiology of back pain
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Fifth most common reason for all physician
visits in US
Second only to common cold as cause of lost
work time
25% of US adults have LBP x1d in last 3 mos
The most common cause of disability in persons
under the age of 45
Your patient with LBP has paresthesias in the lateral foot,
decreased toe-raise strength, diminished sensation lateral foot,
and diminished Achilles reflex. This is suggestive of
dysfunction of which nerve root?
1.
2.
3.
4.
L4
L5
S1
S2
Better anatomy knowledge
=
Better diagnoses and treatments
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Vertebra
– Body, anteriorly
l Functions to support weight
– Vertebral arch, posteriorly
l Formed by two pedicles and two laminae
l Functions to protect neural structures
Ligaments
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Anterior longitudinal ligament
Posterior longitudinal ligament
Ligamentum flavum
Interspinous ligament
Supraspinous ligament
Ligamentous
Anterior longitudinal ligament
Muscles
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Spinalis
Longissimus
Iliocostalis
Quadratus lumborum
– Ilium to lumbar TPs
Intertransversalis
Interspinals
Multifidus
Erector spinae
Sciatica is defined as…
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Pa
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ig
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Pa
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p
t in
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4.
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25% 25% 25% 25%
n
2.
Pain radiating up the
back
Pain radiating to the
thigh
Pain radiating below
the knee
Pain in the butt
Pa
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1.
Neuro-anatomy
•L4
•L5
•S1
PATIENT HISTORY
“OPQRSTU”
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Onset
Palliative/Provocative factors
Quality
Radiation
Severity/Setting in which it occurs
Timing of pain during day
Understanding - how it affects the patient
Which one is NOT considered a
“red flag” of LBP?
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25%
Sc
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25%
Fe
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ov
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50
25%
Ag
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ca
4.
of
3.
25%
or
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2.
History/suspicion of cancer
Age over 50
Fever or chills
Sciatica
Hi
st
1.
“Red Flags” in back pain
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Age < 15 or > 50
Fever, chills, UTI
Significant trauma
Unrelenting night pain; pain at rest
Progressive sensory deficit
Neurologic deficits
– Saddle-area anesthesia
– Urinary and/or fecal incontinence
– Major motor weakness
Unexplained weight loss
Hx or suspicion of Cancer
Hx of Osteoporosis
Hx of IV drug use, steroid use, immunosuppression
Failure to improve after 6 weeks conservative tx
Onset
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Acute - Lift/twist, fall,
MVA
Subacute - inactivity,
occupational (sitting,
driving, flying)
?Pending litigation
Pain effect on:
– work/occupation
– sport/activity (during or
after)
– ADL’s
Other History
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Prior h/o back pain
Prior treatments and response
Exercise habits
Occupation/recreational
activities
Cough/valsalva exacerbation
Diagnoses & Red Flags
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Cancer
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IVDU
Steroid use
Fever
Unrelenting night pain
Failure to improve
Fracture
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Age > 50
History of Cancer
Weight loss
Unrelenting night pain
Failure to improve
Infection
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–
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Age >50
Trauma
Steroid use
Osteoporosis
Cauda Equina Syndrome
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Saddle anesthesia
Bowel/bladder dysfunction
Loss of sphincter control
Major motor weakness
Physical Examination
Msk Big-6
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Inspection
Palpation
Range of motion
Strength testing
Neurologic examination
Special tests
Approach to LBP
History & physical exam
Classify into 1 of 4:
– BAD: LBP from other serious causes
Cancer, infection, cauda equina, fracture
– LBP from radiculopathy or spinal stenosis
– Non-specific LBP
– Non-back LBP
Workup or treatment
BAD low back pain (examples)
What to do about
Possible BAD Low Back Pain
Cauda Equina:
– MRI STAT пѓ Neurosurgery consult
Fracture: x-rays
– MRI/CT if still suspect
Cancer: x-rays + CRP, ESR, CBC (+/- PSA)
– MRI if still suspect
Infection: x-rays; CRP, ESR, CBC, +/- UA
Radiculopathy, Spinal Stenosis
Sciatica (pain below knee)
May have abnl neuro exam
Radiates to leg
Pain worse walking,
better sitting (pseudoclaudication)
What to do about
Suspected Radiculopathy or
Spinal Stenosis
Refer to Physical Therapy
Follow in 2-4 weeks for progress
If no improvement by 6-12 weeks
– Plain films, MRI, +/- EMG/NCV
– Refer for interventions
Epidural steroid injections for radiculopathy
Causes of “Non-specific LBP”
Acute lumbar strain
Facet pain
Discogenic pain
Ligamentous pain
Spondylosis
(Osteoarthritis of
facet/disk)
Spondylolysis/-listhesis
Kyphosis/scoliosis
Management of an acute low back
muscle strain should consist of all the
following EXCEPT:
1.
2.
3.
4.
X-rays to rule out a
fracture
Educate the patient on
generally good
prognosis
Non-opiate analgesics
Remain active
What to do about
Non-specific Low Back Pain
Educate patient about expected good prognosis
Advise to remain active as tolerated
Provide analgesics and self-care directions
FU in 2-4 weeks; adjust tx as needed
Don’t do x-rays unless it becomes chronic
WU if no improvement
“Think Outside the Back”
Renal dz (pyelo, stones,
abscess)
Pelvic dz (PID,
endometriosis, prostate)
Gastrointestinal dz
(cholecystitis, ulcer, cancer)
Retroperitoneal dz
Aortic aneurysm
Zoster
Diabetic radiculopathy
Rheumatologic disorders
–
–
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Reiters
Ankylosing Spondylitis
Inflammatory bowel dz
Psoriatic spondylitis
Neoplasia (multiple
myeloma, metastatic CA,
lymphoma, leukemia,
spinal cord tumors,
vertebral tumors)
What to do about
Non-back LBP
WU and tx as appropriate for suspected diagnoses
Diagnostic Studies
Radiographs
– Early if RED FLAGS
– Symptoms present > 6
weeks despite tx
Diagnostic Studies
MRI indications
– Possible cancer, infection,
cauda equina synd
– >6-12 weeks of pain
– Pre-surgery or invasive therapy
Disadvantages
– False-positives; may not be
causing pain
– More costly, increased time to
scan, problem with
claustrophobic patients
Diagnostic Studies
Bone Scan indications
Adolescent LBP (r/o spondy)
SPECT scan
Cost ~$300
–
Diagnostic Studies
EMG/NCV
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–
–
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r/o peripheral neuropathy
localize nerve injury
correlate with radiographic
changes
order after 6-12 weeks of
symptoms
Pre-surgical or invasive therapy
Lab Studies
Indications
– Chronic LBP
– Suspected systemic disease
CBC, CRP, ESR, +/- UA, SPEP, UPEP
Avoid RF, ANA or others unless indicated
Issues specific to CHRONIC LBP
(>6 weeks and/or non-responsive)
Evaluation
– X-rays, labs
– Evaluate for “YELLOW FLAGS”
Management
– Medication selection
– Interventions
YELLOW FLAGS in Chronic LBP
Affect: anxiety, depression; feeling useless;
irritability
Behavior: adverse coping, impaired sleep,
treatment passivity, activity withdrawal
Social: h/o abuse, lack of support, older age
Work: believe pain will be worse at work;
pending litigation; workers comp problems; poor
job satisfaction; unsupportive work env’t
Medications in Chronic LBP
FIRST: Acetaminophen
Second: NSAIDs
– If one fails, change classes
Meloxicam пѓ naproxen пѓ COX2’s
Third: tramadol
Fourth: tri-cyclic antidepressants
– Radiculopathy: gabapentin
LOATHE: narcotics
Non-pharmacologic treatments
EFFECTIVE
Acupuncture
Exercise therapy
Behavior therapy
Massage
TENS
Spinal manipulation
Multidisciplinary rehab program
NOT EFFECTIVE/
CONFLICTING EVIDENCE
BACK SCHOOLS
LOW-LEVEL LASER
LUMBAR SUPPORTS
PROLOTHERAPY
SHORT WAVE DIATHERMY
TRACTION
ULTRASOUND
Epidural Steroid Injections
Indicated for radiculopathy not responding to
conservative mgmt
– Conflicting evidence
– Small improvement up to 3 months
– Less effective in spinal stenosis
Surgery for Chronic LBP
Most do NOT benefit from surgery
Should have ANATOMIC LESION C/W PAIN
DISTRIBUTION
Significant functional disability, unrelenting pain
– Several months despite conservative tx
Procedures: spinal fusion, spinal decompression,
nerve root decompression, disc arthroplasty,
intradiscal electrothermal therapy
Break for
Physical Examination Hands-on
Session
Inspection
Observe for areas of erythema
– Infection
– Long-term use of heating element
Unusual skin markings
– Café-au-lait spots
Neurofibromatosis
– Hairy patches, lipomata
Tethered cord
– Dimples, nevi (spina bifida)
Inspection (cont.)
Posture
– Shoulders and pelvis should be level
– Bony and soft-tissue structures should appear
symmetrical
Normal lumbar lordosis
– Exaggerated lumbar lordosis is common
characteristic of weakened abdominal wall
Posture
– Shoulders and pelvis should be level
– Bony and soft-tissue structures should appear symmetrical
Normal lumbar lordosis
– Exaggerated lumbar lordosis is common characteristic of
weakened abdominal wall
Bone Palpation
Palpate L4/L5 junction (level of iliac crests)
Palpate spinous processes superiorly and
inferiorly
– S2 spinous process at level of posterior superior
iliac spine
Absence of any sacral and/or lumbar processes
suggests spina bifida
Visible or palpable step-off indicative of
spondylolisthesis
Soft Tissue Palpation
4 clinical zones
– Midline raphe
– Paraspinal muscles
– Gluteal muscles
– Sciatic area
– Anterior abdominal wall and inguinal area
ANTERIOR PALPATION
Flexion - 80Вє
Range of Motion
Extension - 35Вє
Side bending - 40Вє each side
Twisting - 3-18Вє
Neurologic Examinaion
Includes an exam of entire lower extremity, as
lumbar spine pathology is frequently manifested
in extremity as altered reflexes, sensation and
muscle strength
Describes the clinical relationship between
various muscles, reflexes, and sensory areas in the
lower extremity and their particular cord levels
Neurologic Examination
(T12, L1, L2, L3 level)
Motor
– Iliopsoas - main flexor of hip
– With pt in sitting position, raise thigh against
resistance
Reflexes - none
Sensory
– Anterior thigh
Neurologic Examination
(L2, L3, L4 level)
Motor
– Quadriceps - L2, L3, L4, Femoral Nerve
– Hip adductor group - L2, L3, L4, Obturator N.
Reflexes
– Patellar - supplied by L2, L3, and L4, although
essentially an L4 reflex and is tested as such
L2, L3, L4 testing
Neurologic Examination
(L4 level)
Motor
– Tibialis Anterior
Resisted inversion of ankle
Reflexes
– Patellar Reflex (L2, L3, L4)
Sensory
– Medial side of leg
Neurologic Examination
(L5 level)
Motor
– Extensor Hallicus Longus
– Resisted dorsiflexion of great toe
Reflexes - none
Sensory
– Dorsum of foot in midline
Neurologic Examination
(S1 level)
Motor
– Peroneus Longus and Brevis
– Resisted eversion of foot
Reflexes
– Achilles
Sensory
– Lateral side of foot
Special Tests
Tests to stretch spinal cord or sciatic
nerve
Tests to increase intrathecal pressure
Tests to stress the sacroiliac joint
Tests to Stretch the Spinal Cord
or Sciatic Nerve
Straight Leg Raise
Cross Leg SLR
Kernig Test
Test to increase intrathecal
pressure
Valsalva Maneuver
–Reproduction of pain
suggestive of lesion
pressing on thecal sac
Kernig Sign
Pain present
Pain relieved
Tests to stress the Sacroiliac Joint
FABER Test
Gaenslen sign
FABER test:
Flexion
ABduction
External
Rotation
Gaenslen sign
Non-organic Physical Signs
(“Waddell’s signs”)
Non-anatomic superficial tenderness
Non-anatomic weakness or sensory loss
Simulation tests with axial loading and en bloc
rotation producing pain
Distraction test or flip test in which pt has no
pain with full extension of knee while seated, but
the supine SLR is markedly positive
Over-reaction verbally or exaggerated body
language
Waddell, et al. Spine 5(2):117-125, 1980.
Hoover Test
Helps to determine whether pt is malingering
Should be performed in conjunction with SLR
When pt is genuinely attempting to raise leg, he
exerts pressure on opposite calcaneus to gain
leverage
Other
Rectal tone
Anal wink
Cremasteric reflex
Questions?
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