LUMBAR SPINE

o Metastatic CA – hx of CA, unexplained weight loss,

rest pain, age >50
o Infection – unexplained fever, recent bacterial
Conditions of the Lumbar Spine
infection, immunosuppression, IVDA
Low Back Pain
o Fx – steroids, osteoporosis, recent trauma, age >70
 Is a symptom, not a disease
o Cauda Equina Syndrome – urinary
 80% lifetime prevalence, m/c cause of disability in pts < 45
retention/incontinence, saddle anesthesia, ↓ rectal
y/o (one of the causes of absenteeism)
tone, (B) LE weakness/numbness
 Pain, muscle tension, or stiffness localized below the costal
o Severe/progressive focal neurologic deficit
margin and above the inf gluteal folds, c or s leg pain
o Failure to improve c therapy
 International Association for the Study of Pain (IASP)
o Pain > 4 wks
o Low Back Pain
 Red Flags incidence:
 Lumbar spinal pain
o Compression Fx (4%)
 Sacral spinal pain
 Osteoporosis
 Lumbosacral pain
 Location: thoracolumbar junction, midthoracic
o Gluteal and Loin Pain (not considered as LBP)
spine
 Classification (Etiology):
 Thoracolumbar fx may present c lumbosacral
o Mechanical – biomechanics of the lumbar area,
pain
problems c the structures; HNP, OA, spinal stenosis,
o Metastatic CA (0.7%)
spondylolisthesis, compression fx
 Past hx of CA is single strongest indicator
 Non-radicular
 Metastatic (prostate, lung, breast)
 Radicular – involves nerve root impingement
 Multiple myeloma
o Non-mechanical – pathologic
 Tumor – metastases, MM, lymphoma  Lymphoma
 Infection – osteomyelitis, diskitis  ↑ post-test probability from 0.7% - 9%
 Inflammatory Arthritis – RA, AS  Not including non-melanoma skin CA
o Visceral diseases – Aortic Abdominal Aneurysm, o Cauda Equina Syndrome (0.04%)
nephrolithiasis, pancreatitis, prostatitis  Large central disc herniation (L4-L5)
 Urinary retention initially  overflow
 Classification (Diagnosis):
incontinence
o Complicated – red flag conditions
 Normal post-void residual of urine essentially
o Specific Diagnosis
rules it out
 Lumbar radiculopathy
 Surgical emergency
 Lumbar spinal stenosis
o Infection (0.01%)
 Other conditions such as AS
 Non-spinal LBP
o Uncomplicated (non-specific) – used to be called
o AAA
mechanical LBP, dx of exclusion, > 85% of LBP in
o Nephrolithiasis
primary care
 Acute: < 1 mo, rapid improvement in first o Pancreatitis
month in most pts, recurrence rate up to 1/3, 7- o Prostatitis
10% progress to chronic back pain o Pelvic Inflammatory Disease
 Subacute: 1-3 mos  Possible anatomic sources of LBP – controversial
 Chronic: > 3 mos o Discs (back pain), facet jts (back, buttock, thigh pain),
 Red flags: SI jts, ligaments, muscles (back pain)
 Innervated structures: Pts are highly responsive to tricyclic
o Bone: vertebrae antidepressants
o Jts: Zygoapophyseal  More predictive of outcome than severity of
o Disk: External annulus fibrosus, potentially diseased pain or exam findings
disk o Durations of Symptoms
o Ligaments: ALL, PLL, interspinous  Status of pts @ 2 mos may help predict
o Muscles and fascia outcome @ 12 mos
o Nerve roots  Summary
 Non-innervated structures: Ligamentum flavum, internal o Be aware of red flags
annulus fibrosus, nucleus pulposus o Identify specific dx
 Yellow flags: o Uncomplicated LBP is a dx of exclusion
o Previous hx of disability o MRI for complicated and specific dx
o Inconsistent findings o Diagnostic injections
o Abnormal pain behavior o Don’t forget the yellow flags
o Litigation Lumbar Radiculopathy
o Work dissatisfaction o L4-L5 or L5-S1 (90%), L5 and S1 nerve roots
o Attention-seeking o Inflammation > mechanical compression
o Preference for prolonged bed rest o Phosopholipase A2, TNF-alpha
o Depression o Pain c sitting, bending, coughing, radiates below the
o Chemical dependency knee in a narrow band
o Hx of abuse Nerve Pain Motor Sensory DTR
Root Referral
o Family hx of chronic pain
L4 Medial leg Ankle Medial Knee
 Waddell’s Signs – behavioral response to exam, not a proof of dorsiflexi ankle
malingering, > 3 signs suggests presence of non-organic on
factors L5 Lateral leg, Great toe Web space No
o Superficial tenderness – pain elicited from light dorsal foot dorsiflexi between 1st reliable
touch on skin on and 2nd toe reflex
o Simulation – back pain produced by activities that S1 Post calf, Foot Lateral Ankle
should not be painful e.g. axial loading of the head (1- lateral or plantar aspect of
2 lbs), passive rotation of shoulders and pelvis in same sole of foot flexion the sole of
plane foot
o Distraction – Symptomatic response to a test
changes when test is repeated while pt is distracted, Radicular vs. Referred Pain
adjunct for Cognitive Behavioral Therapy Radicular Pain Somatic-referred Pain
o Regionalization – ratchet-like “giving way” weakness Leg > Back Back > Leg
Shooting, lancinating, Dull, pressure-like, deep
or non-neuroanatomic numbness
cutaneous component
o Overreaction – disproportionate response to routine
Travels along limb in a Extends into limbs across a
exams such as collapsing, grimacing, guarding, narrow band wide region
groans, tremors, etc (+)/(-) neurologic defect (-) neurologic deficit
 Prognosis  Listing away from side of disc herniation (paracentral
o Psychosocial risk factors herniation)
 Yellow flags and Waddell’s Signs  SLR for L5 or S1 root
 o Reproduction of radicular pain bet 30-70°  Dx: posterolateral, oblique view demonstrate collar on Scotty
o High sensitivity but low specificity Dog, bone scans (+) 5-7 days and last up to 18 mos
o Crossed SLR (Well Leg Raising) is more specific but Spondylolisthesis
less sensitive  Forward or backward slippage of one vertebral body to
 Natural Hx another, commonly seen in the lumbar region
o Favorable  Six categories:
o Conservative and surgical tx are both successful o Isthmic - m/c, stress fx of pars interarticularis
o Large extruded discs are more likely to ↓ in size o Dysplastic – Congenital, dysplasia of facet joints
Spinal Stenosis o Degenerative – older spine, long-standing instability
 Degenerative changes resulting in disc space narrowing, from generation, commonly affects L4-L5 level
vertebral body osteophytosis, jt arthropathy, which narrows o Traumatic – rare, acute fx secondary to trauma
the central canal and lateral recesses (neuroforamina) o Pathologic – medical causes that can cause ↓ bone
 Possible neural compression and ischemia strength
 Usually present at ~50 y/o affecting the L3 and L4 at the o Postsurgical – instability from extensive
lumbar region decompression
 Differential dx of intermittent claudication  Occurrence 2-4x more likely in males
o Intermittent Claudication – relieved by rest Meyerding Grading of Slippage
o Neurogenic intermittent claudication (Pseudo) – Grade 0 0% slippage
relieved by FLEX, use Bicycle Test of van Gelderen
Grade 1 1-25% slippage
 Etiology
o Congenital Grade 2 26-50%
 Hereditary slippage
 Achondroplastic/dwarfism Grade 3 51-75%
o Acquired slippage
 Degenerative (m/c) Grade 4 76-100%
 Spondylotic/spondylolisthetic slippage
 Iatrogenic (postsurgical) Spondyloptosis >100%
 Posttraumatic slippage
 Metabolic (Paget’s disease)
o Traumatic
Lumbar Spinal Stenosis
o Combined
 Congenital, onset in 30s
 Neurogenic claudication – pain in buttocks, thigh, and leg c
 Acquired
standing, relieved by sitting and bending forward
o Degenerative
Spondylolysis
 M/c, late 50s – early 60s, commonly involved
 M/c seen in children and adolescents at the L5 vertebral level
L4-L5, followed by L3-L4
and occurs at the pars interarticularis (pedicle, transverse
 Commonly affects 2-3 spinal segments
process, lamina, and articulator processes)
o Mechanical Compression
 Commonly unilateral
 Compression of microvasculature  nerve root
 Localized back pain exacerbated by motion (HYPEREXT),
ischemia, ↑ microvascular permeability and
standing, lying prone, relieved by FLEX, normal neurologic
edema
exam
  Insidious, chronic LBP that progresses to buttock, thigh, and to restrictive lung disease), plain films typically normal in
leg pain, fatigue, heaviness, pain in the legs c ambulation early stages
(neurogenic claudication) Herniated Nucleus Pulposus
 Intermittent claudication – commonly seen in pts c ASO  A disc injury in which the nucleus pulposus migrates through
(arteriosclerosis obliterans) highest risk factor is smoking, the annulus fibrosus, most commonly occurs at ages 30-40
TAO (thromboangiitis obliterans, Buerger’s disease) and a higher prevalence in the lumbar (L4-L5 or L5-S1) and
cervical (C5-C6) regions
Symptoms Neurogenic Vascular  M/c direction: posterolateral, which compresses the point of
Back Pain Common Uncommon exit of spinal nerve roots, is one of the causes of
Sitting/flexed position Not positional radiculopathy
Standing and resting Pain relief when  Classification:
Pain Relief
usually insufficient standing o Bulging – No annulus defect, disc convexity is beyond
Often slow (>5 mins) Almost immediate vertebral margin
Ambulatory o Prolapsed – Nuclear material protrudes into an annulus
Variable Fixed
tolerance
defect
Uphill vs.
Downhill more painful Uphill more painful o Extruded – Nuclear material extends into the PLL
Downhill
Bicycle ride No pain Pain o Sequestered disc – Nuclear fragment free in the canal
 Common exam findings:  Dx:
o Loss of lumbar lordosis c limited EXT, trunk FLEX o ↓ disc height, vertebral osteophytosis, sclerosis,
forward in standing and walking (Simian posture), no radiography
significant tenderness, (-) SLR, (n) motor exam despite o Disc desiccations, annular tears, HNP – MRI
report of weakness  Tx:
o MRI o Medications (COX2 inhibitors, anti-neuropathic pain)
 Mild – 75-99 o McKenzie Program to centralize extremity pain – LB
 Moderate – 50-74 exercise (EXT) (Williams Program - FLEX)
 Severe - <50 o Lumbar corsets
 Natural hx: o Vertebral distraction may relieve compression
o P 4 yrs:  Cervical – 20-30° of FLEX c 25 lbs of resistance
 70% no change  Lumbar – may require ↑ force (at least ½ of
 15% improved BW) /split table
 15% worsened
o 5-15% may have coexisting cervical spinal stenosis
Ankylosing Spondylitis – rheumatologic, classified as a
seronegative spondyloarthropathy (negative Rheumatoid Factor)
 Seronegative spondyloarthopathies: Psoriasis, AS, Reactive
Arthritis, Inflammatory Bowel Disease
 Crooked vertebra, bamboo spine
 Earliest clinical features:
o Gradual onset in males < 30 y/o, primary
manifestation: morning stiffness, improves c exercise,
not relieved by rest
 Schober’s Test, chest expansion < 2.5 cm (last stage)
(costovertebral and costotransverse jts involvement) (prone