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Diagnosis, Management and Treatment of Common Spine Conditions

Boyd Crockett, MD, FAAPMR FDC Dept. of Physical Medicine and Rehabilitation

Southwest Spine and Musculoskeletal Medicine

Objectives

Upon completion of this session, the

participant will be able to:

! What is a Physiatrist, what do the commonly treat.

! Identify anatomical structures commonly involved in spine injuries.

! Recognize common injury patterns and outline diagnosis and management of common spine injuries.

! List types and management of vertebral fractures.

What is a Physiatrist?

Physiatry: Definition

Physiatry: From Greek physikos (physical) and iatreia (art of healing)

Known as Physical & Rehabilitation Medicine

Historical Perspective

! Physical modalities date to ancient times

! Modern medical specialty began to develop during WW I

! Coalesced during and after WWII and the polio epidemic

! Addressing need for rehabilitation of injured veterans and polio survivors

! Physiatry formally recognized as medical specialty in 1947

! Today, over 7000 board-certified physiatrists nationwide

Physiatry: Myths and Truths

Physiatrists are… • MDs

• able to diagnose and prescribe

• located throughout the US

• available for in-patient and out-patient care

Physiatrists are NOT… • in competition with PCPs

• physical therapists (physiotherapists)

• chiropractors

• psychiatrists!

Physiatry: Training

! 4-year medical school

! Residency programs

! 81* accredited programs listed in the US in 2000

! 1 year fundamental clinical skills

! 3 years PM&R training

! Fellowships ! Fellowship programs allow for sub-specialization

! Eg. spinal cord injury, sports medicine, pain

AAP. Residency Training Program Directory (2000) Available at: http://www.physiatry.org/education/pdfs/rtdIntro.pdf

Multispecialty Approach

! Residency training is unique in its multispecialty process, which allows a very unique patient care approach

! Physiatrists receive formal orthopedic, rheumatologic, musculoskeletal & neurologic training to care for patients in both the inpatient and outpatient settings

! Physiatrists perform electromyography, musculoskeletal ultrasound & advanced spinal/joint injections

! Priority is to avoid surgery while maintaining function

Physiatry: Improving Function

! Goal is prevention, diagnosis, and treatment of disorders that may produce temporary or permanent impairment

! Restoration of function

! Maximize quality of life

! “Whole-istic” approach (the whole patient, not just a body part): patient-centered care

Physiatry: Conditions Treated

! Musculoskeletal ! Trauma and injuries:

! Sports- or work-related injuries, repetitive use disorders (e.g. carpal tunnel syndrome)

! Acute and chronic pain syndromes:

! Back/neck pain

! Diseases

! Osteoporosis, arthritis

! Other

! Rehabilitation following joint reconstruction, amputation

Physiatry: Conditions Treated

! Cardiovascular ! Cardiac rehabilitation

! Vascular diseases

! Pulmonary ! COPD

! Other respiratory dysfunction

! Others include: ! Rehabilitation for cancer, HIV, pediatrics,

geriatrics

Physiatry: Conditions Treated

! Neurologic ! Spinal cord injury, traumatic brain injury

! Stroke

! Multiple sclerosis

! Peripheral neuropathy

! Movement disorders: Parkinson’s disease, cervical dystonia, other focal dystonias

! Motor neuron disease

The Physiatric Approach to Care

! Examples: ! Traumatic brain injury: improve cognitive and social functioning and return-to-

work issues

! Acute disc herniation: maximize function and decrease pain with various injection techniques (including epidurals) and physical therapy, while avoiding surgical intervention

! Post-hip replacement: decrease pain and improve functional gait/activities

! Sprained ankle: strengthen and improve proprioception

The Physiatric Approach to Care

! Examples: ! Post MI: optimize cardiopulmonary function

! Spinal cord injury: manage spasticity and assess need for appropriate adaptive equipment

! Post-stroke: increase mobility and range of motion in patients with spasticity, use focal treatment with botulinum toxin or phenol injection in conjunction with physical/occupational therapy

Thank You!

Any Questions…

Conservative Management of Low Back Pain

Epidemiology

■ Lumbar Pain ◆ 80% of the population ◆ Gender Males>Females ◆ DDD 3rd decade ◆ Spondylosis 4th-5th decade ◆ Chronic Pain ~30% Population

LBP

■ Disc ◆ Herniations ◆ Discogenic

Pain ■ Mechanical

◆ Spondylolisthesis

◆ Facet Arthropathy

■ Neurogenic ◆Stenosis

■ Soft Tissue Injury ◆Myofascial ◆Ligamentou

s

Anatomy !Anterior Elements Vertebral body Intervertebral disc !Pedicles !Posterior Elements:

Lamina, transverse processes, facet joints, and spinal process.

Pars interarticularis

Intervertebral foramen

Ligaments

! Anterior longitudinal ligament-resist hyperextension

! Posterior longitudinal ligament-resist hyperflexion

! Ligamentum flavum-continuous with facet joint, resist flexion

! Supraspinous and interspinous ligaments-resist flexion

Muscles divided into layers

! (superficial): trapezius, latissimus dorsi, and lumbodorsal fascia

! levator scapulae and rhomboids

! erector spinae group-spinalis, semispinalis, longissimus, iliocostalis

! (deep): multifidi, rotatores, intertransversarii

Nerves! Anterior primary

ramus-lumbosacral plexus, LE

! Posterior primary ramus-cutaneous and muscular innervation to back, Z-joints

! Sinuvertebral nerve-ALL, PLL, posterior annular fibrosis, posterior VB

Innervated structures ! Vertebrae ! Facet Joints ! Disc (external annulus only) ! Ligaments (ALL, PLL, interspinous) ! Muscles and fascia ! Nerve Root Non-innerated structures ! Ligamentum flavum ! Internal annulus ! Nucleus pulposus

Diagnostic

■ Plain radiograph ◆ Can reveal some obvious structural abnormalities ◆ Narrowed disc space, some stenosis, spondylolisthesis, and fractures

SpondylosisDDD

Diagnostic

■ M.R.I. ◆ Detailed imaging of soft tissue ◆ Disc ◆ Ligaments ◆ Thecal Sack ◆ Stenosis

■ With Gadolinium ◆ Can differentiate recurrent disc from

epidural fibrosis in post surgical patient

Normal L4-5 HNP

MRI subjects without Back pain

■ 52% Disc bulge

■ 27% Disc protrusion

■ 1% Disc extrusion

Jensen et al. Magnetic Resonance imaging of the lumbar spine in people without back pain. N Engl J Med, 1994 Jul 14;331(2):69-73

Goals

■ Acute low back pain: 6-12 weeks of pain

■ Goals of treatment ◆ Improve function ◆ Reduce time away from vocation ◆ Relieve pain ◆ Develop coping strategies

Acute Low Back Pain

■ Reassurance 90% resolve in 6 weeks ■ Good Evidence

◆ NSAIDs, Superficial heat, Muscle Relaxants, Exercise Therapy

■ Fair Evidence

◆ Acetamenophen, Systemic Steroids, Opiods, Spinal Manipulation

Ann Intern Med. 2007;147(7):478-491. doi:10.7326/0003-4819-147-7-200710020-00006 From: Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American

Pain Society

2017 ACP Guidelines

! Recommendation 1:Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

! Recommendation 2:For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)

! Recommendation 3:In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

Degenerative Disease

Kirkaldy-Willis 3 Stages in degenerative spine cascade

I. Dysfunction

II. instability

III. stabilization

Degenerative DiseaseDx: Acute or slowly progressive pain in back with or

without radicular symptoms. Motion can increase symptoms based upon structures involved. Pain intensified with flexion suggests anterior involvement (disc) whereas pain intensified with extension suggests posterior element (facet) involvement. Degenerative changes can be identified on plain films, MRI (best to evaluate discs and soft tissues), and CT (best to evaluate osseous structures).

Degenerative DiseaseRx: Short term medications (anti-

inflammatories, analgesics), Physical therapy (modalities, traction, manual therapy, flexibility, strength including lumbar stabilization, education), Bracing (symptomatic), injections to assist rehabilitative progress. Surgery considered if significant symptoms persist despite conservative care, progressive neuro deficit, or bowel/bladder dysfunction.

Lumbar Strain May present acutely (following trauma or

unaccustomed eccentric exercise) or as delayed onset muscle soreness.

! Dx: LBP, segmental hypomobility due to muscle spasm and guarding

! Rx: Relative rest (<3 days), NSAID’s, Physical therapy-modalities (ice, estim), manual therapy to regain tissue flexibility and segmental motion, lumbar stabilization exercises may protect spinal segment from overload, sport/job evaluation, home program

Lumbar Disc Herniation

! Common cause of acute, chronic, and recurrent low back pain

! Incidence highest in 4th decade ! 75% resolve spontaneously within 6

months ! Most commonly posterolaterally, but

may be central ! L5S1 most common, followed by L45·

5-10% with persistent sciatica will require surgery

Dx:

! Mechanism of injury often includes flexion activity with or without rotation.

! LBP with radiation to buttock, thigh, or leg

! Diagnosis can usually be made clinically. MRI will confirm finding in presence of confusing objective findings or to help in prognostication.

Rx: ! Usually conservative ! Relative rest, Anti-inflammatories (NSAID’s

vs. short steroid taper), judicious analgesics ! Physical therapy: modalities, manual tx,

exercise (often extension based, McKenzie) ! Epidural steroids ! Indications for surgical referral: progressive

neurologic deficit, bowel/bladder dysfunction, recalcitrant pain

Lumbar Facet (Syndrome)! Isolated facet arthropathy rare ! 15% - 40% chronic low back pain involves the facet

joints. Dx: ! Pain primarily in low back. Referral patterns

identified to buttock, thigh (rarely below knee) ! Pain intensified with extension, rotation and

improves with activity Rx: Manual therapy, flexion based rehabilitation,

comprehensive exercise including postural mechanics, relative rest, NSAID’s/analgesics, lumbar support. Refractory cases: Facet block, RF medial branch denervation.

Lumbar Spinal Stenosis

! Spinal stenosis may affect central canal, foramen, and/or lateral recess.

! May be congenital, developmental, or due to acquired conditions.

! Most common cause of stenosis is degenerative disease (spur formation, disc disease, narrowing interverterbral space, ligament or facet hypertrophy, subluxation)

! In lumbar spine, L45 is level most commonly affected.

Dx:

Back and leg pain, paresthesias, weakness worsened with standing and walking (psuedoclaudication) and improved with rest, sitting, or forward flexion (shopping cart sign). Walking uphill easier than downhill. Extension may exacerbate pain.

! Diagnosis is confirmed with MRI, CT, CT-myelography.

Rx:

Flexion based exercise, abdominal and spinal strengthening, Anti-inflammatories, relative rest. Refractory pain, progressive neurologic deficit, bowel/bladder dysfunction are indications for decompressive surgery.

SI (sacroiliac) Joint Dysfunction

! The sacroiliac joint is generally accepted as a potential pain generator that can refer to lower limb. Other than true sacroiliitis associated with spondyloarthropathies, exact pathology is unclear.

! Incidence and presentation controversial, but reported in 40% of cases of low back pain below the belt line.

! Consider especially during pregnancy, after trauma, or with HLA-B27 associated conditions (ankylosing spondylitis, Reiter’s, psoriatic arthritis, IBS)

Dx:

! Pain over SIJ and sometimes referred to buttock, groin, lower extremity.

! Physical exam findings (pelvic imbalances/rotations; Motion tests: standing and seated flexion tests, Gillet test; Provocative tests: Compression test, Gapping test, FABERE (Patrick) test, Gaenslen’s test, Shear test assist in diagnosis)

! Presumptive diagnosis confirmed with intra-articular injection.

Rx:

Relative rest, medications, manual therapy (manipulation, muscle energy) to correct SI dysfunction as well as associated segmental dysfunctions, traction, stabilization exercise, SI-belts.

Scoliosis

! Lateral curvature of the spine; involves 3-dimensional rotation

! 2% population have curves>10 degrees

! Higher incidence in girls than boys

Classification:! Idiopathic (65%)

! Infantile (<3yr old)

! Juvenile (4-12 yo girls, 4-14 yo boys)

! Adolescent (>12 yo girls, >14 yo boys)

! Congenital Skeletal Abnormalities (15%)

! Neuromuscular (10%)

! Other (10%) trauma, infection, mesenchymal, tumors, etc.

Dx: ! Spinal curvature, asymmetric shoulder height,

scapula ! Common curve patterns (for idiopathic) 90% single T curve, convex R 80% TL curve, convex R 70% single L curve, convex L 90% double curves: T-R, L-L (L primary T

curve raise possibility of neurologic or neoplastic cause)

Cobb angle: angle at intersection of lines drawn parallel to the most steeply inclined vertebrae at each end of the curve

Tx: ! 15-20 degrees: follow with radiographs every 6-12 mo during rapid

growth

! 30-45 degrees (or documented interval progression 6-7 degrees): Bracing

! >50 degrees: surgery

Fractures

! 77,000 spinal fractures per year in U.S.

! 50% occur between T12 and L2

! 5% suffer neurologic deficit

! Majority due to excessive flexion. Fractures due to isolated extension injury rare.

Vertebrae is divided into 3 structural columns:! Anterior column: anterior

longitudinal ligament, anterior half of vertebral body and disc

! Middle column: posterior half of vertebral body and disc, posterior longitudinal ligament

! Posterior column: Supra/interspinous ligaments, pedicles, facets, lamina, spinous process

! A fracture involving one column is stable. A fracture involving 2 or 3 columns is unstable.

Compression Fracture! Caused by excessive

flexion ! Involves only anterior

column and is thus stable ! With compression >20%

CT should be ordered to rule out unstable burst fracture.

! Rx: Analgesics, consider bracing to prevent flexion (TLSO, CASH orthosis), extension exercise, avoid bending

Burst Fracture

! Caused by excessive flexion and compression

! Involves anterior, middle, and sometimes posterior columns and is thus unstable

! 50% have neurologic deficit ! Lateral plain films shows wedging

>20%, AP film shows widening between pedicles.

! CT scan details osseous anatomy ! Rx: Spine surgery consultation.

Spinal alignment may be treated with total contact brace or surgical fusion. Surgical decompression may be needed if neurologic compression.

Chance Fracture (disruption of ligaments of all 3 columns)

! Caused by excessive flexion, distraction

! All 3 columns are involved, thus this is an unstable fracture.

! Lateral radiograph shows distraction of spinous processes, facets and vertebral bodies. AP may be normal.

! Rx: Spine surgery consultation to consider total contact rigid brace or fusion

Spinous Process and Transverse Process Fractures

! Involve one column and are therefore stable.

! Identified on plain films.

! May be associated with additional injury (burst fx, soft tissue injury: renal, liver, spleen) thus consider further workup (CT, labs) when indicated.

! Rx: Symptomatic

Pars Interarticularis Fracture! A pars stress reaction is injury

in the pars without lytic lesion. The presence of a lytic lesion (separation) is referred to a spondylolysis.

! High risk sport activities include football block (OL), military press, tennis serve, baseball pitch, gymnastics back walkover, butterfly swim stroke

Dx:

! LBP increased with extension, hamstring tightness.

! Spondylolysis best seen on oblique xrays, but may be seen on AP or lateral.

! Bone scan with SPECT is gold standard, especially to document acuity.

! Good cortication on CT indicates older fracture

! Rx: ! Relative rest, medications ! Bracing (controversial): employ when

reasonable likelihood of healing Type and timing of bracing remains

controversial Rigid polypropylene modified Boston overlap

brace 0 degrees flexion Initially 23 hours per day Up to 6 months ! Unilateral pars defects have greater chance of

healing than bilateral. ! Bilateral defects on plain films may have

lesser chance of healing.

! Early lesions more likely to heal. ! Abnormal SPECT scan with normal radiographs

may indicate greater chance of healing and may require greater period of immobilization.

! Physical Therapy: ! Flexibility (particularly hamstrings) ! Strength training to control segmental spinal

mechanics and kinetic chain balance is initiated in neutral to flexion bias (avoiding extension).

Spondylolisthesis ! Anterior slippage of one vertebrae over another ! Categories: ! Isthmic (most common): secondary to spondylolysis ! Dysplastic (congenital): caused by dysplasia of the facet

joints of the upper sacrum, leading to an inability to resist shear forces

! Degenerative: related to longstanding intersegmental instability from degenerative disc and facet disease. Most common degenerative listhesis at L45

! Traumatic: Rare; caused by acute fracture ! Pathologic: Generalized or local bone disease cause

decreased bone strength ! Post-surgical: Following extensive decompression

! The natural history of spondylolisthesis is spontaneous stabilization. There is some controversy regarding higher grades slips (grade 3 or 4) in adolescents where there may be a higher incidence of progression until skeletal maturity.

Dx: Low back pain, often increased with extension.

Intermittent radicular symptoms may be related to dynamic radiculitis. Spondylolisthesis is best seen on lateral film. Lateral flexion-extension views can screen for motion.

Meyerding Grading System Grade % Slip 1 <25% 2 25-49% 3 50-74% 4 75-99% 5 > 100%

Rx:

Treatment for isthmic spondylolisthesis is similar to that described for spondylolysis. Surgery is considered for adolescents with slips grade 3 or more. Degenerative slips are treated conservatively, with surgery reserved for those cases where there is progressive neurologic deficit, progressive instability, persistent radiculopathy or recalcitrant pain.