Lumbosacral Spine & Low Back Pain

Question 1

Ankylosing Spondylitis

Answer 1

• Definition:
  
  • form of arthritis that primarily affects the spine
• Pathophys:
  
  • inflammation of the spinal joint → new bone formation in the spine (ankylosis) →sections of the spine fuse in a fixed, immobile position
• Risks:
  
  • young males 15-30 yo,HLA-B27 gene
• Can also cause inflammation, pain, & stiffness in other areas of the body (shoulders, hip, ribs, heels, & small joints), as well as uveitis.
• Hallmark feature of AS is involvement of the SI joints.
• “Forward stooping” : shopping cart presentation
• S/sxs:
  
  • **insidious onset (> 3 months)
  • pain & stiffness in the lower back & hips: worse in the morning& after periods of inactivity,decreases with activity
  • Limited ROM of spine
  • -Inflammation of multiple areas of the body (eyes, shoulder, ribs)
  • -Bilateral SI joint inflammation
  • -Stooped (hunched over) posture due to early compression fractures
  • -Fatigue, fever, weight loss
  • -Enthesis involvement: soft tissue pain (Achilles tendon)
  • -Acute uveitis, IBD
• Dx:
  
  • Spine xray: bamboo spine (straightening of the spine + fusion of the vertebrae), sclerosis, erosions
  • SI Joint xray: sacroiliitis (narrowing of the joint)
  • MRI, CT, Increased ESR/CRP
• Tx:
  
  • *for symptomatic only
  • NSAIDs = first line
  • -TNF blockers: if no response to NSAIDs. → Remicade (infliximab), Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab pegol) and Simponi (golimumab)
  • PT: to increase ROM & flexibility
  • Joint replacement surgery (THRA)

Question 2

Ankylosing Spondylitis Classification for Dx & Complications

Answer 2

• ASAS Classification:
  
  • *Sacroiliitis on imaging + 1 SpA feature or HLA-B27 (+) + 2 SPA
    
    • SPA: back pain, arthritis, enthesitis, uveitis, dactylitis, psoriasis, Crohn’s, family hx, HLA-B27, elevated CRP
• Complications:
  
  • Predisposes patients to major fracture/dislocation injuries “chalk stick fractures”: spine becomes very stiff so if the patient falls or has trauma → snaps like a chalk stick

Question 3

Spinal Stenosis

Answer 3

• Definition:
  
  • narrowing of the spinal canal with impingement of the nerve roots
• Etiology:
  
  • degenerative (arthritic) changes = most common, spondylolysis, disc bulge/herniation, epidural lipomatosis, epidural abscess, spinal instability
• Risks:
  
  • obesity, repetitive motion such as heavy lifting, manual labor, high-impact sports (facilitate arthritis)
• S/sxs:
  
  • **Insidious onset
  • back pain, numbness, & paresthesias that may radiate to the buttocks & thighs bilaterally
  • Worse with extension (prolonged standing, walking upright)
  • Relieved with flexion (sitting, leaning over a shopping cart)
  • flexion increases canal volume
• Dx:
  
  • MRI (non-contrast): gold standard
  • Xray: non-specific degenerative changes
  • Types:
    
    • *important for telling the surgeon
      
      • Central: main spinal canal
      • Foraminal: where nerve root exits
  • Tx:
    
    • *Dependent on what is causing the stenosis
    • Conservative: pain control, PT, lumbar corticosteroid injections
    • Surgery: if severe or refractory

Question 4

Lumbar Strain/Sprain

Answer 4

• Definition:
  
  • stretch or tear of the paraspinal muscles (strain) or ligaments (sprain), especially after twisting or lifting injuries. Most common cause of lower back pain
• Etiology:
  
  • sudden injury or gradual overuse
• S/sxs:
  
  • low back pain
  • muscle spasms: activity-related
    
    • may have headache b/c muscle pain radiates upward
• PE:
  
  • decreased ROM
  • paraspinal muscle tenderness
  • no neurological changes
• Dx:
  
  • dx of exclusion when imaging studies & exam are negative
• Tx:
  
  • RICE, analgesics (NSAIDs, Tylenol)
  • Core stretching & strengthening exercises
  • PT, lumbar corset strap
  • Transcutaneous electrical nerve stimulation (TENS) unit
  • *usually resolves within 2 weeks but can last 6-8

Question 5

Herniated Nucleus Pulposus (HNP)

Answer 5

• Definition:
  
  • nucleus pulposus bulges/herniates out of a weakened or torn part of the annulus fibrosus → stenosis
• Etiology:
  
  • trauma, “wearing out” of annulus fibrosus, spinal instability, obesity & repetitive motion
• Most common at L5-S1
• S/sxs:
  
  • Radicular (Sciatic) back pain: dermatomal pattern: usually unilateral, may radiate down the leg
  • Numbness or tingling of the affected dermatome
  • Loss of bowel/bladder function (cauda equina syndrome)
• PE:
  
  • Positive straight leg raise
  • Hyperreflexia (3-4+) → not always
  • Weakness of the affected muscle group (i.e. Foot drop)
• Dx:
  
  • MRI (non-contrast)
  • CT myelogram: if MRI contraindicated
• Tx:
  
  • conservative: steroids, NSAIDs, PT, thoracolumbar sacral orthosis (TLSO) brace
  • Epidural steroid injection
  • SPINAL PRECAUTIONS for at least 6 weeks: BLTs (no bending, lifting > 10lbs, or twisting)
  • Neuropathic pain meds: gabapentin, pregabalin, nortriptyline

Management (Neuro Deficit/Intractable Pain):

• Spine surgery: microdiscectomy, laminectomy, laminotomy
• Recurrent/Unstable: instrumentation & fusion

Question 6

Cauda Equina Syndrome

Answer 6

• Definition:
  
  • condition due to damage of the cauda equina. (cauda equina affects bowels/bladder)
• Etiology:
  
  • herniated disc = most common, spinal stenosis, cancer, trauma, epidural abscess, epidural hematoma
• Anatomy:
  
  • cauda equina is a bundle of nerves at the end of the spinal cord before it splits into the nerve roots. It contains nerves that innervate the pelvic organs & lower limbs (both sensory & motor components)
• S/sxs:
  
  • **RAPID ONSET
  • severe lower back pain
  • severe radicular pain into lower extremities (unilateral or bilateral)
  • loss of motor funcx/sensation of lower extremities
  • loss of bowel/bladder funx
  • loss of sexual function
• PE:
  
  • Neuro exam
  • Rectal exam: reveals “saddle anesthesia” &/or loss of rectal tone
• Dx:
  
  • STAT MRI (noncontrast) of the lumbar spine
  • CT myelogram: if patient cannot have an MRI
• Tx:
  
  • MEDICAL EMERGENCY
  • Immediate compression surgery
  • If surgery absolutely must be held (ie patient is on an anticoagulant that cannot be reversed) → start IV steroids ASAP to reduce nerve inflammation

Question 7

Scoliosis

Answer 7

• Definition:
  
  • abnormal S-shaped or C shaped curvature of the spine
• Etiology:
  
  • most are unknown
  • -occurs during the growth spurt just before puberty, muscular dystrophy, cerebral palsy, trauma, infection, birth defects, tumors
• Risks:
  
  • males = females (but females are more likely to need surgery)
• S/sxs:
  
  • *usually identified during school screening or routine exam
  • back pain
  • *severe curves can reduce the amount of space within the chest → difficult for lungs to funx properly & harder for the heart to pump → cardiopulmonary decompensation
• PE:
  
  • uneven shoulders, uneven hips, head not centered on pelvis
  • obvious curvature of spine
  • Adams forward bend test: most sensitive, palpate spine + evaluate height of shoulders & iliac wings
• Dx:
  
  • Xray (36” cassette): full spine scoliosis films q 4-6 months, Cobb’s angle >10 degrees
  • MRI: if rapid curve progression
  • CT
• Tx:
  
  • most are mild & don’t require surgery
  • Mild: observation
  • Moderate-Severe: scoliosis brace to stop progression (custom molded, needed until bones stop growing, worn day & night)
  • Surgical correction: if curve progression worsens, neuro deficit present, or difficulty breathing ; growing rod if progressing rapidly at a young age
  • Adults:
    
    • NSAIDs, water therapy, aerobic activity, strength exercises, surgery (rare)

Question 8

Spondylolysis

Answer 8

• Definition:
  
  • separation of the pars interarticularis (a small bony arch in the back of the spine between the facet joints)
• Risks:
  
  • athletes, adolescent males (involvement in strenuous activity at a young age)
• Etiology:
  
  • unknown but contributed to by physical sports, repetitive activity, & obesity
• Most common at L5-S1 (but can occur in the cervical vertebrae)
• S/sxs:
  
  • **Most are asymptomatic
  • Low back pain: unilateral, aggravated with lumbar spine hyperextension
• Dx:
  
  • Oblique radiograph: Scotty dog sign = 1st line
  • Lateral radiograph: radiolucent defect in pars
  • MRI or CT (non-contrast for both)
  • bone scan
• Tx:
  
  • Activity restriction for 3-6 months
  • Anti-lordotic brace
  • PT for core strengthening
  • Spinal fusion: for severe spondylolisthesis/instability

Question 9

Spondylolisthesis

Answer 9

• Definition:
  
  • anterior, posterior, or lateral slippage of one vertebra over another → central or foraminal stenosis. Usually secondary to spondylolysis
• Etiology: **Many types
  
  • Degenerative: facet arthritis, joint remodeling
  • -Traumatic: rare, results from acute fractures
  • -Dysplastic: congenital abnormalities
  • -Isthmic: defect in pars interarticularis
  • -Pathologic: infx or malignancy
  • -Post-surgical: complications
• S/sxs:
  
  • low back pain
  • Nerve compression:
    
    • radicular pain
    • -weakness of lower extremities
    • -numbness & tingling of lower extremities
    • -Loss of bowel/bladder function
    • -Hyperreflexia
• Grading:
  
  • Grade 1: 25% slip
  • -Grade 2: 50% slip
  • -Grade 3: 75% slip
  • -Grade 4: 100% slips
  • -Grade 5: completely off
• Dx:
  
  • Xray: slipping of vertebrae, lateral views can measure slip angle
  • MRI (non contrast) for neuro sxs
• Tx:
  
  • Unstable but can heal in a slipped state
  • Conservative: activity restriction, brace, PT
  • Nerve sxs: steroids, epidural steroid injections, neuropathic pain meds
  • Spinal fusion: for unstable or refractory sxs
  • Grade 2+ = requires surgery
  • Grade 1 = observation

Question 10

Compression (Wedge Fracture) of the Lumbosacral Spine

Answer 10

• overview:
  
  • Most common fracture of the lumbosacral spine. Involves the anterior column of the spine. The vertebral body is “squished down”
• Etiology:
  
  • impact injuries (jumping, fall), osteoporosis in the elderly (higher risk)
• S/sxs:
  
  • localized back pain with focal midline tenderness (directly) over the fracture site
  • -Can have neurological deficit or radicular pain if nerve roots are compressed (coincide with level of the fracture)
• Dx:
  
  • -Xray: loss of vertebral height in compression & burst fractures
  • -MRI (non-contrast); if x rays are non-conclusive
  • -CT (non-contrast)
  • -Bone scan
• Tx:

*10-12 weeks to heal

• Consult with orthopedics & neurosurgery
• Conservative: TLSO brace, pain medications, spinal precautions (BLTs)
• Surgical: vertebroplasty (cement injected into bone), kyphoplasty (balloon to open up the bone, then cement injected; usually not indicated unless neuro deficits

Question 11

Burst Fracture of the Lumbosacral Spine

Answer 11

• Overview:
  
  • Involves the anterior & middle column. Higher risk of spinal cord or nerve injury.
• Etiology:
  
  • impact injuries (jumping, fall), osteoporosis in the elderly (higher risk)
• S/sxs:
  
  • -localized back pain with focal midline tenderness (directly) over the fracture site
  • -Can have neurological deficit or radicular pain if nerve roots are compressed (coincide with level of the fracture)
• Dx:
  
  • -Xray: loss of vertebral height in compression & burst fractures
  • -MRI (non-contrast); if x rays are non-conclusive
  • -CT (non-contrast)
  • -Bone scan
• Tx:
  
  • *3 months to heal
  • -Conservative: TLSO brace, pain medications, spinal precautions (BLTs)
  • -Surgical: vertebroplasty, kyphoplasty; usually not indicated; may need surgical decompression if burst component causes nerve compression

Question 12

Flexion/Distraction Injury of the Lumbosacral Spine

Answer 12

• Overview:
  
  • Involves the posterior column & tears of the posterior ligaments. Fracture fragments are mildly displaced.
• Etiology:
  
  • high-force flexion mechanism
• S/sxs:
  
  • -localized back pain with focal midline tenderness (directly) over the fracture site
  • -Can have neurological deficit or radicular pain if nerve roots are compressed (coincide with level of the fracture)
• Dx:
  
  • -Xray: loss of vertebral height in compression & burst fractures
  • -MRI (non-contrast); if x rays are non-conclusive
  • -CT (non-contrast)
  • -Bone scan
• Tx:

*3 months to heal

-Conservative: TLSO brace, pain medications, spinal precautions (BLTs)

Question 13

Fracture/Dislocation Injury of the Lumbosacral Spine

Answer 13

• Overview:
  
  • Involves all three columns. Fracture fragments are moderately-severely displaced. Major risk of nerve/spinal cord injury d/t unstable spine.
• Etiology:
  
  • high-force trauma.
• S/sxs:
  
  • -localized back pain with focal midline tenderness (directly) over the fracture site
  • -Can have neurological deficit or radicular pain if nerve roots are compressed (coincide with level of the fracture)
• Dx:
  
  • -Xray: loss of vertebral height in compression & burst fractures
  • -MRI (non-contrast); if x rays are non-conclusive
  • -CT (non-contrast)
  • -Bone scan
• Spinal fusion ASAP due to inherent instability