functional anatomy
DESCRIPTION
TRANSCRIPT
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Lower Back Pain Lower Back Pain
MS3 Sports Medicine Workshop
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Objectives Objectives 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
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““Red FlagsRed Flags” in back pain” in back pain 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
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Epidemiology of back painEpidemiology of back pain
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
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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. L4
2. L5
3. S1
4. S2
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Better anatomy knowledgeBetter anatomy knowledge==
Better diagnoses and treatmentsBetter diagnoses and treatments
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Vertebra
– Body, anteriorlyFunctions to support weight
– Vertebral arch, posteriorlyFormed by two pedicles and two laminaeFunctions to protect neural structures
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LigamentsLigaments
Anterior longitudinal ligament Posterior longitudinal ligament Ligamentum flavum Interspinous ligament Supraspinous ligament
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Anterior longitudinal ligament
Ligamentous
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MusclesMuscles Spinalis Longissimus Iliocostalis Quadratus lumborum
– Ilium to lumbar TPs Intertransversalis Interspinals Multifidus Erector spinae
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Sciatica is defined as…
Pain radiating up th
e back
Pain radiating to
the th
igh
Pain radiating below th
e knee
Pain in th
e butt
25% 25%25%25%1. Pain radiating up the back
2. Pain radiating to the thigh
3. Pain radiating below the knee
4. Pain in the butt
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Neuro-anatomyNeuro-anatomy
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•L4•L5•S1
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PATIENT HISTORY PATIENT HISTORY “OPQRSTU”“OPQRSTU”
Onset Palliative/Provocative factors Quality Radiation Severity/Setting in which it occurs Timing of pain during day Understanding - how it affects the patient
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Which one is NOT considered a “red flag” of LBP?
Hist
ory of c
ancer
Age over 50
Fever o
r chills
Sciatica
25% 25%25%25%1. History/suspicion of cancer
2. Age over 50
3. Fever or chills
4. Sciatica
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““Red FlagsRed Flags” in back pain” in back pain 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
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OnsetOnset 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
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Other HistoryOther History
Prior h/o back pain Prior treatments and response Exercise habits Occupation/recreational
activities Cough/valsalva exacerbation
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Diagnoses & Diagnoses & Red FlagsRed Flags Cancer
– Age > 50– History of Cancer– Weight loss– Unrelenting night pain– Failure to improve
Infection– IVDU– Steroid use– Fever– Unrelenting night pain– Failure to improve
Fracture– Age >50– Trauma – Steroid use– Osteoporosis
Cauda Equina Syndrome– Saddle anesthesia– Bowel/bladder dysfunction– Loss of sphincter control– Major motor weakness
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Physical ExaminationPhysical ExaminationMsk Big-6Msk Big-6
Inspection Palpation Range of motion Strength testing Neurologic examination Special tests
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Approach to LBPApproach to LBP
History & physical exam Classify into 1 of 4:
– BAD: LBP from other serious causesCancer, infection, cauda equina, fracture
– LBP from radiculopathy or spinal stenosis– Non-specific LBP– Non-back LBP
Workup or treatment
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BAD low back pain (examples)BAD low back pain (examples)
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What to do aboutWhat to do about
Possible BAD Low Back PainPossible BAD Low Back Pain Cauda Equina:
– MRI STAT 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
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Radiculopathy, Spinal StenosisRadiculopathy, Spinal Stenosis
Sciatica (pain below knee) May have abnl neuro exam
Radiates to leg Pain worse walking,
better sitting (pseudo-claudication)
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What to do aboutWhat to do about
Suspected Radiculopathy or Suspected Radiculopathy or Spinal StenosisSpinal 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 interventionsEpidural steroid injections for radiculopathy
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Causes of “Non-specific LBP”Causes of “Non-specific LBP”
Spondylosis (Osteoarthritis of facet/disk)
Spondylolysis/-listhesis Kyphosis/scoliosis
Acute lumbar strain Facet pain Discogenic pain Ligamentous pain
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Management of an acute low back muscle strain should consist of all the
following EXCEPT:1. X-rays to rule out a
fracture
2. Educate the patient on generally good prognosis
3. Non-opiate analgesics
4. Remain active
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What to do aboutWhat to do about
Non-specific Low Back PainNon-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
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““Think Outside the Back”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– Reiters– Ankylosing Spondylitis– Inflammatory bowel dz– Psoriatic spondylitis
Neoplasia (multiple myeloma, metastatic CA, lymphoma, leukemia, spinal cord tumors, vertebral tumors)
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What to do aboutWhat to do about
Non-back LBPNon-back LBP
WU and tx as appropriate for suspected diagnoses
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Diagnostic StudiesDiagnostic Studies Radiographs
– Early if RED FLAGS– Symptoms present > 6
weeks despite tx
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Diagnostic StudiesDiagnostic StudiesMRI 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
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Diagnostic StudiesDiagnostic Studies
Bone Scan indications– Adolescent LBP (r/o spondy)
SPECT scan Cost ~$300
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Diagnostic StudiesDiagnostic Studies
EMG/NCV– r/o peripheral neuropathy– localize nerve injury– correlate with radiographic
changes– order after 6-12 weeks of
symptoms– Pre-surgical or invasive therapy
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Lab StudiesLab Studies
Indications– Chronic LBP– Suspected systemic disease
CBC, CRP, ESR, +/- UA, SPEP, UPEP Avoid RF, ANA or others unless indicated
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Issues specific to CHRONIC LBPIssues specific to CHRONIC LBP(>6 weeks and/or non-responsive)(>6 weeks and/or non-responsive) Evaluation
– X-rays, labs
– Evaluate for “YELLOW FLAGS” Management
– Medication selection
– Interventions
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YELLOW FLAGS YELLOW FLAGS in Chronic LBPin 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
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Medications in Chronic LBPMedications in Chronic LBP
FIRST: Acetaminophen Second: NSAIDs
– If one fails, change classesMeloxicam naproxen COX2’s
Third: tramadol Fourth: tri-cyclic antidepressants
– Radiculopathy: gabapentin LOATHE: narcotics
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Non-pharmacologic treatmentsNon-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
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Epidural Steroid InjectionsEpidural Steroid Injections
Indicated for radiculopathy not responding to conservative mgmt
– Conflicting evidence
– Small improvement up to 3 months
– Less effective in spinal stenosis
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Surgery for Chronic LBPSurgery 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
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Break for Break for Physical Examination Hands-on Physical Examination Hands-on
SessionSession
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InspectionInspection
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)
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Inspection (cont.)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
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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
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Bone PalpationBone 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
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Soft Tissue PalpationSoft Tissue Palpation
4 clinical zones
– Midline raphe
– Paraspinal muscles
– Gluteal muscles
– Sciatic area
– Anterior abdominal wall and inguinal area
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ANTERIOR PALPATION
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Flexion - 80º
Extension - 35º
Side bending - 40º each side
Twisting - 3-18º
Range of Motion
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Neurologic ExaminaionNeurologic 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
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Neurologic ExaminationNeurologic Examination(T12, L1, L2, L3 level)(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
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Neurologic ExaminationNeurologic Examination(L2, L3, L4 level)(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
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L2, L3, L4 testing
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Neurologic ExaminationNeurologic Examination(L4 level)(L4 level)
Motor
– Tibialis AnteriorResisted inversion of ankle
Reflexes
– Patellar Reflex (L2, L3, L4) Sensory
– Medial side of leg
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Neurologic ExaminationNeurologic Examination(L5 level)(L5 level)
Motor
– Extensor Hallicus Longus
– Resisted dorsiflexion of great toe Reflexes - none Sensory
– Dorsum of foot in midline
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Neurologic ExaminationNeurologic Examination(S1 level)(S1 level)
Motor
– Peroneus Longus and Brevis
– Resisted eversion of foot Reflexes
– Achilles Sensory
– Lateral side of foot
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Special TestsSpecial Tests
Tests to stretch spinal cord or sciatic nerve
Tests to increase intrathecal pressureTests to stress the sacroiliac joint
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Tests to Stretch the Spinal Cord Tests to Stretch the Spinal Cord or Sciatic Nerveor Sciatic Nerve
Straight Leg RaiseCross Leg SLRKernig Test
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Test to increase intrathecal Test to increase intrathecal pressurepressure
Valsalva Maneuver
–Reproduction of pain suggestive of lesion pressing on thecal sac
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Kernig SignKernig Sign
Pain present Pain relieved
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Tests to stress the Sacroiliac JointTests to stress the Sacroiliac Joint
FABER TestGaenslen sign
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FABER test:FlexionA-BductionExternalRotation
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Gaenslen signGaenslen sign
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Waddell, et al. Spine 5(2):117-125, 1980.
Non-organic Physical SignsNon-organic Physical Signs(“Waddell’s 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
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Hoover TestHoover 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
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OtherOther
Rectal tone Anal wink Cremasteric reflex
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Questions?Questions?