spinal pain mark v. boswell, md, phd asipp board review course
TRANSCRIPT
Spinal Pain
Mark V. Boswell, MD, PhD
ASIPP Board Review Course
ABMS Outline - Relevant to Spinal Pain
XIII. Neck and Back Pain Musculoskeletal Arthritic Rheumatologic Postraumatic Myofascial Facets, ligaments,musculoskeletal Other (? Pseudospinal)
Additional Categories
XVIII. Neuropathic pain RadiculopathyXX. Central Pain States Spinal stenosis
Note: these topics include diagnosis, related problems, therapy, psychiatric morbidity, etc
Focused Review
Spondylotic pain Radiculopathy Spinal stenosis Infection Tumors Postraumatic Rheumatologic Pseudospinal pain
A Huge Differential Diagnosis for Spinal Pain
Differential Diagnosis: Age 20 years
Ankylosing spondylitis Pyogenic sacroiliitis Herpes zoster Osteoid osteoma Vertebral sarcoidosis Rheumatoid arthritis Osteoblastoma Sickle cell disease Scoliosis Lyme disease
DDx. Age 30 yrs Herniated nucleus pulposis Musculoskeletal
Facet pain Trochanteric bursitis Sacroiliac pain Fibromyalgia
Spondylolisthesis Ovarian cancer Pancreatitis Intraspinal neoplasms
DDx. Age 40 years Osteoarthritis DISH (diffuse idiopathic skeletal
hyperostosis) Osteomyelitis/Disciitis Paget’s Chordoma Sarcoma Osteoporosis/fracture Metastases
DDx. Age 50 and over More metastases:
Lung cancer Breast cancer Prostate cancer
Spinal stenosis Rheumatoid diseases Abdominal aneurysm Multiple myeloma
Low Back Pain and Musculoskeletal Disorders
Low Back Pain (any LBP) - 56% Frequent or persistent LBP - 15% Osteoarthritis - 12% Fibromyalgia - 2% Herniated disc (surgical) - 2% Rheumatoid arthritis - 1% Gout - 1%
Low Back Pain - Epidemiology
Age-related prevalence Children / adolescents - 12% Adults - 15% Elderly - 27%
Risk Factors for Low Back Pain
Gender Weak association with female sex Increased risk in pregnancy Stronger relation to occupation than sex Sciatica and disc operations more common
in men Height and weight
Possible increased risk with height Weak correlation with weight
Other Risk Factors for LBP Smoking
Inhibits metabolic processes in the disc Weak relation with heavy smoking
Postural deformities Poor correlation
History of back pain Increased risk of recurrence Previous surgery possible factor
Epidural fibrosis Recurrent disc herniation Spondylodiscitis Arachnoiditis
Structural Basis of LBP
Largest amount of scientific data Facet joints Discogenic pain Sacroiliac joint
Smallest amount of scientific data Myofascial pain Ligament pain Trigger point pain
Psychiatric Disorders and LBP Diagnosable mental disorder - 22% Low Back Pain - 15 to 56% Most common psychiatric disorders seen in
patients with LBP Depression (Major, Dysthymic, Bipolar,etc) Generalized anxiety disorder Somatization disorder Personality disorder
Major depressive disorder - leading cause of disability in US and market economies worldwide
Waddell’s Signs To aid in assessing functional
(nonorganic) disorders 5 signs:
Tenderness Simulation (pressure or rotation) Distraction Regional disturbance (nonanatomic) Overreaction
Significant if 3 or more positiveSpine, 1980
Spondylolysis/Spondylolisthesis
Spondylos (Greek meaning vertebra) Spondylolisthesis: one vertebra has slipped
on adjacent vertebra Spondylolysis: pars defect without slippage 5 major types recognized
I: Dysplasia of L5-S1 facets II: Isthmic - pars interarticularis (L5-S1) III: Degenerative (not pars; typically L4-5) IV:Traumatic V: Pathologic
Spondylolisthesis
Grade I through IV; (25% slippage each) Most common symptom is LBP 50% note onset with injury Leg pain due to nerve root irritation Often patients are asymptomatic Slippage more than 50% may require
surgery if persistent pain and/or neurologic deficit
Posterolateral fusion
Pars Interarticularis Defect
Spondylosis General term for degeneration due to osteoarthritis;
may include ankylosis Common cause of low back pain; multiple etiologies Formerly known as degenerative disc disease Cervical
Age related changes in disc Secondary bony changes
Lumbosacral Disc degeneration/ disc space narrowing Facet degeneration Ligamentous hypertrophy Osteophytes
Facet (Zygapophysial) Joint Pain
Lumbar facet joints recognized as a source of pain since 1911 Facet syndrome: lumbosacral pain with or
without sciatica Pain after rotary movement or twisting Low back pain with radiation to thighs and
buttocks Poor clinical correlation with imaging or
exam
Facet Joint Pain
Definitive diagnosis requires diagnostic blocks
Lumbosacral facet joints - 15 to 45% of cases of low back pain
Cervical facet joints - 54 to 67% of cases of neck pain Common with “whiplash”
Validity, specificity and sensitivity of diagnostic facet joint nerve blocks are considered to be strong
Discogenic Pain Concept of motion segment Discs well innervated and can be source of pain Discography: cardinal component is disc
stimulation, provoking putatively painful disc Concept of concordant pain Concept of high intensity zone; posterior
annular fissure Evidence
Cervical and thoracic discography limited Lumbar discography strong with precision techniques
Sacroiliac Joint Pain
Accepted source of low back and buttock pain
Prevalence of SI pain: 13 to 30% of cases of low back pain
May have radicular component - L5 pattern
Moderate evidence for efficacy of SI joint injections
Postlaminectomy Syndrome Continued pain and disability following
surgical intervention Etiologies:
Canal stenosis Internal disc disruption Recurrent disc, fragment, etc Fibrosis (epidural, intraneural) Radiculopathy Facet syndrome Arachnoiditis
Radicular Syndromes
Definitions
Radiculopathy: disease of nerve rootsRadiculitis: inflammation of nerve
rootsPain, motor and sensory
abnormalities Plexopathy defined as involvement of 2
or more roots
Etiology of Radiculopathy Cervical
Herniated disc and/or spondylosis - 69% Herniated disc - 22%
Thoracic Diabetes (most common cause) Tumor Scoliosis Infection
Lumbar Discogenic/spondylotic
Frequency of Cervical Root Compression by Herniated Disc
Root Percent
C-5 2
C-6 19
C-7 69
C-8 10
Upper Cervical Radiculopathy Lesions of upper roots - C4, C5, C6 roots Weakness: flexion forearm, abduction, internal
and external rotation of arm Deltoid Biceps (reflex diminished or absent) Triceps Brachioradialis Pectoralis Supraspinatus, infraspinatus, subscapularis, teres
major Sensory loss incomplete: hypesthesia outer
arm and forearm
Middle Cervical Radiculopathy
Injury to C7 root Weakness: muscles supplied by
radial nerve:Triceps (blunted reflex)Extensors of wrist and hand
(except brachioradialis) Sensory loss incomplete: dorsal
surface of forearm and dorsal hand
Lower Cervical Radiculopathy
Injury to C8 and T1 roots Weakness: muscles supplied by ulnar
and median nerve Flexor carpi ulnaris Flexor digitorum Interossei (atrophy 1st dorsal interosseus) Thenar and hypothenar muscles
Sensory loss medial arm/forearm and ulnar hand
Cervical Root Syndromes
Root Syndromes with Cervical Disc Herniation
Disc Space C4-5 C5-6 C6-7 C7-T1
Root affected C5 C6 C7 C8
Muscles affected
Deltoid, supraspinatus
Biceps,
brachioradialisTriceps, wrist
extensorsHand
intrinsics, interossei
Area of pain and sensory
loss
Shoulder, anterior arm,
radial forearm
Thumb Thumb, middle fingers
4th, 5th fingers
Reflex affected
Biceps Biceps, triceps
Triceps Triceps
Merritt’s Neurology; Low Back and Neck Pain
Frequency of Lumbosacral Root Compression in 97 patients
Root Percent
L2-3 1
L3-4 9
L4-5 45
L5-S1 42
About 10% of herniations are lateral to canal and root sleeve(Hardy, 1982)
{> 80%
Lumbosacral Root Syndromes
Root Syndromes with Lumbar Disc HerniationDisc Space L3-4 L4-5 L5-S1
Root Affected L4 L5 S-1
Muscles Affected
Quadriceps Peroneal, anterior tibial, extensor hallucis longus
Gluteus max, gastroc, plantar
flexors toes
Area of Pain and Sensory Loss
Anterior thigh, medial shin
Big toe, dorsum foot
Lateral foot, small toe
Reflex Affected Knee jerk Posterior tibial
(medial hamstring)Ankle jerk
Straight Leg Raising
May not increase pain
Aggravates pain
Aggravates pain
MRI of Lumbar HNP
Polyradiculopathy Disease of multiple roots Etiology
Neoplastic infiltration Lyme disease Sarcoidosis Diabetes
Asymmetrical and variable weakness Patchy and less severe than weakness Pain common but not invariable
Spinal Stenosis Technically categorized as central pain in
content outline More correctly considered radiculopathy Probably has ischemic etiology in classic
case Classic description:
Neurogenic claudication in upright position Not necessary to walk to have pain Stenotic canal (< 10 mm) causes root or cauda
equina ischemia producing leg cramps
Spinal Stenosis Compression syndromes of cauda equina
and spinal cord Single root or cauda equina
Abnormally narrow spinal canal Acquired
Spondylosis Arthritic proliferation Ligamentous hypetrophy Disc protrusion may exacerbate syndrome
Congenital (short pedicles)
Spinal Stenosis- MRI/Myelo
Don’t Forget Cervical Spinal Stenosis
May involve single root or cord Cervical myelopathy
Muscles affected with weakness (looks like lower motor neuron disease)
Weakness, atrophy and fasciculations) C5: Deltoid and biceps C7: Triceps and wrist extensors C8: Intrinsic muscles of hand
Cervical interlaminar injections are contraindicated with canal stenosis
Remember Differential Diagnoses
Cervical root and cord problems may be confused with: Supraspinatus tendinitis Acromoclavicular pain Rotator cuff tears Cervical ribs
Must exclude sulcus neoplasms C8-T1 lesions may cause Horner’s
syndrome
Infections of the Spine
Osteomyelitis/DiscitisOsteomyelitis
Uncommon cause of back pain 1:20,000 hospital admissions Gram positive cocci most frequent Urinary tract most common origin Hematogenous seeding (unless spine injection) Back pain is almost always present CRP, ESR best markers
Discitis Osteomyelitis and/or hematogenous spread Surgical and diagnostic procedures
Infections of the Spine
Cervical 8%
Cervical thoracic <1%
Thoracic 35%
Thoracolumar 8%
Lumbar 42%
Lumbosacral 7%
Sacral <1%
Note: Incidence of spontaneous spine infection is 1:20,000 hospital admissions
Sources of Spine InfectionsGenitourinary tract 46%
Skin 19%
Respiratory tract 14%
Spinal surgery 9%
Bowel 4%
IV drug use 3%
Dental 2%
Bacterial endocarditis 1%
Note: half of all sources may not be identified
Organisms IsolatedGram positive aerobic cocci 72%
Staphylococcus aureus 63%
Staphylococcus coagulase neg 2%
Streptococcal species 7%
Gram negative aerobic bacilli 24%
Escherichia coli 16%
Proteus species 5%
Pseudomonas species 1%
Klebsiella species 1%
Other 1%
Anaerobic bacteria (eg, bacteroides) 3%
Fungi (eg, candida); Mycobacteria <1%
Cervical Osteomyelitis
Plain Xray Spondylitis
Axial MRI with Contrast Lumbar Discitis
Tumors of the Spine
Benign Osteoid osteoma Osteoblastoma
Malignant Myeloma Osteosarcoma Chondrosarcoma Skeletal metastases
Malignancy
75% of cases in patients over age 50 yrs Previous history of malignancy - 30% Less than 1% of all patients with back pain Etiology
2/3 are metastatic Myeloma most common primary malignancy Nonspinal malignancy: pancreatic, renal,
retroperitoneal lymphadenopathy
Metastatic Tumors Most common tissues of origin in
decreasing order: Lung Breast Prostate Kidney Unknown site Sarcoma Lymphoma Colon Thyroid Melanoma
Sites of Metastatic Involvement
Cervical Spine 6 - 19%
Thoracic Spine 49% Lumbar spine 46%
Signs, Symptoms and Diagnosis
Constant back pain unrelieved by position change
Night pain; Weight loss ESR good screening test; elevated in 80% Serum immunoelectrophoresis (myeloma) PSA > 10 ng/ml MRI; CT scan; plain films positive in 65% Bone scan positive in osteoblastic tumors
Postraumatic Spine Pain
C Spine Alignment
Examples of C-Spine InjuriesFlexion Injury Anterior subluxation
Wedge compression
Bilateral interfacetal dislocation - “locked facets”
Flexion teardrop fracture
Flexion-rotation Unilateral facet dislocation
Vertical compression Jefferson burst fracture of atlas
Burst fracture
Hyperextension Dislocation
Atlas arch fractures
Traumatic spondylolisthesis (hangman’s C2)
Others Dens fracture
Note: all are unstable to highly unstable
Cervical Locked Facet
Flexion-Rotation Subluxation
Note: may be stable unless fracture or articular mass
Jefferson Fracture
CT Jefferson Fracture
Hangman’s Fracture
Dens Fracture
Dens Fracture
C6 C7 view important
Compression Fracture
Rheumatoid Arthritis
RA 1-3% of population; Male: female 1:3 RA: inflammation synovial joints,
osteoporosis Majority of patients have cervical spine
involvement Pain, headaches and arm numbness Decreased motion of neck Prominence of C2 process Lumbar spine rarely involved May have sacroiliac disease
Cervical Spine Involvement in RA
Atlantoaxial subluxation Anterior most common (46% of patients
postmortem) Insufficiency of transverse ligament or
odontoid erosions or fracture Unstable cervical spine
Vertical subluxation (cranial settling) Subaxial subluxation C3-7
Ankylosing Spondylitis Seronegative spondyloarthopathy Disease of axial skeleton and sacroiliac
joints 1-2% of population; HLA B-27 Enthesitis: inflammation at insertion of
tendon, ligament, capsule or fascia on bone
chondritis osteitis Ankylosis of joints and ossification of
ligaments
Extra-articular Manifestions of AS
Ocular Iritis 25 - 40% of patients
Cardiovascular 10% of patients Fibrosing lesion of aortic valve Cardiac arrhythmias Proximal aortitis
Extra-articular Manifestions of AS
Pulmonary Restrictive disease Kyphosis Late pulmonary fibrosis
Renal Microscopic hematuria Amyloidosis IgA nephropathy
Polymyalgia Rheumatica Hip, neck and shoulder girdle pain Onset over 50 yrs Male: Female 1:3 Upper and lower back Elevated ESR Temporal arteritis in 40 to 50% Treatment: prednisone, methotrexate
Pseudospinal Pain
Back and/or leg pain as the presenting symptom systemic visceral vascular neurologic disorder
Pseudospinal conditions are common
Abdominal Aortic Aneurysm 1-4% of population over 50 yrs 1-2% of all male deaths over 65 yr Abominal pain with radiation to hips
and thighs 12% have back pain Diagnosis: ultrasound or CT Repair if > 6 cm or increasing > 1
cm/yr
Endometriosis Reproductive age Pelvic pain Abdominal pain Back pain 25-31% Diagnosis: laparoscopy Treatment: oral contraceptives, danazol
(testosterone analogue)
Piriformis syndrome
Myofascial v. entrapment syndrome
Simulates L5/S1 radiculopathy Entrapment of sciatic nerve at
piriformis muscle;fibrous band 6% of cases of sciatica
Piriformis syndrome Pseudosciatica - SLR usually negative Freiburg’s sign: internal rotation of hip
(stretches piriformis muscle) Resisted abduction and external
rotation may produce pain EMG: normal proximal; may be slight
change distal Imaging studies equivocal Treatment: stretch; injections, release
Other Disorders Fibromyalgia - 2% Trochanteric bursitis - 25% ? Pelvic inflammatory disease Prostatitis
Lifetime prevalence 50% Nephrolithiasis 3% Pancreatitis and pancreatic cancer
Midepigastric pain radiating through to back
References Manchikanti, et al. Low Back Pain. Various chapters.
ASIPP Publishing, 2002. Borenstein, et al. Low Back Pain, 3rd Edition, Various
Chapters, Saunders, 2004 Rowland, L. Merritt’s Neurology, 10th Edition, various
chapters, Lippincott Williams and Wilkins, 2000. Manchikanti, et al. Evidence-based practice guidelines
for interventional techniques in the management of chronic spinal pain. Pain Physician. 2003: 6:3-81
Tintinalli, et al. Emergency Medicine. A Comprehensive Guide. Various chapters. McGraw-Hill, 2000.