what else could it be?
TRANSCRIPT
Role in SpinePlus• To assess, dx and treat likely non-operative patients• Prescribe exercise rehabilitation, injection therapies
and advice• Fast track possible surgical patients to PL, and other
specialists if required• See emergency referrals
Goal – to provide best possible holistic and integrated care to patients with spinal disorder
Demography - Survey of 200 ReferralsOften had multiple pathologies
Patients 10 Reason for Referral
• 75% Lumbar
• 20% Cervical
• 5% Thoracic
• Final Dx of LxSp Referrals (150)
• 120 had clinically significant 10 Lx pathology
• 30 had 10 non Lx pathology (usually pelvic, occ limb or vascular)
Lumbar Conditions
Disc & Facet joint - degenerate or acute injury
Nerve – neuro-foraminal stenosis
Vertebral crush #
Discitis
Metastatic malignancy (2)
Ankylosing spondylitis (1)
Red Flags – not to be missed• Cauda Equina Syndrome (URGENT)
• Constitutional symptoms
• Immunosuppressed, recent infection, IVDU
• Age >50 (or <20)
• Phx of cancer, or osteoporosis
• Recent significant trauma
• Progressive neurology
• AM Stiffness, relief with exercise and NSAIDs/steroids (Spondyloarthropathy)
Non Lumbar Spine Conditions
• 20% - Why so many?
• Key Points• Both pelvic and Lx spine
pathology are common• Radiology of Lx spine often has
abnormality - ?conincidental• Lx spine conditions frequently refers to
pelvis and legs (disc, facet and nerve)• Some pelvic conditions aggravate LBP
Common Pelvic Conditionsthat mimic Lx Pathology
• Greater Trochanteric Bursitis
• SIJ degeneration
• Hip OA
• Hamstring tendinopathy
• Piriformis syndrome
Case 1
• 68 male – retired farmer
• 6 month Hx of LBP and rt buttock pain - only with walking (RtButtockP >or= LBP), no neuro Sx
• Reduced exercise tolerance (300 metres)
• Emotionally flat, gaining weight (aggravating glucose intolerance)
CT Lx Spine
• Mod/Sev Degenerate L4/5 facet joint arthritis
• Offered posterior spinal fusion
• Wanted second opinion.
Clinical Exam
• Normal gait (not antalgic, trendelenburg – ve, no foot drop)
• Lx flex & ext - mildly restricted (ext pain +)
• No neuro
• Slightly tender (+) central lower Lx spine. Mildly tender ant hip, not over lateral hip or pelvis
• Rt hip IR 0 degrees, buttock pain (+++)
Hip Xray
• Management –-refer to hip surgeon
• Why LBP?
• Key Points
• EXAMINE HIP (v. briefly)
• IR is first movement to be lost in hip pathology
Case 2
• 54 year old female recreational rower
• 6 mo hx of insidious onset of bilateral “sciatic pain” - mild LBP and mod hamstring pain
• Aggravated by sitting, Lx flexion and rowing
• Some leg weakness, no paraesthesia
MRI Lx Spine
• Seen by PL – no objective neural findings, several minor non-compressive disc bulges
• Suspected pelvic problem
Examination
• Mild Lx spine tenderness, good ROM Lx SP
• Mod bilat lower buttock/upper hamstring tenderness
• Sightly restricted SLR – due to hamstring tightness, -ve slump test, -ve Lasegues test,
• Weak hamstring curl and bridge
Management
• Modified activity
• Physiotherapy (prescribed hamstring conditioning program)
• Autologous blood injections
• ?Surgical opinion – if not improving after 3-6 months
Case 3
• 65 year old retired nurse –“nurses back”
• 6 month hx of insidious onset LBP, rt hip and thigh pain – esp at night, arising from chair, walking uphill
• Physio ++ with core stability exercises
• Referred CT Lx Spine
Examination
• Overweight• Reasonable ROM Lx Sp – mild end range pain• No neuro signs• Mild lower Lx and buttock tenderness (R>L)• Normal Rt hip IR• Bilaterally tender over greater trochanters (R>>L)• Poor Rt abductor strength (Pos trendelenburg
sign & gait)• Weak on gluteus medius testing
Management
• Prescription of abductor conditioning rehab exercises
• CSI to 20 bursa (to permit enhanced exercise rehab)
• Advice, weight loss, general light exercise ++
• May need ABI/PRP/?ATI injections
• ?Surgical decompression – last resort (note full thickness tears need early surgical opinion as poor outcome)