Slide 1: Dr. Aseem. N. Parekh
Prof. and Head,
Dept. of Orthopaedics
B.Y.L.Nair Hospital
Slide 2: Lumbar Spine
• Each lumbar vertebra is formed
by a round block of bone, called
a vertebral body, and a bony arch
attached to the back of each
vertebral body
• The bony arch has two parts (a)
two pedicle bones and two
lamina bones
• When the vertebrae are stacked
on top of each other, they form a
hollow tube that surrounds the
spinal cord and nerves. The
laminae provide a protective roof
over these
• The intervertebral disc sits
between two adjacent vertebrae
and is a cushion enclosed by
thick a capsule
Lumbar Spine Disease : Lumbar Spine Disease 75-80% of all people have back pain at some time in their life
Pain of Intervertebral disc orign includes disc herniation,internal disc disruption,DDD
5th most common cause of admission to the hospital
Degenerative Disc Disease: Herniation : Degenerative Disc Disease: Herniation Represents <2% of LBP
More likely at L4-L5 and L5-S1
Increased risk if overweight
Less common if <20 or >65 yrs
Slide 6: Lumbar Disc Degeneration
• Due to natural loss of elasticity and
/ or injury over the years, the disc
degenerates. The degenerated disc
may herniate backwards into the
spinal canal and press on a spinal
nerve root
• 90% occurs in either the L4-5 or
L5-S1 region
• Compression of the spinal nerves
results in severe radiating pain or
numbness or weakness of muscles
• Severe compression can lead to
permanent nerve damage
Spectrum of Pathological Changes in Facet Joints and Discs : Spectrum of Pathological Changes in Facet Joints and Discs Dysfunction Instability Stabilization
Modified from Kirkaldy-Willis WH, ed: Managing low back pain, New York, 1983, Churchill Livingstone.
Effects of discdegeneration• Healthy on top toseverely degenerateddiscs• Adams et al., 2002 : Effects of discdegeneration• Healthy on top toseverely degenerateddiscs• Adams et al., 2002
Clinical Presentation… : Clinical Presentation… A 30 y/o previously healthy male
CC: “My back and leg hurts and it’s keeping me from working.”
Onset 1 week ago; no inciting trauma recalled
Pain is sharp and burning. Radiates to posterolateral leg (unilateral)
Pain is worse with movements of back and sitting
Gait is not affected
…Clinical Presentation : …Clinical Presentation Numbness and tingling along lateral leg, big toe and dorsum of foot after 30 seconds of sitting leg extension test
Bladder/bowel fxn nml
Lab tests?
Differential Diagnosis?
Evaluation of Lumbar Spine Disease : Evaluation of Lumbar Spine Disease Patient History:
Location of pain
Duration of pain
Character/quality of pain
Weakness
Numbness
Evaluation of Lumbar Spine Disease : Evaluation of Lumbar Spine Disease Physical Exam:
Strength
Sensation
Reflexes
Range of Motion
Palpation
Evaluation of Lumbar Spine Disease : Evaluation of Lumbar Spine Disease Strength exam:
L3 - iliopsoas muscle (hip flexion), adductor longus (hip adduction)
L4 - quadriceps femoris (knee extension), tibialis anterior (dorsiflexion and inversion) L5 - gluteus medius/minimus (thigh abduction and medial rotation), extensor hallicus longus (big toe extension), peroneus longus and brevis (plantar flexion and eversion)
S1 - gluteus maximus (thigh abduction), biceps femoris (hip extension), gastrocnemius (plantar flexion)
Lower Limb Dermatomes : Lower Limb Dermatomes
Evaluation of Lumbar Spine Disease : Evaluation of Lumbar Spine Disease Reflexes:
L3 - iliopsoas reflex (meaningful?)
L4 - knee jerk
L5 - extensor hallicus reflex (meaningful?)
S1 - ankle jerk
Babinski - in adults, UMN lesion from motor strip to lower spinal cord
Evaluation of Lumbar Spine Disease : Evaluation of Lumbar Spine Disease Range of Motion:
Straight leg raise - most sensitive for sciatic pain syndromes
Pain in contralateral leg with straight leg raise is most specific for sciatic pain syndromes
Lumbar flexion/extension (lumbar stenosis worse with extension, better with flexion)
Evaluation of Lumbar Spine Disease : Evaluation of Lumbar Spine Disease ROM to rule out other causes of back/leg pain: internal and external hip rotation
Palpation over spine, SI joint, pelvis and hip
Evaluation of Lumbar Spine Disease : Evaluation of Lumbar Spine Disease Prior or current treatments including medication
Smoking (smokers complain of more severe symptoms and have less improvement postsurgery)
Obesity (carry more comorbidities)
Diabetes (may need neurophysiology testing) Psychological factors: anxiety, depression, somatization symptoms, stressful responsibilities, job dissatisfaction, mental stress at work, negative body image.(prospective predictors of developing back pain)
Activities that affect pain (e.g. leaning forward in spinal stenosis, sitting down, coughing, sneezing, Valsalva for herniated discs)
Differential Diagnosis : Differential Diagnosis Lumbar disc herniation: pain, paresthesias, weakness, depressed DTRs in an anatomic distribution (i.e. down lower extremity)
Lumbar stenosis: diagnosis made mainly by history. neurogenic claudication
Differential Diagnosis.. : Differential Diagnosis.. Lumbar instability: pain with motion; improved with lying down; motion on flexion/extension x-rays indicates unstable motion segment; look for defects in neural arch (lamina, pedicle, pars interarticularis); 30% of patients with degenerative spondylolisthesis (subluxation) will have progressive slippage
Compression fracture: acute to subacute onset of pain, pain to palpation; +/- history of trauma/cancer
Musculoskeletal: pain with active but not passive motion; point tenderness over joint; +/- history of trauma
Approach : Approach Options when clinical suspicion of PID
Observe (80-90% will resolve in <6 weeks)
most common diagnosis of acute (i.e. <6 weeks) back pain = “lumbar strain”
pathobiology may be any pain sensitive structure: muscle, tendon, ligaments, disc, facet joints, periosteum, meninges, blood vessels, or ‘degenerative changes’
Counsel the patient regarding the natural history .
Educate the patient about the need to have a good posture and to avoid provocative activities
Imaging of Lumbar Spine Disease : Imaging of Lumbar Spine Disease If clinical suspicion high for intraspinal source of symptoms
1)Radiographs-loss of lordosis,scoliotic list,rarely reduced disc space
can show infection, tumors, or other anomalies/pathologies.
2) MRI investigation of choice unless there is a contraindication (see next slide)
Add contrast only if patient has had prior surgery or a history of cancer; perhaps with a demyelinating process like multiple sclerosis
If not sure; order without contrast and radiology will pick up the ones that do need it
Imaging of Lumbar Spine Disease : Imaging of Lumbar Spine Disease 3) If there is a contraindication to MRI then CT myelogram (contraindications to MRI = heart stent < 2 weeks old, defibrillator, pacemaker, pain pump, spinal cord or deep brain stimulator, prior lumbar spine instrumentation, programmable shunt)
If patient is too large for closed MRI then order open MRI
CT is WAY OVERUTILIZED as a spine diagnostic test and delivers A LOT of radiation to the patient
MRI : MRI TIMING--Only indicated after 4-6 wks of conservative management(except when urgent surgery indicated)
Confirms the clinical diagnosis; not the other way around
Disc protrusion is found in 80% of asymptomatic people over age 60*
Does not correlate with symptoms or
severity Jensen, MC, Brant-Zawadzki, MN, Obuchowski, N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 1994; 331:69.
MRI.. : MRI.. Site, Side ,Size, Type, Associated findings
Can be used for prognosis/counseling
any Disc >6mm on MRI-patient has significant postoperative immediate relief.
Disc<6mm –usually no immediate relief
Conservative Management : Conservative Management Even with radicular symptoms 70% will resolve within 4 weeks
Bed rest for 2 Days (any longer does not improve outcome)
NSAIDs, COX-2 inh,
Walking to the point of pain
Physio-Torso stabilizing,paraspinal Ms.,Abdominal Ms strenghthening Whitman, JM, Flynn, TW, Childs, JD, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine 2006; 31:2541.
Faas A, Chavannes AW, van Eijk JT, Gubbels JW. A randomized, placebo-controlled trial of exercise therapy in patients with acute low back pain. Spine 1993;18:1388-95.
Slide 28: Ultrasound/Electrical Stimulation /Massage
??Bracing/Traction
Correction of posture
Osteopathic/chiropractic manipulations
Oral steroids (e.g. prednisone or methylprednisolone)
An epidural (cortisone) injection
??Ozone therapy
Surgical Management of Lumbar Disc Herniation : Surgical Management of Lumbar Disc Herniation
Indications for Surgery : Indications for Surgery Absolute
Cauda Equina Syndrome
Recent Onset, Severe and Progressive Motor Deficit
Relative
Failure of “adequate trial” of non operative treatment for radicular pain
Severe intractable radicular pain
Herniation into an already stenotic spinal or nerve root canal
Significant motor deficits with positive nerve root tension signs
Large extruded fragments
Recurrent radicular pain after successful trial of non operative treatment
The presence of a mild or moderate motor deficit does not necessarily affect the indication for operative or non operative treatment
Timing of Surgery : Timing of Surgery Cauda Equina Syndrome
ASAP
Relative Indications
Lack of scientific evidence on optimal timing
Rarely <6 weeks
Period in which improvement in symptoms generally known to occur
Should not be delayed beyond 6 weeks
Chances of improvement in radicular pain are slight and decrease further with time
Available Surgical Interventions : Available Surgical Interventions Open Discectomy(Laminectomy,Hemilaminectomy,Fenestration)
Microdiscectomy
?? Chymopapain chemonucleolysis
Automated Percutaneous Nucleotomy
Manual Percutaneous Discectomy
Percutaneous Endoscopic Discectomy
Endoscopic or Percutaneous Laser Discectomy
??Intradiscal Electrothermal Therapy
Complications of Surgery : Complications of Surgery Wrong Level 1.2 – 3.3 %
Durotomy 0.8 – 7.2 %
Nerve Root injury 0.2 %
Infection 2 – 3 %
Recurrent Herniations 2-12%
Epidural Fibrosis
Difficult to distinguish from recurrent herniation
Contrast MRI investigation of choice
No correlation between extent and symptoms
No intervention or material shown to alter incidence
Epidural Haematoma
Cauda Equina Syndrome
Iatrogenic Instability
Results of Surgery : Results of Surgery 85 – 95 % good to excellent short term results
Long Term good to excellent results diminish to 55 – 70 %
10 – 18 % having required additional surgery
Lower back pain usually the cause of dissatisfaction
No difference between surgery or conservative
Microdiscectomy
Shorter hospital stay
Faster return to sedentary work
No difference c/w open discectomy after 8 –12 weeks
No statistically significant difference in established motor deficit recovery after 3-4 months with or without surgery
Patient Factors Predicting Favourable Outcomes : Patient Factors Predicting Favourable Outcomes Absence of Lower Back Pain
Radicular pain distribution with positive tension signs
Compliance to post operative rehabilitation protocols
Non work-related injury
Higher socioeconomic status/Literate
Minimal psychosocial stressors
Recurrent Disc Prolapse : Recurrent Disc Prolapse Defined as re-herniation at the same level after a pain free interval of 6 months or more(Suk et al)
Up to 2-12 % of the cases.
Presentation is recurrent sciatic pain
Most common same level and same side,same level> opposite side same level
Investigation-MRI Gd enhanced
Fusion may have to be considered after first or second recurrent disc
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