sign in sign up
<<
Home , Radicular pain

All Comes To An End, Eventually

Low From Youth To Grave

Michael Jaffe MD Physical Medicine and Rehabilitation

2017 CME-n-Ski 1 age <5 Very uncommon Discitis (refuse to walk, avoid bending, back and , fever, usually staph aureus) Tumor (night pain, red flags) Osteomyelitis (Staph/TB) Labs CBC, ESR, CRP, blood Cx, peripheral smear, CMP Xray

2017 CME-n-Ski Adolescence LBP Spondylolyisis Discogenic Fracture Spondyloarthropathy Scheuermann’s (thoracic) Posterior element overuse syndrome Pain amplification syndrome Slipped vertebral apophesis Hyperlaxity Infection Tumor 2017 CME-n-Ski 2017 CME-n-Ski Common (4% age 6, 6% adults, 15% elite adolescent athletes) Overuse disorder Risk factor hyperlordosis PE: tight hamstrings, pain with extension, hyperlordosis Preferred work up…

2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Spondylolysis +/- - Diagnosis

MRI with pars edema is best imaging. CT and bone scan are discouraged to limit radiation exposure. If a gap exists on CT or Xray the lysis can’t be healed.

2017 CME-n-Ski 2017 CME-n-Ski Treatment Spondylolysis Rehabilitate rest Posterior pelvic tilts Stabilization Stretching- quad and psoas Muscle imbalances Sports specific exercises Return to sport when asymptomatic Bracing Surgery

2017 CME-n-Ski If MRI normal but exam extension based Posterior overuse syndrome

Treatment: relative rest Core stabilization- neutral to flexion biased Stretching- quads and psoas

2017 CME-n-Ski 2017 CME-n-Ski Spondylolytic Spondylolisthesis- Adult Average age of surgery 34.5 years Symptoms activity based Unilateral with or without L5 radicular pain/ No need to rest Neutral or flexion biased stabilization, centralization and stretching quad and psoas >hamstring, neural glides Injections- L5 SNRBs, pars defect (no free endings), MBB/RF Surgical- fusion 85% successful

2017 CME-n-Ski 2017 CME-n-Ski Adolescent disc problems Increasing prevalence with sedentary population Can be primary low back pain (degeneration, Schmorls nodes, annular fissure, internal disc disruption) Can cause radicular features if herniation

2017 CME-n-Ski Adolescent disc degeneration Treat similar to adults Activity modification (avoid lumbar flexion and sitting) Weight loss Stabilization Centralization (McKenzie/MDT) Manual/manipulation HEP Stretching Yoga 2017 CME-n-Ski Fracture Trauma Substance abuse Physical abuse

Imaging: Xray, CT, MRI

2017 CME-n-Ski Inflammatory spondyloarthropathy Ankylosing spondyloarthropathy Morning stiffness SI tenderness and + FABER Test Associated joint pain and enthesopathies + Schober Test

2017 CME-n-Ski Inflammatory spondyloarthropathy Xray MRI Lab: CBC, ESR, CRP, HLA B27, ANA, RF

2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Scoliosis 32% painful 10% underlying pathology (tethered cord, tumor) Idiopathic Congenital malformation Neuromuscular Adolescent idiopathic scoliosis

2017 CME-n-Ski 2017 CME-n-Ski Adolescent idiopathic scoliosis treatment <25 degrees- Observation. X-rays every 4 to 6 months 25-45 degrees- Bracing until finished growing >50 degrees or high risk of continued worsening- Surgery

2013 25% who wore a brace had curves 50º or more 58% who did not wear a brace progressed to 50º or more brace < 6 hours a day negligible help >13 hours a day better results

Yoga, physical therapy, or chiropractic medicine have not been proven to prevent curve progression

2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Scheuermann’s Kyphosis Typically thoracic pain Increase as day goes on Stiffness 5 degree, 3 adjacent vertebra, loss of disc height, Schmorls nodes, endplate irregularity

2017 CME-n-Ski Syndrome Type 3 common 1:10,000 (mostly subluxation) Joint subluxations and dislocation Skin fragile and reduced elasticity Vascular disease

2017 CME-n-Ski 2017 CME-n-Ski Hypermobility Treatment Joint protection Strength Motor control Avoid overstretching

2017 CME-n-Ski Other Slipped vertebral apophosis (growth plate) Sickle cell Pain amplification syndromes

2017 CME-n-Ski Adult Low Back Pain? • Lifetime Prevalence: 84% • Cost: $90 billion annually in the U.S. (Treatment and lost productivity.) • Recurrence 50% at 6 months • Chronicity • Debility/disability • Savings opportunities • Reduction in treatment variation • Improved outcomes and utilization management • Prevention 2017 CME-n-Ski Why no routine imaging in acute LBP?

• Xrays don’t usually change care (unless older, child/teenager, trauma or red flags) • MRIs and CT scans are reveal asymptomatic abnormalities, increase interventions • Higher cost and not improved outcomes

2017 CME-n-Ski Etiology- mechanical • Disc herniation/degeneration/internal disruption- younger, sitting, coughing, sneezing, bending, 50% prevalence if <50 years old • Facet- older, prevalence up to 50% if > 70 years old • Sacroiliac joint- buttock pain 5-15% • • Fracture or endplate injury • Degenerative spondylolisthesis >55, female • Spondylolysis and spondylolisthesis age 10-20 years old initially (LBP) then again at 30-55 (radicular pain)

2017 CME-n-Ski Etiology- Psychological • Fear avoidance (afraid work or exercise will cause harm or pain, and that pain = harm/injury) • Depression • Anxiety • Insomnia • Secondary gain • Poor coping skills

2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Core Treatments- Mechanical Back Pain Manipulation- acute, non radiating, stiff back, limber hips, low fear avoidance Stabilization- core strength, 8-10 seconds hold in neutral spine, goal high muscular action but low spinal shear or spinal flexion, endurance Directional preference- McKenzie Avoid triggers- discs injured with flexion and sitting, maintain neutral spine, avoid morning flexion Prevention- low BMI, no smoking, aerobic fitness, endurance, coordination

2017 CME-n-Ski Discogenic LBP

Most common cause of LBP especially in <55 year old 60% of all LBP Discs are part of the anterior column of the spine with vertebral body and support compression and flexion Mechanism of disc injury includes flexion Injury location can be at endplates, annulus or attachment of annulus (micro-fractures of trabecular bone)

2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Risk factors- Disc Sedentary seated jobs and activities- compression and vibration Prolonged flexed postures Highest and lowest activity level are at highest risk of injury Flexion, creep and overload are the discs enemies

2017 CME-n-Ski Aggravating factors- Disc symptoms Sitting Driving Lifting Bending forward Mornings Sneezing

2017 CME-n-Ski Location of pain- Disc Midline Bilateral Unilateral- on side of tear or injury

2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Other disc imaging finding Bulges, protrusions and endplate spurs not reliable findings as pain generators.

Desiccation implies prior injury.

Normal hydration but herniated implies acute injury

Large high intensity zones suggest grade 4 or 5 annular tears and discs that don’t pressure properly

(large disc herniations are uncommon in asymptomatic persons)

2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Treatment- Disc (non specific LBP) Reassure patient improvement is anticipated but recurrence common so an active long term exercise program is indicated. Bed rest contraindicated. Avoid prolonged sitting/driving, and lumbar flexion. Avoid lifting in flexed spine position.

McKenzie style extension exercises, stabilization, HEP, varied activity, core endurance, leg flexibility (not spine), aerobic training

Manual treatments- mobilization and manipulation

2017 CME-n-Ski Future Experimental Treatment - Disc PRP Progenitor cells Enzymes Magic stuff de jour

2017 CME-n-Ski Older person (>55) with extension/activity based pain Degenerative spondylolisthesis (DS) Degenerative scoliosis Adult idiopathic scoliosis Facet arthropathy is not reliably extension based and MRI of facet OA is not diagnostic

2017 CME-n-Ski Facet Similar pain distribution Unilateral > bilateral More common aging population Imaging findings help diagnosis such as facet edema (T2 and STIR) “Gapped” facets (DS) Bone scan

2017 CME-n-Ski 2017 CME-n-Ski Facet Treatments PT program Medial branch blocks to diagnose Radiofrequency Ablation

2017 CME-n-Ski Sacroiliac Joint Pain

5-15% prevalence Buttock pain or below L5 Frequent below spinal fusion

2017 CME-n-Ski 2017 CME-n-Ski Radicular Pain and Radiculopathy

1. Disc herniation- acute, unilateral, inflammatory, + SLR, most recall no injury or bending type movement, hurts to sit

2. Spinal stenosis- chronic, bilateral () if central stenosis or unilateral if foraminal or lateral recess, older, negative SLR, hurts to stand and walk

2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Radicular Pain- Disc Herniation

+ SLR. Reabsorption of disc herniation is common but not guaranteed. SNRBs best for acute pain control. PT if not miserable or great responder. Microdiscectomy about 80-90% likely to be helpful (leg > back). Re-herniations are 20% but half the time are asymptomatic. After surgeries 20% of patients end up with repeat imaging suggesting 80% success. McKenzie, glides and avoiding sitting may be helpful.

2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski 2017 CME-n-Ski Spinal Stenosis Chronic, bilateral (neurogenic claudication) if central stenosis Unilateral if foraminal or lateral recess stenosis Limits standing and walking Aging population Negative SLR

2017 CME-n-Ski Treatment- Spinal Stenosis Surgical- decompression Surgical - decompression with fusion Epidural cortisone injection Rolling walker with seat Physical therapy- endurance, strengthening core and legs, mobilization, balance, and stretching

2017 CME-n-Ski 2017 CME-n-Ski Degenerative Spndylolisthesis (DS)

DS is most common at L4-5> L3-4 > L5-S1 4:1 female to male ratio DS is a reliable finding that usually is a pain generator. Often associated with central and foramina stenosis.

2017 CME-n-Ski DS- treatment Exercise- flexion biased stabilization, flexibility (quad, psoas, anterior hip capsule), leg strength, thoracic mobilization, aerobic training (seated biking) and postural exercises. Walker RF and facet cortisone injections SNRB/ESI Lumbar laminectomy with fusion has best outcome data Medical co-morbidities like , CV disease, DM help guide treatment options.

2017 CME-n-Ski 2017 CME-n-Ski Degenerative Scoliosis • Common in older woman > men • Very little evidence based treatment besides spine surgery • Multilevel fusion from thoracic spine to L5 or S1 • 30% major complication risk • Non surgical options include: • PT • Brace • ESI • RFA

2017 CME-n-Ski Pathologic fracture

Diagnosis based on history

2017 CME-n-Ski 2017 CME-n-Ski Osteoporotic compression fracture treatment Relative rest Lifting avoidance +/- brace +/- kyphoplasty or vertebroplasty Osteoporosis work up and treatment - get labs early but DEXA can wait Avoid NSAIDs +/-Teriparatide (Forteo) +/-Vitamin D Calcitonin Nasal Spray

2017 CME-n-Ski Chronic Muscular Pain or Myofascial

Diagnosis of exclusion. May coexist with spinal pain generator Spinal at insertion of tendon (common extensor, QL, etc.) TPI and placebo injections help 30% of the time so low risk This type of diagnosis is useful to support injection.

Manual treatment, stabilization, stretching

2017 CME-n-Ski Piriformis Syndrome

Over diagnosed and very rare Causes of radicular pain outside scope of this talk

2017 CME-n-Ski 2017 CME-n-Ski Stabilization concepts Goal- develop motor control to restrain aberrant micro-motion, and reduce associated pain.

2017 CME-n-Ski Stabilization- exercises Repeated sub-maximal efforts 20-30 reps, 8 second holds Best exercises are high muscular recruitment with low compression and shear forces. No spine flexion. Often started quadruped- bird dog, curl up (no spine motion), side bridge Engage gluts - squats and single leg squats Wall torques Advance to standing, labile surfaces, dynamics

2017 CME-n-Ski