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Objectives: n Understanding of basic lumbar anatomy. Diagnosing and Treating n Differentiate the etiologies, physiologies, physical examination techniques, and differential diagnoses Lumbar Spine Disorders: of common lumbar spine disorders using EBP Evidence-Based guidelines. n Recognize presented lumbar spine disorders Guidelines through a review of lumbar radiographs. n Construct EBP recommended nonpharmacol ogical and pharmacological treatments, as well as patient Robert Metzger, DNP, APRN, FNP-BC education, for lumbar spine disorders. n Describe overview of new research endeavors relating to some lumbar spine diagnoses.

LUMBAR SPINE n Vertebrae ¨ Kidney shaped bodies ¨ ML > AP This presenter dimensions - Smaller Transverse has no conflicts of interest Process - Spinal Processes to report are large, square, and horizontal - Foramen - Vertebral: wider and triangular - Intervertebral: 33% occupied by nerve

Lumbar Vertebral Joints INTERVERTEBRAL DISCS n Discs are located between the endplates of the n Facet Joints - formed by vertebral bodies the superior & inferior n Most important and unique articulating system in articular processes of the spine, allowing for multi-planar motion opposing vertebrae n Make up ¼ of the total length of the spine column n Largest avascular structure in the human body n Pars Interarticularis – the n Cartilaginous joint of the motion segment space between the n Shock absorbers of the spine, which are so strong superior & inferior that with compression the vertebral bodies will fail articular processes of the before the discs same

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Intervertebral Discs (brief overview) n 2 Components n Anterior Longitudinal ¨ Annulus Fibrosus n Outer part of the disc n Posterior Longitudinal n Collagen fibers w/ water Ligament and proteoglycans n Ligamentum Flavum n Layered in concentric layers called Lamellae, (noncontinuous, yellow which are thicker and color) more numerous in the n Interspinous Ligament anterior portion of disc (connects the SPs) ¨ Nucleus Pulposus n Supraspinous Ligament n Interior substance of the (connects the tips of the disc (gelatinous) SPs) n Increased water and n proteogylcan content Intertransverse Ligament (85% Water content) (connects the TPs)

SPINAL CORD / NERVES n In lumbar region, the exits n below the ¨ Begins at Foramen Magnum and vertebral body continues w/ terminus at Conus n Example: Medullaris near L1 At the level of n Cauda Equina the L4/5 disc, ¨ Collection of nerves which run from the L4 nerve conus medullaris to the filum roots exit terminale through the n Nerve Roots neuroforamen ¨ Canal is broader in cervical/ lumbar and the L5 regions due to the large number of nerve roots nerve roots traverse along ¨ Branch off the spinal cord higher within the thecal than actual exit through the sac intervertebral foramen

DERMATOMES umbar Diagnoses: Incidence / Prevalence n Areas of skin innervated by sensory fibers from a single spinal nerve L n 5th for reasons US patients present for an office visit n 2nd most common chief complaint n Prevalent among all age groups, especially adolescents to elderly n LBP care / economic losses exceeds $90-100 billion annually n Most common reason for disability for patients ≤ 45 years old n Prevalence for continued disability is 60-80% after one year n Patients with h/o prior work absenteeism showed a 40% prevalence for future occurrences

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Lumbar Diagnoses – 2 Main Differentiations Non-specific Low Back Pain (NSLBP) Low Back Pain Low Back Pain n Mechanical type pain that varies with (w/o lower extremity pain) (w/ lower extremity pain) activity and posture ¨ Non-specific LBP (NSLBP) ¨ Lumbar Stenosis n Unrelated to a recognizable pathology, n Degenerative Disc Disease ¨ Lumbar Radiculopat hy (r/t n Hypertrophy Lumbar Disc osteoporosis, structural deformity, or n Ver tebr al Endplate Sc ler os is Displacement) radicular syndrome n Vertebral ¨ Lumbar Radiculopat hy (r/t n ¨ Lumbar Stenosis * Facet Synovial Cyst) Usually difficult in identifying a cause ¨ Lumbar Disc Displacement * ¨ Lumbar Radiculopat hy (r/t n Mostly associated with muscular strain ¨ Spondylolysis & Spondylolisthesis ) n Spondylolisthesis * Typically is related to degenerative ¨ Lumbar Fractures changes in the disc, facet joint ¨ Exists in 25-57% of all ¨ hypertrophy, vertebral endplate lumbar cases sclerosis, or vertebral osteophytes * = may sometimes cause leg pain

Degenerative Disc Disease (DDD)

n Presentation n Loss of normal tissue structure and function due to the aging process. ¨Back pain increased by changes in n Usually is a gradual process, position or with flexion of the spine however acute trauma will accelerate the process ¨Pain noted with prolonged sitting n Changes within the intervertebral (differentiating symptom) disc ¨ Water and proteoglycan ¨If located midline over the spinous decrease in the nucleus first, processes, 84% association with DDD then the annulus ¨ Fibers of the annulus become distorted, tears may occur in the lamellae decreasing the strength of the disc n Most common level is L4/5 n By age of 50, 95% of people will have evidence of DDD

Spinal Stenosis n Effects the entire n Refers to narrowing present in the neuroforaminal motion segment spaces, lateral recesses, or central canal ¨ Facet joints override and wear at the hyaline n Primary (Developmental/Congenital) or Secondary cartilage (Acquired, which is the most common) ¨ Disc shrinks and the n Secondary Stenosis disc space narrows ¨Acquired through degenerative changes, ¨ Loads are transferred from disc to the pathological changes, or prior surgery endplates ¨Typically found in the older population > 50 years ¨ Osteophytes may old develop and encroach ¨ on neurological L3/4, L4/5 are most involved lumbar segments structures ¨Diagnosis and severity are largely dependent on the history and physical examination

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Stenosis Symptoms ¨ Presence or absence of LBP Lumbar Disc Displacement (Herniation) ¨ Pain is typically improved with forward flexion (grocery cart test) as the canal space increases and with rest n Most frequent surgically treated pathologies of the spine ¨ Neurogenic n Commonly occurs at L4/5 & L5/S1 (regions with the n Most common finding for lumbar stenosis severely impacting greatest ROM and axial loading) patients’ function and quality of life n Internal disruption to the disc is permanent due to the n Radiating pain into the bilateral / unilateral buttock, anterior disc being avascular thigh, or posterior pain down the leg to the calf and sometimes to the feet (usually bilateral) n Four degrees of herniation

n Worse with standing, walking upright, and extension 1. Fissure / Bulging

n Can include sensation of weakness and/or heaviness, 2. Protrusion , fatigue, hamstring tightness, and occasional 3. Extrusion nocturnal cramps 4. Fragmented / Segmented n Important to differentiate from vascular claudication, which is n Symptoms are similar to NSLBP or Lumbar pain relieved upon standing alone, typically below the knee, unchanged by flexion of the spine, and with a fixed duration , depending on leg involvement of walking

Lumbar Radiculopathy Radiculopathy Symptoms

n Pain radiating from the lumbar region that is primarily n Pain radiating from the lower back into the legs as a result of unilateral and greater than patients LBP, with some patients not having any LBP impingement on the nerve roots n Typically worse during rest or in the night n Causes: n Paresthesias (burning, numbness, tingling) that follow a ¨ Lumbar Disc Displacement dermatomal pattern (mostly along L4-S1) (primary cause) n Muscle Weakness, typically below the knee ¨ Facet Synovial Cyst n Changes in patellar or Achilles reflexes ¨ Spondylolisthesis n Pain may be increased with Valsalva n Typically in younger patients maneuvers

Spondylolysis & Spondylolisthesis Spondylolisthesis n Slippage of one vertebrae in relation to the adjacent n Confusing Terminology: vertebrae n Incidence is approximately 3-4% of all populations ¨ – degenerative changes in vertebrae at the disc and facet joints n Strong hereditary factor n Noticed more in gymnasts, football linemen, and ¨Spondylolysis – defect in the vertebrae in area weightlifters of pars interarticularis n Most slips are related to a deficit in the pars interarticularis n n Disc degeneration is associated with almost all forms of Descriptive Terminology: spondylolisthesis ¨Anteriolisthesis – anterior / forward n Symptoms ¨Retrolisthesis – posterior/ backward ¨ Most common complaint is LBP ¨ Radiation into the buttocks and occasionally posterior ¨Lateral – sideways movement thighs

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SPINAL FRACTURES Scoliosis n Most common fractures seen in an outpatient setting: n Defined as a lateral curvature of the spine ¨ Compression / Burst n Adult scoliosis: Idiopathic / Degenerative ¨ Idiopathic n Associated with falls from greater than 6 feet or any fall in a patient with osteoporosis n Continued progression from adolescent ¨ Degenerative ¨ Transverse Process / Spinous Process n Onset of scoliosis in previous straight spine

¨ Burst (severe compression) or Facet fractures are more n Result of asymmetric deterioration of spinal components, common in emergent settings caused by spondylosis n Trauma to spine implies injury to any or all anatomical structures: bony elements, soft tissues, and neurological structures

Key Items in History The n Provider should classify LBP from back pain with lower extremity pain n Should be specific regarding locations of pain (midline, History lateral, bilateral), especially if leg pain is present ¨ Determination of leg pain aids in differentiating between stenosis and radiculopathy & n List the degree of pain on the visual analog scale n Activity difficulties (walking, sitting, standing, Physical flexion/extension) n Sensorimotor deficits Exam n Aggravating / Alleviating factors n Prior beneficial / failed treatments, especially in regards to regimens

Key Items in Physical Examination Special Tests (LUMBAR): n Gait Testing (Motor) – n Should encompass inspection and palpation for alignment, ¨ Normal Gait Pattern ( no evidence of foot drop) tenderness, and/or erythema / edema ¨ Heel Walking – If difficult, can indicate L4/5 involvement n Neurological Assessment ¨ Tip Toe Walking – If difficult, can indicate S1 involvement ¨ Motor assessment n [AKA Laseque’s test] (Neurological) – n Muscle strength (graded on 5 scale) or atrophy ¨ Perform if history includes nerve root symptoms ¨ 5 – Normal strength (full resistance) ¨ 4 – Movement possible against some resistance by examiner ¨ Pt lays supine or sits upright while provider passively raises ¨ 3 – Movement possible against gravity, but not against examiner’s resistance ¨ 2 – Movement possible, but not against gravity (test in horizontal plane) each leg individually with knee extended until the patient ¨ 1 – Muscle flicker, but no movement complains of pain down the back of the leg. Once pain is ¨ 0 – No contraction elicited, drop the leg slowly until they feel no pain, then ¨ Sensory assessment – tactile to detect dermatomal deficits dorsiflex the foot. ¨ Reflex Testing ¨ Positive if pain is elicited within the leg between 35-70 ¨ Special Tests degrees of elevation. Dorsiflexion should increase this pain (if n Cardiovascular Assessment (bruits, decreased , not, likely hamstring tightness). Hamstring pain involves only the posterior thigh. Back pain alone is not a positive SLR. pitting edema)

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Special Tests (LUMBAR) – cont.: Long Tract Signs (Pathologic Reflexes) [suggestive of upper motor neuron lesions] n FABER [AKA Patrick’s Maneuver & LaFebere test] (Motor) – ¨ Flex the knee and place ankle above contralateral knee. Apply downward force onto the flexed knee to stress the lower n DTR’s back, SI joint, & . ¨ Standard 2+ and equal bilaterally ¨ Positive – pt will elicit pain that should point to the source of pathology ¨ Positive if < or > than 2+ unilaterally or bilaterally n Femoral Nerve Stretch (Neurological) – n Ankle Clonus ¨ Opposite of SLR and tests L3 (femoral nerve) ¨ Quick dorsiflexion of the ¨ Conducted in standing or prone position with back straight, relaxed ankle joint. examiner grasps the limb flexing the knee while slightly ¨ Positive with repetitive (4+) hyperextending the hip twitching/pulsing of the foot ¨ Positive – produces L2-4 radicular symptoms to the anterior n Babinski’s knee ¨ Stroking of lateral aspect of n Rectal Assessment (Neurologic al) – sole of foot from the heel to ¨ Performed for c/o saddle paresthesias or bowel incontinence the toes n Special Reminders ¨ Positive with extension of great toe and fanning of ¨ Multiple Myotome / Dermatome Dances / Sayings four small toes ¨ Umbilicus – Level of L3/4 ¨ Line across iliac crests – Level of L4/5

Lumbar Key Points Differential Diagnoses

T12 – L3 M Hip Flexion (Knee Raising - Iliopsoas) – L2, Quadriceps (Knee Extension) – L3, n Primary EBP goal = rule out serious pathology, Hip Adduction R NONE present in 5% of cases (red flags) S L1 – Proximal third of Anterior Thigh ¨ Spinal Cancer L2 – Middle third of A nterior Thi gh L3 – Distal third of Anterior Thigh (to knee) n Age greater than 50

L4 M Foot Inversion (Tibialis Anterior), Ankle Dorsiflexion n Prior h/o cancer (prostate, thyroid, breast, lung, kidney) R Patellar Tendon reflex n Insidious onset, recent weight loss, night pain, pain at multiple sites, S Medial Leg (Tibial Crest – Medially), Medial Foot, and Medial Great Toe esp. at rest, urinary retention, unresponsiveness to prior care

L5 M Hip Abduction (Gluteus Medius), Great Toe Extension (EHL), 2nd-5th Toe ¨ Spinal Fracture Extension (E DL) R NONE n Age greater than 50 S Lateral Leg (Tibial Crest – Laterally), Dorsum of Foot n H/O osteoporosis, trauma, or chronic use

S1 M Foot Eversion, Calf Raises (Gastrocnemius), Hip Extension (Gluteus Maximus) ¨ Spinal Infection R Achilles Tendon Reflex n Recent fever, h/o IVDA, prior or current infections, esp. from prior S Lateral Foot, Portion of Plantar Surface lumbar ESIs, and immunocompression S2 – S4 M Intrinsic Muscles of Foot, Bladder motor supply, Knee flexion – S2 ¨ R Superficial Anal Reflex (Sphincter Wink) S Concentric Rings – S2 – Outermost Ring, S3 – Middle Ring, & S4/S5 – n Acute or worsening radicular symptoms, sensorimotor deficits, foot Innermost Ring drop, saddle paresthesias, and/or bladder/bowel incontinence

n Secondary goal = classify patients as radicular or non- Diagnostic Examination radicular LBP n Routine use is not ¨ Non-radicular major causes (lumbar strain/sprain, myofascial pain, DDD) warranted based on ¨ Radicular (Lumbar Stenosis / Radiculopathy) current guidelines n Make sure to differentiate neurogenic claudication from vascular claudication n Should be reserved n Other possible diagnoses: , diffuse for patients with idiopathic skeletal hyperostosis (DISH), aortic aneurysm, progressive pancreatitis, or renal calculi neurologic involvement or if suspicious of an underlying pathology

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Diagnostics Computed Tomography (CT SCANS – high radiation) X-rays n Particularly good for detecting bone pathology n Provides basic evaluation of bone and disc spacing allowing visualization of degeneration, fractures, and instability of the spine n May consider CT if patient had prior hardware and there’s concern for artifact on MRI or lucency of the hardware n AP/Lateral for pathology n Flexion/Extension added if concerned about spinal instability n Oblique added if concerned about spondylolysis / spondylolisthesis CT Myelogram (high radiation) (Scotty Dog) n Secondary test if concern for neurological involvement n Needle is introduced into the subarachnoid space and contrast is Magnetic Resonance Imaging (MRI SCANS – non-radiation) injected with the patient tilted on the table so the dye will go to the n Primary diagnostic for neurologic al involvement specific region we are testing n Adept at evaluation of soft tissue pathology (i.e. nerves, spinal cord, and discs) n AP/Lateral views of spine are then taken n Order w/ contrast if prior surgery has been done to r/o scar tissue ¨ Contrast appears white w/ neural structures dark involvement or tumor ¨ Compression or displacement of neural elements may be visualized n Can be performed unless pt has pacemaker/defibrillator implant, aneurysm clips, other motor run implants, spinal cord stimulators, or a n Painful procedure bullet close to the spine

AP View (Owl)

Pedic les Ver tebr al Body

Transverse Process Spinous Pr oc es s

The eyes should be open. Winking owls is typically sign of pathology. Nose should be one piece. If separated in the middle, indicative of occulta

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Spondylolysis

Spondylolisthesis

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Treatment Options Patient Education n Education regarding their n Evidence shows that most treatment diagnosis, which is options have minimal impact on outcomes, important for self- management and are typically short term, and rarely change reassurance the longer term prognosis n Shared Decision Making n Goals of treatment include: n Encouragement for Active Lifestyle ¨pain relief n Health Seeking Behaviors ¨improvement of function ¨ Smoking Cessation ¨ Exercise ¨reduced work absence ¨ Weight Loss ¨prevention of chronicity.

n Recognize & Evaluate for Psychosocial Risk Factors (yellow flags) Nonpharmacological ¨ Inappropriate attitudes and beliefs about back n Exercise pain ¨ Physical Therapy ¨ Fear-avoidance behavior ¨ Aqua Therapy ¨ Anxiety ¨ ¨ Depression IHEP (Walking, Stretching, Swimming, & Cycling) ¨ Workers’ compensation claim status n Chiropractic Care (aka spinal manipulation therapy) ¨ Litigation status n Massage ¨ Socioeconomic factors n ¨ Malingering pain Heat / Ice ¨ Persistent request for narcotic n Traction when inappropriate for treatment n Acupuncture n Biofeedback w/ Adaptive Coping Behaviors n TENS ¨ Distraction n Back Supports ¨ Endurance n Behavior Modification

Pharmacological Common Medications for LBP Management

n Acetaminophen n Traditional NSAIDs: etodolac (Lodine) diclofenac (Voltaren) n NSAIDs (oral / naproxen (Naprosyn, Aleve) topical) n Cyclooxygenas e- 2 (COX-2) n Weak Opioids inhibitor NSAID: celecoxib (Celebrex) ¨ Tramadol n Weak Opioids: tramadol (Ultram) ¨ Tylenol #3 acetaminophen/codeine (Tylenol #3) n Antidepressants n Muscle Relaxants: baclofen (Gablofen, Lioresal) n Muscle Relaxants tizanidine (Zanaflex) n Antiepileptic / methocarbomal (Robaxin) Antineuropathics cyclobenzaprine (Flexeril) n Antiepileptics: (Neurontin) n topiramate (Topamax)

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Invasive Procedures n Probable causal factors n Pain Injections ¨ Increased tumor necrosis factor ¨ Epidural Steroids α ¨ Facet Injections n Genetic Predisposition ¨ Rhizotomy ¨ Changes in Interleukin 1, ¨ Nerve Blocks aggrecan, vitamin D receptors, ¨ IDET collagen fiber genes (I, IX, XI), n Surgical Referral matrix metalloproteinase 3, and ¨ Stenosis = lumbar / decompression several proteins ¨ Radiculopathy = lumbar n n Smoking

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