Differential Diagnosis of the Spine

DifferentialDifferential DiagnosisDiagnosis ofof thethe SpineSpine

PaulaPaula SammaroneSammarone Turocy,Turocy, EdD,EdD, ATCATC DuquesneDuquesne UniversityUniversity EtiologyEtiology ofof BackBack PainPain

Reid DC. Sports Injury Assessment and Rehabilitation. New York, NY: Churchill Livingston. 1992. ““RedRed Flags”Flags” ofof BackBack PainPain

„„ CancerCancer (<1%)(<1%) „ PatientPatient Presentation:Presentation: UnexplainedUnexplained weightweight lossloss (>10%),(>10%), pastpast HxHx ofof cancer,cancer, nightnight pain,pain, durationduration >> 11 month,month, failurefailure ofof conservativeconservative backback treatmenttreatment

„„ SpinalSpinal InfectionInfection (.01%)(.01%) „ PatientPatient Presentation:Presentation: Fever,Fever, chills,chills, nightnight painpain thatthat interruptsinterrupts sleep,sleep, IVIV drugdrug use,use, HxHx ofof infectioninfection elsewhereelsewhere ““RedRed Flags”Flags” ofof BackBack PainPain

„„ AnkylosingAnkylosing SpondylitisSpondylitis (.3%)(.3%) „ InflammatoryInflammatory arthropathyarthropathy thatthat firstfirst affectsaffects spine,spine, thenthen otherother jointsjoints andand organsorgans „ AsAs diseasedisease progresses,progresses, patientpatient assumesassumes fixed,fixed, stoopedstooped postureposture withwith flexionflexion inin lumbarlumbar spine,spine, knees,knees, andand hipships toto decreasedecrease painpain ““RedRed Flags”Flags” ofof BackBack PainPain-- Ankylosing Spondylitis

„ PatientPatient Presentation:Presentation: „ LumbarLumbar painpain thatthat resolvesresolves withwith activityactivity „ occursoccurs inin menmen <40<40 yoyo,, AMAM stiffness,stiffness, nightnight pain,pain, gradualgradual onset,onset, >3>3 monthsmonths withwith symptomssymptoms ““RedRed Flags”Flags” ofof BackBack PainPain

„„ CaudaCauda EquinaEquina SyndromeSyndrome „ CompressionCompression onon CaudaCauda EquinaEquina duedue toto massive,massive, centralcentral discdisc herniationsherniations (occurs(occurs inin onlyonly 11--2%2% ofof allall discdisc protrusions)protrusions) „ RequiresRequires surgicalsurgical interventionintervention „ PatientPatient Presentation:Presentation: BladderBladder dysfunctiondysfunction (urinary(urinary retention,retention, increasedincreased frequency,frequency, overflow,overflow, incontinence,incontinence, saddlesaddle anesthesia,anesthesia, bilateralbilateral painpain and/orand/or weaknessweakness ““RedRed Flags”Flags” ofof BackBack PainPain

„„ CerebralCerebral SpinalSpinal FluidFluid LeakageLeakage „ UsuallyUsually occursoccurs followingfollowing backback surgerysurgery „ Clear/slightlyClear/slightly yellowyellow--tingedtinged fluidfluid slowlyslowly dripsdrips fromfrom spinalspinal incisionincision „ AsAs amountamount ofof CerebralCerebral SpinalSpinal FluidFluid lossloss increases,increases, patientpatient developsdevelops followingfollowing „ Severe headache „ Nausea „ Slight disorientation SciaticaSciatica „ Injury,Injury, Problem,Problem, SymptomSymptom

„ InflammationInflammation ofof thethe SciaticSciatic NerveNerve (neuritis)(neuritis) usuallyusually associatedassociated withwith peripheralperipheral nervenerve rootroot compressioncompression

„ SciaticSciatic NerveNerve isis susceptiblesusceptible toto „ Torsion „ Direct blows - ischial tuberosity „ Compression - spasms/tightness in piriformis muscle SciaticaSciatica „ MechanismMechanism ofof InjuryInjury „ Disc/nerveDisc/nerve injuryinjury „ HipHip hyperflexionhyperflexion „ PiriformisPiriformis pathologypathology

„ PatientPatient Presentation:Presentation: „ ParasthesiaParasthesia/anesthesia/anesthesia alongalong portion/lengthportion/length ofof nervenerve ((proximalproximalÆÆdistaldistal)) „ MuscleMuscle weaknessweakness „ PossiblePossible decreasedecrease inin Achilles/HamstringAchilles/Hamstring reflexesreflexes SciaticaSciatica PresentationPresentation andand TreatmentTreatment Condition at Presentation Investigation Treatment Sciatica. Reflex changes. Muscle CT Scan or MRI Consider immediate surgical weakness. Altered bladder function decompressions Sciatica. Reflex changes. Muscle Plain films of lumbar spine. If Complete withdrawal from activity. weakness. Normal bowel and improves in 10-14 days, follow Modified activity for few days bladder function. Acute onset. patient. If not, consider CT, MRI, or according to pain. NSAIDS, myelogram. analgesics. Therapy. If improves, progress treatment as per symptoms. Sciatica. Reflex changes. Muscle Consider above investigations Treat as above. weakness. Normal bladder function. immediately. Repeat or chronic Sciatica, sensory changes, mild or Plain lumbar spine films. If not Take careful history. Elicit no reflex changes. Normal muscle improvement at 6 weeks, consider aggravating factors. Two weeks rest strength. Bladder normal. further investigation. from activity. Therapy. NSAIDS. If no improvement, further modify activity. If improves, progress PRN. Sciatica only. Sensory normal. Plain films of lumbar spine. If no Detailed active history. Modify Muscle normal. improvement at 6 weeks, consider activity appropriately. Therapy. further investigation. NSAIDS. If improves progress PRN. Sciatica with atypical features such Plain films of lumbar spine. Treat according to magnitude of as fever, weight loss, chronic cough, Consider complete blood screen. symptoms and findings of screening abdominal pain, altered bowel ESR. Acid and alkaline tests. habits or rectal bleeding, long tract phosphatase. Bone scan. Where signs or onset in very young or diagnosis not apparent, CT or MRI. elderly. Chest film. CommonCommon PathologiesPathologies ofof thethe SpineSpine

„ FacetFacet JointJoint InjuriesInjuries „ Normally non-weight bearing joint „ Becomes weight bearing with increased trunk extension

„ Trunk extension also places stress on longitudinal ligaments

„ Injury may be to capsule or meniscal-like structure in joint FacetFacet JointJoint InjuryInjury

„ PatientPatient Presentation:Presentation:

„ BackBack PainPain >> LegLeg PainPain „ PainPain increasesincreases withwith standing,standing, sitting,sitting, walkingwalking „ PainPain withwith rollingrolling overover inin bedbed „ PainPain withwith trunktrunk extensionextension andand rotationrotation „ ++ SLRSLR „ PtPt tendertender overover laterallateral toto spinousspinous processprocess (over(over facetfacet joint)joint) CommonCommon PathologiesPathologies ofof thethe SpineSpine

„ DiscDisc InjuryInjury „ PainPain producedproduced isis asas aa resultresult ofof „ Associated nerve being stretched across and pressed upon the bulging disc into the posterolateral space and/or „ Change of spinal mechanics that result in abnormal function at the vertebral joint

„ 90%90% ofof discdisc injuriesinjuries occuroccur atat L4L4ÆÆS1S1

„ OnlyOnly 1%1% ofof thosethose diagnoseddiagnosed casescases occuroccur inin 1010--2020 yearyear oldsolds AnnularAnnular FibrosusFibrosus TearTear

„ UsuallyUsually aa circularcircular oror “bucket“bucket handle”handle” teartear thatthat occursoccurs inin thethe annularannular fibersfibers

„ PatientPatient Presentation:Presentation: „ Pain with twisting/bending (torsion) type motion „ Pain mostly in center of spine „ Normal SLR test, because usually no nuclear bulge „ + MRI Schmorl’sSchmorl’s NodesNodes

„ PressurePressure onon thethe discdisc becomesbecomes greatgreat enoughenough toto causecause defectsdefects inin cartilaginouscartilaginous endend plateplate

„ PressurePressure causescauses herniationherniation ofof thethe nucleusnucleus pulposuspulposus intointo thethe vertebralvertebral bodybody

„ NormalNormal fluidfluid mechanicsmechanics ofof thethe discdisc becomebecome impaired/disruptedimpaired/disrupted NormalNormal andand ImpairedImpaired DiscDisc FunctionFunction ((Schmorl’sSchmorl’s Nodes/EndNodes/End PlatePlate Fracture)Fracture) NucleusNucleus PulposusPulposus InjuriesInjuries

„ Progression of Nucleus Pulposus Injury 1.1. DiscDisc ProtrusionProtrusion 2.2. DiscDisc ProlapseProlapse 3.3. DiscDisc ExtrusionExtrusion 4.4. SequestratedSequestrated DiscDisc NucleusNucleus PulposusPulposus InjuriesInjuries

„ DiscDisc ProtrusionProtrusion „ The nucleus pulposus of the disc begins to bulge posteriorly without rupturing the annulus fibrosus

„ DiscDisc ProlapseProlapse „ Only the outermost fibers of the annulus fibrosus can contain the nucleus NucleusNucleus PulposusPulposus InjuriesInjuries

„ DiscDisc ExtrusionExtrusion „ The nucleus pulposus moves into the epidural space, placing pressure on nerve root

„ SequestratedSequestrated DiscDisc „ Formation of discal fragments that may leave the disc area after the nucleus and annulus fibrosus ruptures PainPain fromfrom NerveNerve RootRoot PressurePressure

„ McKenzieMcKenzie DerangementsDerangements SacroSacro--iliaciliac JointJoint (SI(SI Joint)Joint)

„ DiarthroidialDiarthroidial jointjoint untiluntil earlyearly inin adultadult lifelife

„ ROMROM decreasesdecreases andand jointjoint maymay becomebecome ankylosedankylosed duringduring agingaging processprocess ÆÆarthrosisarthrosis

„ NoNo musclesmuscles actuallyactually movemove thethe SISI joint;joint; jointjoint supportedsupported solelysolely fromfrom capsulescapsules andand ligamentsligaments SISI JointJoint DysfunctionDysfunction Mechanism „ Ilia(ilium) wedging and locking with sacrum „ Result of abnormal pelvic motion and/or rotation on the sacrum

„ Common mechanisms „ Hurdling/punting „ Change of terrain „ Chronic crowned-road running „ Stepping in hole or off curb „ Abnormal heel strike and/or running technique SISI DysfunctionDysfunction

„ PatientPatient Presentation:Presentation: „ May occur secondarily to lower leg injury that results in irregular mechanics „ Pain increases with sitting „ Pain and limited ROM with same side side-bending „ Pain when going down stairs „ Heaviness or dullness in leg „ Possible impaired reflexes „ Ilium position either anterior or posterior to neutral SISI DysfunctionDysfunction SpecialSpecial TestsTests

„ SISI CompressionCompression „ SISI DistractionDistraction (Spring)(Spring) „ SISI RockRock TestsTests „ FABERFABER „ ProneProne KneeKnee FlexionFlexion TestTest „ LongLong SittingSitting TestTest „ SISI FixationFixation TestTest „ StandingStanding FlexionFlexion TestTest „ SphinxSphinx TestTest SpondylolysisSpondylolysis

„ Fracture of the Pars Interarticularis

„ Etiology debate

„ Mechanism:Mechanism: „ Gravitationally-related to hyperlordosis „ Severe impact to low back forcing hyperlordosis „ Chronic stress to low back

„ Occurs in 6-10% of normal population SpondylolysisSpondylolysis

„ UsuallyUsually associatedassociated withwith segmentalsegmental lordosislordosis „ OftenOften palpablepalpable bonybony prominenceprominence inin lumbosacrallumbosacral segmentsegment „ DiagnosisDiagnosis „ AP/Lateral/Oblique*AP/Lateral/Oblique* radiographsradiographs „ BoneBone scanscan ifif stressstress fracturefracture „ AppearsAppears asas aa “Scotty“Scotty Dog”Dog” withwith aa collarcollar SpondylolysisSpondylolysis

„„ PatientPatient Presentation:Presentation: „ PointPoint TendernessTenderness „ PainPain increasesincreases withwith activityactivity „ ConstantConstant painpain regardlessregardless ofof weightweight--bearingbearing statusstatus „ SciaticaSciatica „ MuscleMuscle weakness/atrophyweakness/atrophy „ PossiblePossible impairedimpaired reflexesreflexes „ PositivePositive OneOne--LegLeg StandingStanding TestTest SpondylolisthesisSpondylolisthesis

„ ShiftShift ofof thethe vertebralvertebral bodybody anteriorlyanteriorly awayaway fromfrom thethe spinousspinous processprocess followingfollowing aa spondylolysisspondylolysis „ MayMay occuroccur graduallygradually „ GreaterGreater slippageslippageÆÆ moremore unstableunstable DiagnosisDiagnosis byby xx--rayray onlyonly „ >1>1 cmcm slippageslippage ÆÆ neurologicalneurological pathologypathology „ MechanismMechanism „ SameSame asas spondylolysisspondylolysis

TypesTypes ofof SpondylolisthesisSpondylolisthesis

„ DysplasticDysplastic „ Congenital anomalies in upper sacrum or posterior arch of L5

„ IsthmicIsthmic „ Defect in Pars Interarticularis, or fatigue fracture in bone, or elongated area with pars in tact

„ DegenerativeDegenerative

„ TraumaticTraumatic

„ PathologicPathologic SpondylolisthesisSpondylolisthesis

„ PatientPatient PresentationPresentation (General):(General): „ PointPoint tendernesstenderness „ ActivityActivity andand weightweight bearingbearing increasesincreases painpain „ SciaticaSciatica „ MuscleMuscle weaknessweakness and/orand/or atrophyatrophy „ PossiblePossible impairedimpaired reflexesreflexes GradeGrade 11 SpondylolisthesisSpondylolisthesis

„ ArchArch defectdefect inin L5L5 „ MildMild forwardforward slippageslippage ofof L5L5 onon S1S1 „ BackacheBackache „ NoNo grossgross instabilityinstability GradeGrade 22 SpondylolisthesisSpondylolisthesis

„ MoreMore slippageslippage betweenbetween L4L4--L5L5 withwith collapsecollapse ofof discdisc „ DefiniteDefinite symptomaticsymptomatic backback „ RestrictedRestricted ROMROM „ MuscleMuscle spasmsspasms „ RestrictedRestricted activitiesactivities GradeGrade 33 SpondylolisthesisSpondylolisthesis

„ MoreMore extensiveextensive slippageslippage withwith widewide separationseparation ofof archarch defectdefect „ DegenerativeDegenerative changeschanges inin discdisc „ GrosslyGrossly symptomaticsymptomatic „ GreatGreat instabilityinstability GradeGrade 44 SpondylolisthesisSpondylolisthesis

„ VertebraeVertebrae slippedslipped forwardforward moremore thanthan 50%50% „ SevereSevere disabilitydisability „ SevereSevere instabilityinstability SpinaSpina BifidaBifida

„ DysplasticDysplastic congenitalcongenital defectsdefects „ MalformationMalformation ofof thethe posteriorposterior aspectaspect ofof thethe spinalspinal columncolumn inin whichwhich somesome portionportion ofof thethe vertebralvertebral archarch failsfails toto formform overover thethe spinalspinal cordcord „ 1/10001/1000 infantsinfants bornborn withwith thisthis defectdefect „ AthletesAthletes maymay developdevelop neurologicalneurological impairmentsimpairments „ MeningesMeninges may/maymay/may notnot bebe distendeddistended

SpinaSpina BifidaBifida

„ MechanismMechanism „ NoneNone

„ PatientPatient Presentation:Presentation: „ PainPain inin localizedlocalized oror generalgeneral areaarea ofof spinespine „ PossiblePossible instabilityinstability „ ChronicChronic neurologicalneurological symptomssymptoms thatthat areare moremore difficultdifficult toto resolveresolve thanthan normalnormal „ PalpablePalpable defectdefect inin spinespine PiriformisPiriformis SyndromeSyndrome

„ LowLow backback painpain inin back,back, buttocks,buttocks, posteriorposterior thighthigh causedcaused byby hyperirritabilityhyperirritability ofof thethe piriformispiriformis musclemuscle

„„ Mechanisms:Mechanisms: „ (Trauma)(Trauma) LiftingLifting heavyheavy objectsobjects „ (Indirect)(Indirect) TightTight hiphip externalexternal rotatorsrotators applyapply pressurepressure toto sciaticsciatic nervenerve

PiriformisPiriformis SyndromeSyndrome

„„ PatientPatient Presentation:Presentation: „ NonNon--specificspecific sciaticsciatic painpain „ PainPain increasesincreases withwith prolongedprolonged sitting,sitting, gettinggetting upup fromfrom sittingsitting oror atat nightnight „ TightTight and/orand/or painfulpainful hiphip internalinternal rotationrotation

„„ SpecialSpecial Tests:Tests: „ FABERFABER testtest „ LasegueLasegue (SLR)(SLR) testtest „ PainPain withwith resistiveresistive hiphip abductionabduction SpinalSpinal StenosisStenosis ((SpondylosisSpondylosis))

„ NarrowingNarrowing ofof spinalspinal canalcanal thatthat placesplaces pressurepressure onon nervenerve rootsroots and/orand/or spinalspinal cordcord

„„ Mechanism:Mechanism: „ ArthriticArthritic changeschanges andand spurringspurring vertebralvertebral bodiesbodies (permanent(permanent condition)condition) „ PseudoclaudicationPseudoclaudication (temporary(temporary condition)condition)

SpinalSpinal StenosisStenosis

„„ PatientPatient Presentation:Presentation: „ PainPain afterafter longlong periodsperiods ofof walkingwalking oror prolongedprolonged standingstanding „ InIn truetrue stenosisstenosis,, whenwhen activityactivity stops,stops, painpain stopsstops „ PainPain isis alleviatedalleviated withwith sittingsitting oror flexedflexed postureposture toto decreasedecrease lordosislordosis „ PositivePositive Milgrim’sMilgrim’s Test,Test, SLRSLR >70>700 ErectorErector SpinaeSpinae StrainStrain

„„ Mechanism:Mechanism: „ ForcedForced FlexionFlexion „ Overuse/abuseOveruse/abuse inin hyperextensionhyperextension „ EccentricEccentric LoadsLoads toto spinespine (lifting,(lifting, gardening)gardening)

„„ PatientPatient Presentation:Presentation: „ AcuteAcute onsetonset „ PainPain mostlymostly inin backback „ PainPain increasesincreases withwith passivepassive flexionflexion „ WeaknessWeakness withwith trunktrunk extensionextension ErectorErector SpinaeSpinae StrainStrain

„„ SpecialSpecial Tests:Tests: „ MMTMMT forfor ErectorErector SpinaeSpinae (trunk(trunk extensors)extensors) „ PainPain alleviatedalleviated whenwhen musclesmuscles shortenedshortened ThankThank YouYou

Paula Sammarone Turocy, EdD, ATC Department Chair & Associate Professor Duquesne University Pittsburgh, PA