2015 SNU Orthopedic update (I) : SPINE
Musculoskeletal condition mimicking spinal disorder: Lower extremity
서상교
서울대학교병원 정형외과
Cause of lower extremity pain
• Neurologic disorder
• Vascular problem
• Peripheral nerve compression
• Local musculoskeletal disorders
• DM neuropathy Spinal origin pain
• Spinal stenosis (Instr Course Lect, 2009) - Disc degeneration, facet joint arthrosis, hypertrophy of the lig. flavum - Radicular pain through a combination of - direct mechanical compression of nerve roots - restriction of microvascular circulation and flow, inflammatory mediators
- Low back pain - Bilateral lower extremity pain - Paresthesia - Neurologic deficits that occur concomitantly with anatomic narrowing of the neural pathway through the spine Vascular problem
• Peripheral arterial disease (J Appl Physiol, Muller, 1985)
- Clinical manifestations of atherosclerosis affecting the circulation in the legs - Comorbid conditions : HTN, dyslipidemia, diabetes, smoking, physical inactivity - Complex, multi-organ disease
- Hallmark symptom : exertional pain in the buttocks, thigh or calf that promptly resolves with rest
- Ankle-Brachial index, Doppler, CT angio Peripheral nerve compression
• After trauma or iatrogenic injury or by entrapment at areas of anatomic restriction • Symptom : Paresthesia, Pain, Tingling sense
• Sciatic nerve - Most largest nerve, L4, 5, S1, 2, 3 - Greater sciatic notch 통과 : tibial division, peroneal division - Thigh의 lower 1/3에서 분지가 분리 - Hamstring muscle에분포 - 하퇴 내측의 감각기능 제외한 무릎 아래 모든 감각, 운동 기능 담당 Peripheral nerve compression
• Piriformis syndrome (Eur Spine J, Kevork, 2010)
- Compression of the sciatic n. by the piriformis m. - Trauma history(*) - Buttock pain(m/c) , external tenderness over the greater sciatic notch - Aggravation of the pain through sitting - Augmentation of the pain with maneuver that increase piriformis m. tension - Sciatica 환자의 5-8% - FAIR test - EMG/NCS, MRI (contracture of spasm) - Tx : good response to conservative treatment Peripheral nerve compression
• Common peroneal nerve - Popliteal fossa의 superolateral 에서 biceps 와 gastrocnemius lateral head 사이를 뚫고 나옴 - Direct compression : cast - Foot drop, foot atrophy - Dorsum of foot and 4개 toe medial side의 tingling sense - TA, EHL, Pernous 악화 동반 - Tx : conservative Tx., neurolysis
• Deep peroneal nerve - SER, IER 안쪽 or TN joint 높이 지날때 EHL 사이에서 발생 - Squeezing shoes, direct blow - Ant. Tarsal tunnel syndrome Peripheral nerve compression
• Superficial peroneal nerve
- Peroneus longus와 EDL 사이 - Lower leg distal1/3에서 deep fascia penetrating, mainly entrapment - Fibrosis after contusion, chronic lateral compartment syndrome - Ankle sprain - 발등전체, 모든 발가락 통증, 거리고 먹먹한 감각 - Conservative Tx., nerve block Peripheral nerve compression
• Posterior tibial nerve
- Tarsal tunnel : TP FHL FDL posterior tibial n. and a. - Bony exostosis, callus formation, tenosynovitis, valgus deformity, RA, DM, varicose vein - Paresthesia, tingling sense, causalgia - Tinnel sign, aggravating with WB (valgus deformity) - MRI - Underlying disease correction, nerve block, flexor retinaculum release Peripheral nerve compression
• Plantar nerve
- Branch of tibialis posterior n. - Valgus deformity, pain, causalgia
- Paresthesia, tingling sense, causalgia - Tinnel sign, aggravating with WB
- Tx. : Valgus correction, triamcinolone injection, operation Musculoskeletal disorders
• Musculoskeletal disorders in referrals for suspected lumbosacral radiculopathy (Am J Phys Med Rehab 2007)
- Electrodiagnostic evalution for suspected lumbosacral radiculopathy - Total prevalence of musculoskeletal disorders : 32%
- In lumbosacral radiculopahty - Myofascial pain : 12% - Trochanteric bursitis/ITB syndrome : 12% - Plantar fasciitis 3% Myofascial pain syndrome
• Trigger point (Acta Neurochir, 2005, Phys Med Rehabil Clin N Am, 2002)
- Arise from active trigger-point activity : focus of hyperirritability in a muscle or fascia - Referred pain pattern that is specific for the muscle in which the trigger point lies. - Jump sign with palpation of the trigger point
- Gluteus minimus radiate down the posterior or lateral part of the leg : similar to radiculopathy L4-5, L5-S1 - MRI : spine - Injection Hip and Pelvis
• Groin : L1-3, hip : L4-S1 • Greater trochanteric bursitis - 25-30% of patients with LBP - m/c hip bursitis - From overuse, mechanical factors or trauma - Direct tenderness - Exacerbating with abd, ER - Lateral aspect pain of the hip that radiate to buttock or lateral thigh and knee - Leg paresthesias - MRI, conservative Tx, Surgery Hip and Pelvis
• Groin : L1-3, hip : L4-S1
• Ischial bursitis - Direct stress such as prolonged sitting - Worse with sitting or walking, similar to disc disease - Tenderness - Exacerbated with passive hip flex, resisted hip ext - Find a more comfortable position - MRI, conservative Tx., Surgery Knee
• Numerous bursae, tendons, muscles, ligaments
• Iliotibial band syndrome - L4-5 - Lateral aspect of the thigh and finally attaching at Gerdy’s tubercle - Lateral knee pain with radiation to the lateral aspect of the thigh and calf - Worse with activity, but symptoms progress, pain persist at rest Knee
• Numerous bursae, tendons, muscles, ligaments
• Iliotibial band syndrome - Tenderness along the ITB and over the prominence of the lateral condyle - Ober’s test Knee
• Pes anserine bursa inflammation
- Behind the medial hamstrings(sartorius, gracilis, semitendinosus) - Medial knee pain radiating proximally along the tendons - Tenderness 4 to 5 cm below the medial knee joint - Aggravated with active knee flexion
- MRI - Medication > Operation Foot and Ankle
- S1-2 radiculopathy - Pain : diffuse, migratory, eventually localize to medial calcaneal tuberosity - Gradual onset - Worse on first WB and resting - Unilateral > Bilateral - Local tenderness
- Tx. : Passive dorsiflexion of the great toe Foot and Ankle
• Morton’s neuroma (Interdigital neuroma)
- S1-2 - Pain on weight bearing - Local tenderness - Pain persistent after medication
- SONO, MRI
- Tx. : Insole, injection, operation DM neuropathy
• Microvascular complication (J Diabetes Meta Dis, 2014)
- Prevalence 16-50% of DM (diabetic neuropathy) - Painful diabetic peripheal
- Diffuse, affecting several parts of the pain, or focal, affecting a specific nerve and part of the body - Chronic, symmetrical, length-dependent sensorimotor polyneuropathy - Both motor and sensory, symmetrical, distal and primarily sensory polyneuropathy - Gloves-socks hypoesthesia Case reports
• Quadriceps muscle rupture mimicking lumbar radiculopathy (Eur Spine J, 2012)
• Postpartum sacral stress fracture mimicking lumbar radiculopathy (Ann Rehab Med, 2013)
• Pseudogout of the knee mimicking L2-3 radiculopathy (Eur Spine J, 1997) Case F/83
C.C> Lt. buttock pain (onset : 3MA)
P.I> '07.06.12 TKRA (both) '09.2.11 Open reduction internal fixation of fracture, subtrochanter of femur, Rt.
• Risendronate : 2008-2013.7
• Radiating pain to Lt. buttock & L/E
F/83
MRI 1. Multiple old compression fractures at T-L spine 2. Degenerative central canal stenosis at L3/4, L4/5, L5/S1 3. Degenerative foraminal stenosis at L5/S1 Lt, mild
Lt. L4 nerve root block 후 증상 호전되어 퇴원하였다가 다시 통증 발생
Micro decompression, L4/5, Lt. 위해 입원
입원후 검진상 왼쪽 다리 딛기 어렵고, 다리 힘이 없기보다는 buttock pain 으로 걷지 못함.
F/58
C.C> Radiating pain to Lt. L/E (3YA) P.I> LBP Buttock pain Radiating pain to Lt. L/E (posterolateral aspect) Forefoot pain, 3, 4 toe area
Nerve root block, L5, Lt.
이후 buttock pain, radiating pain 호전 Forefoot pain 지속 F/58
C.C> Radiating pain to Lt. L/E (3YA) P.I> 이후 buttock pain, radiating pain 호전 Forefoot pain 지속
SONO : Morton’s neuroma, 3rd web space
Triam injection Take home message
• Careful history taking / physical examination
• Concomitant musculoskeletal disorders in patients with radiculopathy Thank You For Your Attention