8/11/16 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 vertebra 1 8/11/16 Intervertebral Discs Ligaments (brief overview) n 2 Components n Anterior Longitudinal ¨ Annulus Fibrosus Ligament 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 nerve root exits n Spinal cord 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 2 8/11/16 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 Facet Joint hypertrophy Lumbar Disc osteoporosis, structural deformity, or n Ver tebr al Endplate Sc ler os is Displacement) radicular syndrome n Vertebral Osteophytes ¨ 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 ¨ Scoliosis 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 3 8/11/16 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 claudication 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 paresthesias, 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 Radiculopathy, 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 ¨Spondylosis – 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 4 8/11/16 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