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 • Plantar fasciitis - 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.