Evaluation of Patient with Spine Symptoms. Kenneth Nguyen, DO Providence Physiatry

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2 Evaluation of Patient with Spine Symptoms Kenneth Nguyen, DO Providence Physiatry

3 Epidemiology of Low Back Pain (LBP) Lifetime prevalence of 84% Chronic symptoms in 10-15% 80-90% of economic resources are for the 10% who develop chronic LBP 1% of US adults are permanently disabled from back pain Largest Predictor of disabling pain Maladaptive pain coping behavior Presence of non-organic signs Concomitant psychiatric disease Low baseline physical function Low general health

4 Biomechanics of the Lumbar Spine Intervertebral disc: annulus fibrosis, not the nucleus, that absorbs shock Flexion loads the anterior disc, particularly flexion with rotation Lifting load close to body safest Z-joint (facet) allow for flex-ext 90% occur at L4-5 and L5-S1

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6 The Degenerative Cascade Tears of the annulus is the 1 st sign of degenerative wear Loss of disc height, will put more stress on posterior elements (facet joint) Disc degeneration can precede facet joint disease by as much as 20 years Chain reaction, one level affective the levels above and below

7 Psychosocial Factors 30-40% of those with chronic low back pain have depression High correlation with anger and pain Possibly related to deficient opioid modulation in those with high anxiety, anger, and fear reactivity As clinicians, try to reduce fear avoidance Pain will be permanent; related to activity; exercise will damage their back Recognize pain catastrophizing Excessively negative thoughts, high fear of movement Reassure patient that they are not damaging their spine Changes in beliefs account for 71% reduction in disability

8 HPI In addition to typical evaluation, r/o red flags Cancer, infection, long tract signs, and fracture Yellow flags associated with developing chronic disabling pain Catastrophic thinking, negative expectations, avoidance of normal activity, poor sleep, compensation issues, stress/anxiety, work issues, extended time off work Enquire about functional decline- what can t the patient do anymore? What position gives them the most comfort? What position does the patient sleep in? What hurts the most? Prolonged sitting, standing, or walking For cervical symptoms: Is the pain aggravated by reading, driving, looking up

9 Physical exam (cont.) Tenderness, ROM, what direction causes more discomfort Don t miss UMN or asymmetric reflexes Check for subtle signs of motor weakness ie EHL weakness for L5 radic Check for core/abdominal strength-can the person do a plank or bridge? Watch patient try to do a sit up

10 Differential Diagnosis: Back>Leg pain Non-specific: 85% do not receive a specific diagnosis Multi-factorial: deconditioning, poor muscle recruitment, emotional distress, arthritis, discogenic back pain Lumbar spondylosis: Often used for older patients with LBP Facet joint point can refer to the knees or even below Tight hip flexors increased lumbar lordosis posterior element stress Biomechanically, lumbar extension and rotation increase facet joint forces Facet loading maneuver is often documented, but diagnosis is through spinal injection 15% in younger patients, 40% in older age groups

11 Low back pain > leg pain Lumbar paraspinal muscle atrophy seen more likely in chronic low back, deconditioned patients and post-surgical patients Facet synovitis and arthropathy - Check for instability

12 Lumbar Disc Disease Internal Disc Disruption: External surface remains normal, but internal architecture is disrupted Degradation of the nucleus pulposus and radial fissures extending to the outer third of the annulus (HIZ or high intensity zones on MRI) Pain is transmitted by the sinuvertebral nerve Diagnosis is through discogram and post-discography CT Disc Herniation: Bulge (>50% circumference) vs Herniation (<50%) 95% herniations at L4-5 and L5-S1, followed by L3-4 and L2-3 Annulus fibrosis is weakest posterolaterally Inflammatory and mechanical compression of nerve root

13 Disc Herniations (HNP) Clinical picture is variable. Some patients only have axial low back pain Various movements are provocative Posterolateral herniation: Pain with flexion Central herniation: Pain with extension Lateral herniation: Pain with ipsilateral side bending Most do well with conservative management Directional preference therapy and core stabilization for physical therapy Lumbar epidural is used to provide pain relief to allow patient to maximize physical therapy

14 Lumbar Spinal Stenosis (LSS) ETIOLOGY Degenerative: most common. Typically >60 y.o. Obesity and family hx are risk factors Spondylolisthesis (One vertebrae translating over the other, usually L4-5 or L5-S1) Mass: lipoma, synovial cyst, cancer, epidural lipomatosis Traumatic/post-operative fibrosis Skeletal disease: DISH (diffuse idiopathic hyperostosis) Congenital: dwarfism and spinal bifida

15 Degenerative LSS

16 Epidural Lipomatosis Another relatively common cause of LSS R/o medical causes Hyperlipidemia Excessive steroid use? Consider EMG Refer to spine specialist

17 Clinical Presentation of LSS Neurogenic claudication is classic feature Pain with walking/standing, relieved with rest Pain 93% Numbness/tingling 63% Weakness 43% Examination DTR absent in ankle 43% or knee %18 Weakness in 37% DIAGNOSIS: 1. Confirm with advanced imaging i.e. MRI L spine 2. I often use EMG/NCS to determine the severity - Look for active axonal damage Cauda equina uncommon Absent reflexes, motor weakness, and bladder/bowel dysfunction

18 Piriformis Syndrome Piriformis is an external rotator, but in flexion is an abductor Combining active piriformis test and seated piriformis stretch test resulted in 91% sensitivity Active piriformis test (pace test): patient seated, place hands on lateral aspect of knees, and tell patient to push hands apart Passive piriformis stretch: patient lies on side, affected side up, flex hip to 60 with knees flexed. Apply downward pressure to the knee.

19 Intra-articular Hip Pathology (HP) Loss of internal rotation (IR) and hip flexion (HF) are 1 st signs of HP IR less than 15; HF less than 115 degrees FABER (Patrick s test, figure 4): Sensitivity 57%, Specificity 71% Groin pain = hip pathology Back or buttock pain = lumbar facet joint or sacroiliac joint pathology Resisted straight leg raise: increases pressure on labrum as the iliopsoas contracts

20 Femoroacetabular Impingement (FAI) FAI is abnormal contact between femoral head and the acetabular rim at terminal ROM Anterior impingement test (FADDIR): flexion, adduction, internal rotation Brings proximal and anterior part of the femoral neck into the rim of acetabulum

21 Neck pain Annual prevalence 30-50% Cervical radiculopathy less common 83.2 per 100,000 The lower cervical C3-C7 have unique synovial joint like articulations, uncovertebral joints (Luschka), located between the uncinate process Arthritic changes in this area can be a cause of radiculopathy

22 Cervical spine anatomy 7 cervical vertebrae 8 cervical spine nerves Many pain generators Facet Uncovertebral Disc Nerve root (radicular pain) Muscles/ligaments

23 Inspection/Palpation Forward head position can cause 25-50% limitations in rotation and increases work requirement of capital and cervical musculature C7 is thought to be most easily palpated but only 47.9% of physicians were able to identify, 77% when neck was flexed Fails to identify the correct pain generator many times

24 Range of Motion Atlantooccipital (AO) and atlantoaxial (AA) joints are not true joints AA accounts for 50% of total rotation Flexion is primarily from C5-6, and C6-7 (17 and 16 degrees) Lateral bending C3-4 and C4-5 (11 and 12 degrees)

25 Neuromuscular Exam Most important part of the examination. RULE OUT MYELOPATHY! Test deltoid (axillary), bicep (musculocutaneous), tricep (radial), pronator teres (median), ECR/wrist extension (radial), and ADM (abd of 5 th digit, ulnar) Spine level C3- supraclavicular fossa C4- tip of acromion C5- lateral epicondyle C6- thumb C7- middle digit C8-5 th digit

26 Special tests Spurlings test first described in 1944 and only based on 12 patients Currently, accepted that extension/rotation/compression or extension/lateral bending/compression are most consistent Shoulder abduction test: Relief of symptoms is + Lhermitte Sign: electric discharge (cord injury) Neck flexion with legs straight in sitting position Hoffman sign: in isolation not useful

27 Axial Neck pain More Common Sprain/strain injuries (80-85%) Cervical facet pain (usually upper region, C3-4-5 levels) Cervicogenic headaches Facet pain from C2-3

28 Radicular Pain Pattern for C4,C5, C6, and C7 radicular pain Radiculopathy is more likely from facet or uncovertebral arthropathy, not HNP

29 Central Stenosis/Myelopathy Middle aged to elderly, C4-C7 UMN in the lower limbs but LMN (lower motor nerve injury) in UE Gait dysfunction, ataxia, hypertonicity, weakness, proprioceptive deficits PE: wide based, unsteady gait; weakness in the hands with + Hoffman, difficulty with rapid movements (foot tapping), fine motor control impaired Central diameter less than 10 mm is considered spinal stenosis

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31 Thoracic outlet syndrome Clinically rare with many various maneuvers- 91% of normal patients had one + test Adson test: no studies have documented reliability of the test; sensitivity has been reported to reach 94% Can be suspected in more isolated arm pain without neck pain EMG can show lower trunk injury without entrapment neuropathy

32 Wrap Up and Questions Keep the patient moving! Maximize conservative measures If red flags or failure of conservative management- please refer to specialist Any questions? Providence Physiatry Kenneth Nguyen Steven Andersen Bessie Joy Perkey Aaron Lyles