Common Thoraco- Lumbar Problems in the Mature Athlete

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Nathaniel King
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1 Common Thoraco- Lumbar Problems in the Mature Athlete Diana Heiman, MD Associate Professor, Family Medicine Residency Director East Tennessee State University

2 Objectives Review the pathophysiology of the aging spine Define the thoraco-lumbar conditions that affect the mature athlete Review evidence-based treatments for these conditions

3 Age-Related Changes Overall Spine flexibility decreases by 20-30% by age 70 Female > Male Thoracic Thoracic curve becomes more pronounced, disk dessiccation, height loss Decreased BMD Lumbar Increased degeneration at L4-5, L5-S1 Male = female Associated with obesity and repetitive lifting (especially improper) Spinal stenosis typically > 40

4 Normal Mechanics Disks add stability and mobility to spine Shock absorption Viscoelastic properties of inner annulus and nucleus pulposus Torsional, shear and axial forces Further stability from facets, and ligamentous structures Limited vascularity of nucleus puts it at risk for injury and degeneration Peripheral innervation of disk

$5%/yr after age 40, increases by 2-3%/y in postmenopausal women Compression fractures increase$

5 Osteopenia/Osteoporosis BMD decreases 0.5%/yr after age 40, increases by 2-3%/y in postmenopausal women Compression fractures increase thoracic kyphosis Leads to gait and balance impairment as well as pain

6 Osteopenia/Osteoporosis Participation in weight-bearing exercise in 2 nd -3 rd decades improves peak BMD Protective increase even if activity is not maintained in older years Total body BMD of male masters runners at the 2005 National Senior Olympic Games was higher than swimmers and sedentary controls, but no difference seen in females at all or in spine BMD

7 Osteopenia/Osteoporosis Pain associated primarily with acute compression fractures May be dull achy pain just from the osteoporosis Treat acute pain with nasal calcitonin, opioid pain meds as needed; avoid NSAIDs due to delay in healing Chronic management includes calcium, vitamin D, bisphosphonates for max of 5 years, continued weight-bearing activity, ± HRT in postmenopausal women

Spondylosis Pathophysiology Degeneration with wear and tear of daily activity Dessication of disk Loss of normal proteoglycan and collagen

8 Spondylosis Pathophysiology Degeneration with wear and tear of daily activity Dessication of disk Loss of normal proteoglycan and collagen Annulus breakdown, fissures Stiffening of disk Predisposes to herniation Natural process of aging Many asymptomatic changes seen radiographically

9 Spondylosis Presentation Axial pain LBP, muscle spasm without neurologic impairment Pure racidular pain pain radiating into the leg Combination axial and radicular pain both LBP as well as radiation into the leg

10 Progression of Changes A: normal disk B: disk degeneration and thinning C: disk bulge D: disk herniation E: spondylosis with disk degeneration and osteophytes

11 Spondylosis

12 Dermatomes

13 Diagnosis Thorough History Pain location, radiation Pain quality Duration Exacerbating and relieving characteristics Red flags Thorough Exam Inspection Palpation ROM Strength Neuro Exam Special tests SLR Crossed SLR

14 X-rays initially MRI Diagnosis Prolonged symptoms Lack of response to conservative therapy Cauda equina syndrome (URGENT) Significant or worsening weakness Myelopathic symptoms EMG/NCS Diagnostic injections

15 MRI Evaluation

16 Treatment Initially conservative unless profound weakness or diffuse symptoms PT, including traction Analgesics Relative rest (NOT BEDREST!) Heat, ice, etc. Weight loss Injections Facet Epidural Nerve root

17 Treatment Surgery (MANY) Discectomy and fusion Minimally invasive discectomy Intradiscal electrothermy (IDET) Disc replacement

18 Prognosis Typically self-limited problem Most resolve with conservative care within 3 months Many will have recurrent episodes, especially with cervical disease

19 Cauda Equina Syndrome Surgical Emergency! Compression of multiple sacral roots Saddle anesthesia Bowel/bladder incontinence Sexual dysfunction Severe lower extremity weakness, pain, anesthesia

20 Cauda Equina Syndrome

21 Spinal Stenosis Congenital Disk herniation Osteophyte impingement Spondylolisthesis

22 Spinal Stenosis

23 Spinal Stenosis - Lumbar Neurogenic claudication (pseudoclaudication) Lower extremity weakness, pain, paresthesia exacerbated by walking and relieved with sitting and flexion of the spine Symptoms occasionally present at rest Worse with hyperextension or lying prone Better with flexion Pulses normal

24 Spinal Stenosis Conservative management with mild, chronic symptoms Cauda equina syndrome and myelopathy treated surgically

25 Facet Arthropathy Typically presents with pain upon extension with rotation Decreasing exacerbating movements leads to more stiffness and more pain with movement May have associated radicular pain with nerve root irritation Treat with analgesics, maintaining activity as able, facet injections or medial branch blocks

26 Facet Arthropathy

27 Summary Lumbar disk disease is more commonly traumatic in nature. Radicular symptoms are common. Remembering pain and paresthesia patterns and neurologic exam is key to diagnosis.

Comprehension of the common spine disorder.

Objectives Comprehension of the common spine disorder. Disc degeneration/hernia. Spinal stenosis. Common spinal deformity (Spondylolisthesis, Scoliosis). Osteoporotic fracture. Anatomy Anatomy Anatomy